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The Role of Community Pharmacists in Patient Safety

What is a community pharmacy.

Community pharmacies are sometimes equated to retail pharmacies, operating out of both large and small chains or grocery stores. However, what constitutes a community-based pharmacy is much broader than the traditional retail setting. Community-based pharmacies also include outpatient pharmacies found within health systems, Federally Qualified Health Centers, primary care clinics, compounding pharmacies that prepare medications for patients who require unique dosing or modified formulations, 1 and specialty pharmacies where patients receive outpatient care for complex medication therapies. 2 Pharmacists may pursue community-based residencies or fellowships to enhance their clinical and leadership skills, preparing them for a role in community pharmacy. 3

What roles does a community pharmacist play in patient safety?

Historically, the concept of the “five rights” has been used to describe the steps that lead to safe medication use: the right dose of the right medication taken by the right patient at the right time and by the right route. However, this concept is oversimplified, as there are additional steps of safe medication use that should also be considered; steps that are dependent on the context in which the medication-related process is occurring. Each part of the medication use process may contain different numbers and types of “rights”. For example, in the community pharmacy setting, outcomes like the right education, right monitoring, right documentation, and right drug formulation may also be considered.

The modern concept of medication safety is much broader in scope than the “five rights” and the focus has subsequently shifted with an increased emphasis placed on the contribution of systems factors to medication safety. Factors not directly related to medications are considered, including how the workflow, technologies, policies and procedures, and other systems factors support the outcomes of the various rights, rather than focusing solely on completion of an oversimplified checklist.

Pharmacists in the community ensure medication safety similarly to how they would in any healthcare environment: throughout the medication-use process, including the ordering of medications to their storage, transcription, preparation, dispensing, counseling, and more. Prior to the dispensing process, the community pharmacist provides a clinical review of prescribed medications to ensure the therapies are appropriate. This review includes dosing appropriateness, interactions with other prescribed medications, contraindications, and more, while also considering that medications may have been ordered by multiple prescribers. 4,5 The pharmacist also provides critical monitoring in the dispensing of controlled substances, such as consulting prescription drug monitoring programs to look for patterns that might indicate abuse or diversion and to screen for potentially fatal interactions between medications that may come from multiple prescribers. 6,7 Pharmacists must identify patients at risk for fatal overdose and facilitate access to the emergency opioid reversal drug Narcan® (naloxone) as well as substance abuse treatment services when appropriate.

A clinical review is essential for all prescriptions and can help ensure that any errors occurring as a result of the care transition process are caught and corrected before the medication is dispensed. 8 For example, in the discharge process, the inpatient providers may have an incomplete history of the patient’s existing prescriptions when formulating the treatment plan. In addition, medications that may have been appropriate during the inpatient stay, but inappropriate for home use, may inadvertently be carried over into the patient’s outpatient treatment plan.

In addition to the dispensing process, the community pharmacist plays a critical patient safety role when it comes to ensuring that patients appropriately understand their medications. 4 Community pharmacists are equipped to provide education and counseling to patients to address questions they may have regarding factors such as dosing, administration, storage, potential side effects, and how to taper medications for acute events. Similarly, community pharmacists are an invaluable resource for supporting public health initiatives. One study found that patients visited a community-based pharmacy 35 times per year, as compared to a primary care physician, which occurs, on average, 4 times per year. 2 This frequent contact with patients makes community pharmacists optimally positioned to support public health initiatives and triage concerns. Numerous studies have proven the positive impact of pharmacists on preventative care such as health screenings and immunizations, opioid management, smoking cessation efforts, and management of chronic diseases such as diabetes. 9

What supports community pharmacies in providing patient safety?

Patient safety is best achieved in organizations that have a strong culture of safety . Organizations with a strong culture of safety are not only better positioned to ensure patient safety from the outset, but also more likely to recognize the importance of dedicating the time and resources to tracking, understanding, and appropriately addressing patient safety events or near-misses. Surveys such as the Agency for Healthcare Research and Quality Community Pharmacy Survey on Patient Safety can help pharmacies assess the current state of their safety culture and identify any areas for improvement.

In addition to a strong culture of safety, open communication with, and ease of access to, prescribers can support community pharmacists in the prevention of errors. 10,11 Interoperability between data systems, notably electronic health records and state-based health information exchanges, facilitates this open communication by ensuring consistency of information and seamless sharing of patient data between the pharmacist and the prescriber. Ease of access to providers enables the pharmacist to efficiently address potential concerns discovered upon clinical review of the patient’s treatment plan.

Finally, fostering relationships between patients and pharmacists can support safe continuity of care by helping patients develop trust in their pharmacists, increasing their likelihood to seek counseling, address concerns regarding their medication therapy, and provide a more comprehensive medical history.

Georgia Galanou Luchen, Pharm. D. Director, Member Relations Section of Community Pharmacy Practitioners and Section of Pharmacy Educators American Society of Health-System Pharmacists Bethesda, MD

Kendall K. Hall, MD, MS Managing Director, IMPAQ Health IMPAQ International Columbia, MD

Kate R. Hough, MA Editor, IMPAQ Health IMPAQ International Columbia, MD

• Compounding. National Community Pharmacists Association. Accessed June 25, 2021. https://ncpa.org/compounding
• Moose J, Branham A. Pharmacists as influencers of patient adherence. Pharmacy Times. August 21, 2014. Accessed June 25, 2021. https://www.pharmacytimes.com/view/pharmacists-as-influencers-of-patient-adherence-
• American Society of Health-System Pharmacists, American Pharmacists Association. Guidance document for the accreditation standard for postgraduate year one (PGY1) community-based pharmacy residency program. Updated March 2021. Accessed June 28, 2021. https://www.ashp.org/-/media/assets/professional-development/residencies/docs/ashp-apha-pgy1-community-based-standard-guidance.ashx
• Goode JV, Owen J, Page A, Gatewood S. Community-based pharmacy practice innovation and the role of the community-based pharmacist practitioner in the United States. Pharmacy (Basel) . 2019;7(3):106. doi:10.3390/pharmacy7030106
• Messerli M, Blozik E, Vriends N, Hersberger KE. Impact of a community pharmacist-led medication review on medicines use in patients on polypharmacy--a prospective randomised controlled trial. BMC Health Serv Res . 2016;16:145. doi:10.1186/s12913-016-1384-8
• Doong KS, Gaccione DM, Brown TA. Community pharmacist involvement in prescription drug monitoring programs. Pharmacy Times . December 13, 2016. Accessed June 25, 2021. https://www.pharmacytimes.com/view/community-pharmacist-involvement-in-prescription-drug-monitoring-programs
• Upton C, Gernant SA, Rickles NM. Prescription drug monitoring programs in community pharmacy: an exploration of pharmacist time requirements and labor cost. J Am Pharm Assoc (2003). 2020;60(6):943-950. doi:10.1016/j.japh.2020.07.002
• Tetuan CE, Guthrie KD, Stoner SC, May JR, Hartwig DM, Liu Y. Impact of community pharmacist-performed post-discharge medication reviews in transitions of care. J Am Pharm Assoc (2003). 2018;58(6):659-666. doi:10.1016/j.japh.2018.06.017
• Strand MA, DiPietro Mager NA, Hall L, Martin SL, Sarpong DF. Pharmacy contributions to improved population health: expanding the public health roundtable. Prev Chronic Dis. 2020;17:E113. Published 2020 Sep 24. doi:10.5888/pcd17.200350
• Botross A, Botross E, Ho C. Communication is key to medication safety. Hospital News. Accessed June 25, 2021. https://hospitalnews.com/communication-is-key-to-medication-safety
• National Healthcareer Association. Effective communication in vital for pharmacy technicians. Pharmacy Times. May 7, 2021. Accessed June 25, 2021. https://www.pharmacytimes.com/view/effective-communication-is-vital-for-pharmacy-technicians

In Conversation With... Georgia Galanou Luchen, Pharm. D.

Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Relations at the American Society of Health-System Pharmacists (ASHP). In this role, she leads initiatives related to community pharmacy practitioners and their impact throughout the care continuum. We spoke with her about different types of community pharmacists and the role they play in ensuring patient safety. 

Kendall Hall: So, Gina, can you just introduce yourself and describe your current role?

Gina Luchen: My name is Gina Galanou Luchen, and I am a pharmacist by training. I completed my undergraduate and Doctor of Pharmacy degrees at the University of Kansas School of Pharmacy. I then completed a postgraduate community-based pharmacy residency, followed by the ASHP [American Society of Health-System Pharmacists] Executive Fellowship in Association Leadership and Management. I am currently serving as the ASHP Director of Member Relations for the Section of Community Pharmacy Practitioners and Section of Pharmacy Educators. A little bit about my organization: the American Society of Health-System Pharmacists (ASHP) represents pharmacists serving as patient care providers both in acute and ambulatory care settings. We have nearly 58,000 members that work in pharmacy across the continuum of care with a goal to improve medication use, enhance patient safety, and advance pharmacy practice. In my role, I focus on community-based practitioners who are practicing within health systems or other community pharmacy settings. I am also highly involved with pharmacy education, supporting our members who educate student pharmacists and pharmacy residents and train the pharmacy workforce.

KH: Let’s talk about the training. Are there differences between how you train for working in an acute care facility versus in a community setting?

GL: That's a great question. When you graduate from a college or school of pharmacy, there are many postgraduate training opportunities. There are first- and second-year residency training programs. First-year pharmacy residencies are broken down into three major categories. One is what we consider the traditional pharmacy practice residency in an acute care setting. Residents usually train in a hospital or health-system environment, providing inpatient and outpatient pharmacy services within that institution. Second are community-based residencies, focusing on training within community pharmacies and ambulatory care clinics. Third are managed care residencies, and that's more specialized and looks at using clinical evidence and economics to optimize population health outcomes and medication benefits. There are also fellowship programs in research, policy, academia, nonprofit, industry, or other specialty practice areas.

KH: Thank you—that's very helpful for some context. To provide some clarity for individuals who may not be as familiar, what does it mean to be a community pharmacy, and what are the various operational types?

GL: When you think about a community pharmacy, most people bring to their mind their neighborhood pharmacy. But in the broad sense, community pharmacy is any healthcare setting that provides medication-related services to a patient within their community. The practice encompasses a large number of services and settings. You have the retail setting that can be found as stand-alone stores, both in smaller or larger chains, within grocery stores, or other retail settings. Then you have hospital or health-system outpatient pharmacies, which may serve patients of that particular institution or serve the larger public. And then you have clinic-based pharmacies that might be part of an ambulatory practice. For example, think of a specialized psychiatry clinic, or a primary care and multi-specialty physicians’ office, or assisted living facilities that may have community pharmacies embedded within them. Then you might have pharmacies that serve individuals who are homebound or provide home infusion therapy. Some pharmacies are designated as specialty pharmacies, and they provide specialized medications that treat complex conditions. There are also mail order pharmacies. And, if a patient requires nontraditional dosage forms or strengths of the medication, there are compounding pharmacies that handle custom compounded medications. In a nutshell, there are many settings in which community pharmacists practice and where community pharmacies can be found, but whenever you think of a patient condition that requires any type of medication therapy or any type of intervention within the community, you will likely find a pharmacy that helps to serve that patient and meet those needs.

KH: Wonderful. Thank you. I don't think we realized just how broad that term is and what it covers. With all of these different settings, what are the common and overarching goals of these community-based pharmacies?

GL: I think the goal of community-based practice is to support patients on an individual level not just in managing their medications, but also in managing their health, and to support public health in general. Outside of the traditional dispensing of medications, pharmacies in the community setting offer a variety of other services like medication counseling or disease state education. They assist patients in managing their entire medication therapy. Most community pharmacies today also provide immunizations, they provide point-of-care testing, and they provide consultations and other services needed within that population. There was a study that looked at accessibility for community pharmacies and found that nearly 90% of Americans live within 5 miles of a pharmacy. 1 This represents the tremendous opportunity that community pharmacists have to impact patient care, and that's why all these services that go beyond medication dispensing are so crucial to patients. When you think about the pharmacy’s responsibility, it's really to protect patients and to ensure that their therapy is optimal, safe, and effective. The pharmacist role within the community, and really across the continuum of care, is to increase medication optimization and safety, and ultimately to practice at the top of their license to help patients be healthier.

KH: Well, I think that's a great transition point to start talking about patient safety. What are some of the common patient safety events that can occur across these different settings? And what are some of the considerations that the pharmacist manages in order to protect the public?

GL: Pharmacists in the community manage safety similarly to how they would in any healthcare environment where patients are treated, and medications are handled. To start with, every pharmacist ensures that the services they provide encompass what we refer to as the “Five Rights,” and those are that the right drug makes it to the right patient, at the right dose, in the right route, and at the right time. Although these Five Rights are fundamental in establishing medication handling and dispensing, it's not always simple to ensure because, as we mentioned earlier, community-based pharmacists are part of a larger care continuum, and they provide services that are well beyond the dispensing process. So, when we're thinking about the safety considerations for a community pharmacy, we have to look at every single step, from the medication order to dispensing, the patient’s receipt of the medication, and the patient’s home.

The Institute for Safe Medication Practices (ISMP) released a report 2 about the key elements of a medication review system for community pharmacies, and they described a number of different elements within that process. But in summary, it starts with the procurement of the medication, so that's purchasing the medication, which includes navigating through drug shortages, verifying that the medication comes from reputable sources, accounting for the shelf life and the storage of the medication, and even keeping a quantity on hand of key medications that are needed in the community for immediate access. That’s all what we call part of the medication supply chain safety and integrity, and those are things that community pharmacists look at on a daily basis.

You then have the therapeutic considerations of safety—that is, ensuring that the medication prescribed is intended to treat or manage the patient’s disease appropriately. This can take into account pharmacists screening for medication duplications, omissions, allergy screenings that could interfere with the prescribed therapy, a new diagnosis that may have been added and needs to be accounted for, ensuring that the dose is appropriate, looking at drug interaction, etc. So there’s a whole therapeutic profile review that occurs in every medication that's dispensed in the community, and it requires a full understanding of the patient's medication profile and their health status. Sometimes verification requires picking up the phone and calling the prescriber or patient.

Then you move into the dispensing process. We mentioned those Five Rights, verifying that the interpretation of the prescription you're getting is appropriately entered and accurately dispensed and that you're filling the correct medication. Other factors would be operational workflow, staffing, technology, and the environment.

Two more things that people don't necessarily think about within the pharmacist’s realm of what we do to secure patient safety include the patient education component. This is ensuring that the patient understands the treatment provided to them. An example can be a pharmacist who is completing a medication review to ensure that the patient is comfortable with what they're taking, that they understand why they're taking their therapy, or counseling on controlled substance utilization or even opioid storage and safety. Lastly, care transitions. It's important to remember that community pharmacists are part of the overall healthcare team for a patient. Their role is crucial in reinforcing education after discharge, coordinating with the prescriber or multiple specialists, to ensure that everybody is on the same page as far as the medication profile for the patient, and preventing any duplications or omissions. The pharmacist is the last line of defense between the patient and that medication, and it's the last opportunity to protect the health of patients.

KH: Listening to you makes me realize that there's such an opportunity for the pharmacist in these settings to serve as a safety net or a double check to some of the things that go on both in the physician's office and at home. How do you take advantage of that? Is it the education piece with the patients?

GL: The community pharmacy, and pharmacy as a profession in general, has a really strong culture of safety. We realize how important our role is in protecting the public. If you look at the oath of the pharmacist, it starts by saying, “I'll consider the welfare of humanity and relief of suffering as my primary concerns” and then goes on to mention that assuring optimal outcomes for patients is really a top priority. You carry a lot of that responsibility as part of the overall culture of being a pharmacist. But the responsibility is with everyone. It starts with the pharmacy technician who takes the medication at the drop-off, to the pharmacist that provides the review, through to the collaboration between the pharmacist and the nurse or the physician to discuss any questions that may arise. From a culture standpoint, there are protocols in place for continuous evaluation and quality improvement within the pharmacy. Each institution has their own methods for ensuring that the staff is well-trained and comfortable performing their duties, that there's appropriate automation and technology, and the environment is distraction-free. And then, of course, there are tools that community pharmacies use to continue enhancing that safety culture. AHRQ [the Agency for Healthcare Research and Quality] has a community pharmacy survey, Community Pharmacy Survey on Patient Safety Culture , that's intended for pharmacy sites to evaluate their approach to safety. It is a self-critique of sorts and asks, “How can I learn from my staff? How can I learn from my patients?” For improving that safety process, ISMP has a self-assessment for community pharmacies as well, outlining different elements of the medication use system to help improve and prevent errors. Then there are even voluntary accreditations for pharmacies. ASHP has an accreditation standard for community and outpatient pharmacy practices with an entire section dedicated to medication safety, patient safety, and supporting continuous quality improvement. So, I think it's an ongoing process, regardless of your setting, establishing that culture to ensure that anyone who touches any aspect of care regards the patient’s safety as a top priority.

KH: So, what would you say are the biggest challenges to safety in the community pharmacy space?

GL: Every community pharmacy operates a little differently and the patient populations and services they offer also vary, but I think if you're speaking generally about common challenges we see in the community-based setting, I would say time available for conducting patient-related services. Again, ISMP has looked at errors that relate to the time the pharmacist has available to review and dispense the medication. and it's clear that pushing for higher volumes and faster dispensing and introducing multiple interruptions creates a risk. Another big challenge for community-based practitioners is that reimbursement is tied to the dispensing, not the clinical services that are so crucial to the safety. This means that the time the pharmacist spends conducting the therapeutic review, clarifying questions with the provider, and talking to the patient are not covered by reimbursement. This limits the availability that you have as a pharmacist.

Then you have interoperability concerns. Having access to patient information is extremely important for ensuring that community pharmacies are able to appropriately conduct a profile review, screen for allergies, do that therapeutic screening that we discussed earlier. If you're tied to a clinic or hospital, you might have access to the patient's direct chart or patient records, which allows you to do a more comprehensive review. However, unfortunately, that's not the case for most of our community pharmacies, who may have to piece it together and spend the extra time calling the nurse line and trying to get a hold of the physician, which I think brings us to a third challenge, which is access to the providers. This again affects the timing and safety of working with patients. In a clinic or health system, you might have a direct line of communication with providers when issues arise. That becomes more challenging in community settings where a pharmacist has to spend a significant amount of time trying to access the prescriber and there's no standard way to communicate with every provider. But overall, when you think about patient safety, it's important to remember it’s not just about the dispensing, it’s about the service provided, and it's about assessing the overall care and the overall system to ensure that safety is in place. Community pharmacies are great at continuous quality improvement as a gold standard. They keep looking at the issues and they keep evaluating what's going right and what's going wrong, in order to continue improving.

KH: You know, it seems that having continuity is something that I keep hearing in what you're saying in terms of having good communication with providers, with the patients. With transitions of care, could we talk a bit about those pharmacies that are part of health systems and their role in care transitions?

GL: I think every pharmacy has an extremely important role in care transitions. Ultimately, we talked about community pharmacies being the final safety net for that patient before they go home with a medication. But going back to the issues that we mentioned, interoperability is a huge component of being able to perform safe transitions. In an ideal world, what we would like to see is all community pharmacists having access to patient records and being able to review medication profiles, have access to providers, and document their interventions. Think about care as a feedback loop versus silos of care. Community pharmacies have a tremendous role to play because they often have the most touch points with the patient. At times they see patients on a weekly basis. So that's an opportunity for education, an opportunity for further clarification, an opportunity to look at the patient and evaluate, how's your adherence? Are you comfortable with your therapy? Can you afford your medication? These are all factors that play into patient safety. We could do everything right and then that patient goes home and doesn’t understand their therapy and doesn’t adhere to the therapy and then we're back to non-optimized use, not because anything went wrong with the diagnosis or anything went wrong with the actual care of the patient, but because they just didn't understand how to appropriately utilize their treatment. So, care transitions are critical in ensuring patient safety, and community pharmacies are really important in helping establish those relationships with providers and with patients and avoiding those mistakes.

KH: Are there any tools available for pharmacies that are not part of the system where the patient usually gets care? Or is it a reliance on the use of interoperable computer systems?

GL: There are definitely ways to ensure patient safety, no matter if you're part of an integrated system or a part of a stand-alone pharmacy. For a pharmacy provider who works in a community setting that may not have access to the electronic health record, or may not have direct access to the provider, there's still the responsibility of taking care of the patient. Professional education in these instances is so important, ensuring that you're up to speed with the latest treatment guidelines and understanding the appropriateness of therapy from your clinical expertise. The pharmacy team has the responsibility to serve as a patient advocate and communicate on behalf of the patient. The team also participates in quality reviews, looking at where errors happened, and collecting data that can be presented both to their institution, but also to collaborative organizations or collaborative practitioners and say, “Hey, we're seeing that these are the errors that are occurring, how can we work together to improve them? How can we collaborate better?” Most errors are related to system gaps, not individual providers, so constant reassessment of the processes is key.

Engaging patients in their own care is really important because ultimately, the patient can give you more information than anybody else. Maybe they can connect you directly to their provider, or maybe they can provide you more information about where the confusion arises. From the patient’s standpoint, they, or their caregivers, need to ensure they are actively involved in their own care and advocate for their own needs. Ensure that they understand why a medication change was made to their treatment. Sometimes patients are afraid to ask, but it's really important to talk with their pharmacist, talk with their provider, and understand why changes are being made so an error can be prevented, and medication use can be optimized. It also allows the development of trusting relationships with providers. We often hear the term “pharmacy hopping.” But it is important to establish long-term relationships with one pharmacist, one primary provider, and consistent specialists. This brings continuity to your care and goes a long way in preventing errors.  

KH: Are there formal mechanisms by which pharmacists and clinicians whose patients are coming to them can communicate about patterns or trends?

GL: It goes back to the ongoing patient safety monitoring and the error reports that pharmacists review. A really strong, ongoing safety program is documenting errors or near-misses. There are many different documentation forms out there- one is called Assess-ERR™, and it guides you through how to document the error or near-miss to understand what type of error was it? What kind of medication did it involve? What were the circumstances around it? So, when the pharmacist or administrator reviews these documents, they can look at trends and determine if something is a one-off mistake or a pattern.  Sometimes there could be a systems issue that requires staff education or updating a policy or process. Or it could be we're seeing a recurring misunderstanding from a provider warranting a call or clarification. So that's why that continuous quality improvement process is so important, because it looks at errors not only in an isolated incident, but trends over time, and identifies internal and external opportunities in a more formalized way.

KH: How is that feedback provided? Is it provided directly to those involved? Is it provided back to the safety group at the hospital? How do you to make sure that you get the information to the right people?

GL: It depends on the circumstances. If it's a prescribing or dispensing trend like we talked about earlier, then that would be a communication with the specific provider’s office or mak[ing] an internal change to the system or process. But if it is a transitions-of-care concern that you find, such as a medication missed at discharge, the pharmacist would call the discharge facility to confirm whether there was, in fact, an error or if it was intentional, and then make the changes with the provider. So, it's all on a case-by-case basis, depending on what type of error you're seeing. Overall, the complete medication review is that key component that happens before the patient goes home to ensure that all medications are correct.

KH: Is there anything that you think we should cover that we've missed or anything additional around patient safety in this setting?

GL: I think talking about some of the changes that are on the horizon that are helpful in planning for patient safety would be good to cover. From an operational standpoint, there's an effort to provide broader access to key providers and ensure that community pharmacists everywhere have access to the health information data that they need. CMS [the Centers for Medicare & Medicaid Services] is working to build out a roadmap for electronic exchange of data and e-prescribing to avoid errors and help with more communication and integration. There are also groups like the Pharmacy HIT [Health Information Technology] Collaborative that advocate for integrated networks of care. And then similarly, CPESN [Community Pharmacy Enhanced Services Network] is working to encourage community pharmacies’ involvement in providing enhanced patient care services. So, from an interoperability standpoint, there's a lot of action because we realize it's so important to communicate with one another. We're also seeing consistent use of technology to avoid errors, like barcode scanning and clinical decision support tools. These [technologies] catch errors that maybe the provider might not. We're also seeing innovative partnerships between settings to promote safety. For example, we're seeing partnerships between health systems and community-based pharmacies, creating collaborations for care transitions. Lastly, we mentioned some barriers with the time available for dispensing and clinical services, such as patient education. There is a push for regulatory change right now in recognizing pharmacists as providers and reimbursement for both dispensing and for other clinical responsibilities, such as counseling. The important thing to recognize is that community pharmacists do so much more than dispense medication.

1. National Association of Chain Drug Stores Foundation. Face-to-face with community pharmacies. Accessed July 12, 2021. https://www.nacds.org/pdfs/about/rximpact-leavebehind.pdf

2. Institute for Safe Medication Practices. Improving medication safety in community pharmacy: Assessing risk and opportunities for change. 2009. Accessed July 12, 2021. https://www.ismp.org/sites/default/files/attachments/2018-02/ISMP_AROC_whole_document.pdf

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

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2018 John M. Eisenberg Patient Safety and Quality Awards. July 17, 2019

Measuring shared mental models in healthcare. November 7, 2018

Contributions from Ergonomics and Human Factors. November 17, 2010

Patient Safety Papers. November 22, 2006

Medical errors in dentistry. November 4, 2015

Leading High-Reliability Organizations in Healthcare. May 4, 2016

Rethinking hospital restraints. September 3, 2014

Freedom to Speak Up: A Review of Whistleblowing in the NHS. May 27, 2015

The fading art of the physical exam. September 29, 2010

US drug shortages threatening those whose lives depend on crucial remedies. May 18, 2011

Silencing many hospital alarms leads to better health care. February 5, 2014

Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. February 20, 2013

The best medicine for fixing the modern hospital. December 12, 2012

ISMP Targeted Medication Safety Best Practices for Community Pharmacy. April 19, 2023

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. February 22, 2023

ASHP Guidelines on Preventing Diversion of Controlled Substances. December 14, 2022

Concerns regarding tablet splitting: a systematic review. December 7, 2022

Medication adverse events in the ambulatory setting: a mixed-methods analysis. October 26, 2022

Community Pharmacy Survey on Patient Safety Culture. October 24, 2022

Disrespectful behavior in your workplace. April 13, 2022

Pharmacy Education and Practice. January 26, 2022

Medication safety issues with newly authorized PAXLOVID. January 12, 2022

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines. October 20, 2021

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. October 26, 2021 - October 26, 2021

Medicine self-administration errors in the older adult population: a systematic review. June 9, 2021

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study. May 5, 2021

Drug shortages amid the COVID-19 pandemic. February 24, 2021

Pharmacist counseling when dispensing naloxone by standing order: a secret shopper study of 4 chain pharmacies. December 9, 2020

Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. November 4, 2020

Fighting against COVID-19: innovative strategies for clinical pharmacists. May 6, 2020

Pharmacist linkage in care transitions: from academic medical center to community. October 30, 2019

Special Issue on Prescription Drug Misuse. September 25, 2019

Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study. September 4, 2019

Ten ways to improve medication safety in community pharmacies. August 7, 2019

Impact of medication reviews delivered by community pharmacist to elderly patients on polypharmacy: a meta-analysis of randomized controlled trials. June 26, 2019

Effect of a central call center on employee perceptions of safety culture within community pharmacies in an academic health system. June 5, 2019

Patient Safety. May 22, 2019

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The role of community pharmacy in addressing health inequalities

Abstract: health inequalities are unfair, avoidable differences in health and access to healthcare between population groups. this article explains the link between social factors and health, the wider context of health inequalities in the uk, as well as exploring the role that community pharmacy can play in addressing health inequalities, with examples of work that is already underway., key words: health inequalities; equality; life expectancy; social determinants of health; community pharmacy, introduction.

Health inequalities are defined as “unfair and avoidable differences” in health and access to healthcare across communities and geographical areas, or specific population groups (e.g. sex workers, vulnerable migrants and people without homes) ​[1,2]​ .  

People may experience health inequalities in a wide range of areas, including:

• Access to care (e.g. the availability of a specific health service or healthcare personnel);
• Experience and quality of care (e.g. being treated with dignity);
• Wider determinants of health (e.g. access to green spaces, good education, income);
• Life expectancy (e.g. differences in life expectancy for people in different geographical areas).

In his 2010 report, Sir Michael Marmot highlighted that reducing health inequalities “is a matter of fairness and social justice” because they are avoidable and do not occur by chance ​[2]​ . These are systemic differences that are largely beyond an individual’s control. 

In the decade following Marmot’s report, life expectancy across the UK has stagnated (see Figure ). Marmot’s 2020 review — ’10 years on’ — highlighted that life expectancy had fallen in the most deprived communities outside London for women and in some regions (the North East, Yorkshire and the Humber and the East of England) for men . These data show that health outcomes for those living in the northern parts of England were significantly worse than for those in the south of England. People living in the north of England showed an increased number of years in ill health, compared with those living in the south of England, and this is more prominent in those who live in poorer areas ​[3]​ .

Health inequalities do not just affect people from an ethnic minority background or those on low incomes; they are underpinned by a combination and interplay of social and economic conditions, which is known as intersectionality. 

For example, education, work environment, housing, water, sanitation and individual lifestyle factors — such as smoking, being physically active and employment — all affect a person’s health outcomes. These are called the ‘social determinants of health’. The Marmot Review states that action on health inequalities requires action across all the social determinants of health ​[2,4]​ . As a result, having good, secure employment with a living wage and support for healthy living initiatives, such as access to outdoor spaces, clean air and acceptable living standards, could all reduce health inequalities.

Importance of addressing health inequalities

The impact of health inequalities is profound and permeates all aspects of society. Inequalities are a matter of life and death, health and sickness, or wellbeing and misery ​[2]​ . Populations in poorer areas tend to experience lower wages and job instability, but they also have higher stress levels, more mental health challenges and poorer physical health[2]. This demographic is more likely to live with multiple chronic illnesses and mental health disorders and may have overall shorter lives ​[2,5]​ . In 2020–2021, the life expectancy gap between the most and least deprived quintiles of England was 8.6 years ​[6]​ . The figure below shows UK life expectancy at birth for males and females between 1980–1982 and 2020–2022 ​[7]​ . The male–female difference in life expectancy is greater in more deprived areas ​[6]​ .

These issues present challenges to individuals in maintaining stable employment and achieving good educational outcomes, resulting in increased demand placed on healthcare systems. Therefore, everyone in society is affected by health inequalities because everyone is affected by these factors. It is imperative, therefore, to put efforts into reducing inequalities ​[2,8]​ . Less time in ill health means more economic productivity, less pressure on health systems owing to chronic ill health, and improved social lives.

Addressing health inequalities is also important because it is a matter of social justice and fairness. Moreover, the NHS urges healthcare professionals to embody NHS values by ensuring that high-quality healthcare is available and accessible to all (see Box) ​[9]​ .

Box: The NHS’s values

• Working together for patients: patients come first in everything we do;
• Respect and dignity: we value every person — whether patient, family member, carer, or staff — as an individual, respect their aspirations and commitments in life, and seek to understand their priorities, needs, abilities and limits;
• Commitment to quality of care: we earn the trust placed in us by insisting on quality and striving to get the basics of quality of care — safety, effectiveness and patient experience — right every time;
• Compassion: we ensure that compassion is central to the care we provide and respond with humanity and kindness to each person’s pain, distress, anxiety or need;
• Improving lives: we strive to improve health and wellbeing and people’s experiences of the NHS;
• Everyone counts: we maximise our resources for the benefit of the whole community, and make sure nobody is excluded, discriminated against or left behind.

In 2013, the UCL Institute of Health Equity published a report on the role of healthcare professionals in reducing health inequalities, including workforce training, practical actions to be taken during interactions with patients, ways of working in partnership and the role of advocacy ​[10]​ . Although there was no representation of pharmacy in that report, pharmacy has always been a core stakeholder in healthcare provision and access, with evolving roles in clinical provision and patient care.

The COVID-19 pandemic highlighted many existing health disparities between population groups. People who were already disadvantaged suffered worse health outcomes and higher mortality ​[11]​ .

Healthcare workers, including pharmacists, stepped up during the COVID-19 pandemic and recovery ​[12,13]​ . As an integral component of local communities, pharmacies remained open to the public when other healthcare providers had restricted their access. Pharmacists consistently provided ongoing support to patients and played a major role in administering flu and COVID-19 vaccinations ​[13]​ . The impact that healthcare providers, including pharmacists, had on public health and efforts to reduce inequalities in health have been published across the four nations of the UK ​[14,15]​ .

Addressing health inequalities is complex and challenging. It requires policy change, government funding for the right interventions, and integrated working between local authority, health services, voluntary sectors and grassroot communities. These are not easy issues, especially in the current economic climate following a period of high inflation, higher interest rates, stretched budgets and overall economic uncertainty. When considered alongside the increasing cost of medicines and overall cost of running a pharmacy amid high patient demand, the challenges are considerable ​[16,17]​ . 

Community pharmacies across the UK play a crucial role in enabling fair access to healthcare because pharmacies are predominantly situated in the heart of local communities. This positioning enables community pharmacy teams to build trust and respect, foster good relationships, gather information about local needs and priorities, and provide information to benefit patients and members of the public. 

Core20Plus5 framework

NHS England has developed the CORE20Plus5 framework for tackling health inequalities experienced by adults ​[18]​ . It has also been adapted to apply to children and young people at a national and system level. The approach focuses on the most deprived 20% of the national population, plus five primary clinical areas for accelerated improvement:

• Maternity ;
• Severe mental illness ;
• Chronic respiratory disease ;
• Early cancer diagnosis ;
• Hypertension case finding. 

It also acknowledges that smoking cessation positively affects all five clinical areas. 

Community pharmacies should use the Core20plus5 framework to establish closer working relationships and collaborations within integrated care systems (ICSs) to identify their ‘Plus’ populations. The ‘Plus’ represents population groups who experience poorer than average health access, who may not be captured in the Core20 alone and would benefit from a tailored healthcare approach. 

For example, community pharmacies, in collaboration with their ICSs, could provide pharmaceutical services or enhanced services that are locally negotiated with the local pharmaceutical committees and local authorities. Such services may be tailored to the needs of the population, with a view to achieving equitable outcomes for the most disadvantaged, deprived or excluded groups. Examples of local enhanced services may include translation services for medication and health advice, learning disabilities medication review, smoking cessation and substance misuse. 

Importance of integrated working

ICSs were established across England in 2022. The aim is for these partnerships to plan and work together with a focus on delivering joined-up health and care services. They are aimed at improving population health and reducing inequalities in outcomes, experience and access to healthcare ​[19]​ . Community pharmacy teams within these ICSs play a significant role in disease prevention, monitoring, and providing advice and health coaching to their local communities.

Within weeks of the inception of ICSs, a new vision for integrating primary care was set out in the ‘Fuller stocktake report’ ​[20]​ . The report called for more proactive, personalised care with support from a multidisciplinary team of professionals, also known as ‘integrated neighbourhood teams’, which will evolve from primary care networks (PCNs). According to the report, the PCNs that were most effective in improving population health and tackling health inequalities were those that worked in partnership with their communities and local authority colleagues ​[20]​ . These structural changes have made it increasingly necessary for community pharmacy teams to work collaboratively with local partners to improve the health and wellbeing of their patients, achieve population health goals and reduce inequalities. 

Pharmacists are increasingly working in an integrated way as part of the multidisciplinary healthcare team. Community pharmacists who work closely with general practice teams have reported better working relationships, which result in improved patient outcomes ​[21]​ . The contribution of community pharmacists across the UK and globally to public health and the reduction of health inequalities has been previously reported ​[15,22]​ . 

Strategic directions for community pharmacy have been set in Scotland, Wales, Northern Ireland and England ​[4,23–27]​ . These strategic plans encourage pharmacy professionals to engage patients in shared decision-making , have person-centred conversations , improve access to care and help prevent ill-health through health improvement services, such as immunisations, smoking cessation, hypertension case finding and weight management. They can be used as a base to guide pharmacy teams on practical ways to address health inequalities through community pharmacies ​[8,21,23–28]​ . However, to successfully reduce health inequalities, community pharmacy teams must work collaboratively with other teams across geographical areas and neighbourhoods ​[20]​ . 

Across the four nations of the UK, there are many examples of the contributions that community pharmacies have made to addressing health inequalities and ambitions to integrate into health and social care teams, a selection of which are summarised below. 

Northern Ireland

Since the launch of the service in July 2022, community pharmacists across Northern Ireland provided almost 22,000 emergency hormonal contraception (EHC) by November 2023 ​[28]​ . Funding was also secured to enable the roll-out of a regional Pharmacy First Service for the management of uncomplicated UTI in women aged 16–64 years from November 2023 until the end of March 2024 ​[29]​ . In addition, the Pharmacy First Service was launched in Northern Ireland for winter conditions and EHC in March 2022 ​[4]​ . These schemes are good examples of how community pharmacies are supporting improved access to primary care.

Mental and social wellbeing is a strategic priority in Wales and Public Health Wales has committed to working with health and social care professionals to reduce inequalities in mental and social well-being ​[25]​ . The report by the Welsh Health and Social Care Committee stated that “connection” is imperative in tackling health inequalities. By connecting people with services and their communities, positive environments that support and nurture positive mental health can be co-produced by people with lived experience and the wider health and social care workforce. 

The paper suggested that community pharmacists could play a greater role in supporting people experiencing low-level mental health issues ​[25,26]​ . This can be facilitated by community pharmacy services, such as the discharge medicines service and new medicine service (NMS).

The NMS is already available in England for certain patient groups and conditions and is currently being piloted to include prescriptions for antidepressants ​[30]​ . If the pilot in England is successful, the service could potentially be implemented in Wales for people starting antidepressants while providing them with emotional and psychological support through community pharmacy teams ​[24,30]​ .

Additionally, in a response to the Health and Social Care Committee, Community Pharmacy Wales outlined an aspiration to tackle health inequalities through smoking cessation and weight management services that would enable pharmacies to engage in the National Exercise Referral Scheme ​[24]​ .

In Scotland, community pharmacies have been most effective in reducing health inequalities by developing and negotiating free national pharmacy services for all community patients. These services include NHS Pharmacy First and NHS Pharmacy First Plus, which improve access to healthcare advice and the treatment of common conditions, including medicines that would previously require a GP prescription ​[31]​ .

Personal characteristics can predispose groups of people to being treated differently, which can exacerbate health inequalities ​[32]​ . For example, women who are unable to access timely contraception may suffer unintended consequences, such as unwanted pregnancies, which could adversely affect maternal and child health ​[33]​ . In 2021, to address this inequality, community pharmacies in Scotland began offering a walk-in service for long-term contraceptive supply to women who struggled to gain timely access to sexual health services or their GP. This resulted in participants reporting greater awareness of contraception and contraceptive services ​[14]​ . 

Drug-related deaths have increased significantly in Scotland and Community Pharmacy Scotland has prioritised this as an area for tackling health inequalities ​[31]​ . Currently, almost all community pharmacy teams in Scotland deliver support for people who use drugs and those in treatment for drug use, on behalf of the NHS; however, there is unwanted variation in the level of service provision and further support is required from the health boards to enable community pharmacy teams to provide a package of care that addresses population health needs and reduces inequalities in healthcare provision ​[31]​ .

In May 2023, the government announced its delivery plan for recovering access to primary care and its commitment to expanding community pharmacy services through a Pharmacy First model and expansion of the blood pressure and contraception services ​[34]​ . Pharmacy First was launched on 31 January 2024 and enables community pharmacies to supply prescription-only medicines for seven common conditions. This, in addition to the expansion of the oral contraception and blood pressure check services, will provide pharmacy teams with the opportunity to prevent ill health, and engage with and improve healthcare access for those who otherwise find it challenging to access healthcare. To support pharmacists with this expanded services list, NHS England has launched training packages, including clinical examination skills and independent prescribing, to equip community pharmacists with the skills to deliver these and future clinical services effectively ​[35]​ .

Improving cooperation

Community pharmacists have called attention to how a lack of interoperability between pharmacy and GP systems acts as a barrier to providing optimal patient care ​[36]​ . However, there are innovations in community pharmacy (e.g. independent prescribing) and the potential for instant digital communication between community pharmacy and other healthcare providers (e.g. patient records). This could be a game-changer because more people are likely to access services within the community pharmacy if systems are better connected ​[27]​ . NHS England is funding improvements to the digital infrastructure between general practice and community pharmacy and, since February 2024, community pharmacy IT systems have been automatically sending details of a community pharmacy consultation to the GP clinical IT system, ready for a GP to check and update the patient’s record. This will remove the need for general practice staff to transcribe information from emails.

Interventions beyond the provision of clinical services

Community pharmacy teams can go beyond the provision of clinical services to improve public awareness of health priorities. They can build on the trust and rapport they have developed locally to participate in community outreach efforts and pursue closer working partnerships with other stakeholders, such as the local authority, PCNs , health and wellbeing workers, and the voluntary, charity and faith networks. 

Often, community pharmacy staff reflect the the diversity of the populations they serve. Staff who have knowledge of the local area and population can help to facilitate engagement in public health campaigns that address the social determinants of health. This may include signposting people to link workers and social prescribers within a given geographic area or integrated neighbourhood team. 

Community pharmacy teams can encourage physical activity, for example, by signposting people to green spaces or leisure or fitness centres. These interventions could support healthy-living discussions during consultations for a range of physical and mental health-related conversations. Other interventions include motivational interviewing, practical weight-management support , or culturally competent advice for healthy eating suited to the local population’s needs.

Behavioural insight is useful for helping community pharmacy teams understand local populations. It concerns how people perceive things, make decisions and behave. Community pharmacy teams alongside local stakeholders can use behavioural insights to create solutions and services that are tailored to local priorities ​[37]​ . Co-creation or co-designing means designing services with the people for whom the service or intervention is meant for. Through outreach, co-design and creation of services, community pharmacy teams will be more likely to successfully engage with communities and people from varying backgrounds to improve health outcomes. 

Inclusive pharmacy practice and culturally competent healthcare 

The ‘Joint national plan for inclusive pharmacy practice in England’ was published in 2021 ​[38]​ . The plan outlines two patient-facing aims for pharmacy professionals:

• To work collaboratively to develop and embed inclusive pharmacy professional practice into everyday care for patients and members of the public; 
• To support the prevention of ill-health and address health inequalities within diverse communities. 

An inclusive pharmacy resource was subsequently developed to help pharmacy teams deliver culturally competent healthcare for communities and people with an ethnic minority background ​[39]​ .

Cultural competence is about being aware of one’s own cultural beliefs and values, and acknowledging that these may be different from other people’s cultural values. Developing cultural competence builds self-awareness and facilitates effective and engaging communication with others. Practical ways to practice inclusive pharmacy include making provisions for alternative languages (e.g. translating labels or instructions) and providing different formats of healthcare advice, such as telephone translation services, to suit local populations. 

Stress on pharmacy professionals

Two reports by Public Health England confirmed that COVID-19 had a disproportionate impact on staff and communities from black, Asian and minority ethnic backgrounds ​[5,40]​ . As pharmacy teams work to address inequalities in health, there is a need for introspection and understanding of the health and social care needs of the pharmacy team itself. A stressful work environment negatively affects the health and wellbeing of staff and their productivity. Low morale, poor productivity and absence from work can prove expensive for employers. Furthermore, results of the Royal Pharmaceutical Society workforce wellbeing survey results pointed to the current pressure that is being faced by community pharmacy team members and the impact on wellbeing ​[41]​ .

The ‘Pharmacy workforce race equality standard report’, published in September 2023, showed that pharmacy team members of black, Asian and minority ethnic origin experience more harassment, discrimination, bullying and abuse, and poorer career progression than white pharmacy team members. It also highlights that pharmacy team members of Black ethnic origin do not feel supported for career progression or promotion, and that Black, Asian and minority ethnic female pharmacy team members report the most personal discrimination at work ​[42]​ .

Fairness and inclusion are essential in tackling health inequalities. Healthcare teams have the opportunity to be more innovative when they are composed of members with diverse backgrounds, and well engaged and supported diverse teams improve patient outcomes ​[38,43]​ . To retain diverse teams, support pharmacy staff by providing compassionate leadership, improving workplace conditions, sharing good practice and committing to inclusive pharmacy practice principles. According to the ‘Joint national plan for inclusive pharmacy practice in England’, “leaders valuing diversity and fairness results in support and inclusion for all patients and staff” ​[38]​ .

Workforce pressures

To tackle health inequalities, community pharmacy teams must have the capability and capacity to do so effectively. The UK has been facing a shortage in the pharmacy workforce for some time. The ‘NHS Long Term Workforce Plan’ for England was announced in June 2023; it calls for change to the status quo and outlines ambitious plans to train, retain and reform the NHS workforce ​[44]​ .

Community pharmacy teams should also engage with these ambitions ​[44]​ . To effectively tackle inequalities in access to healthcare through community pharmacy, the right number of staff with the right training and skill mix are needed to deliver high-quality, safe and successful patient-centred care. 

Population health and data

Data and dashboards are very useful for strategic planning and population health management. Community pharmacy teams can develop expertise in data handling by working with other stakeholders within the ICS and integrated neighbourhood teams. The work of pharmacists reaching out to help their local communities have been documented ​[45]​ .

The ‘NHS community pharmacy hypertension case-finding service’, launched in October 2021, is a good example. Hypertension case-finding is one of the five core clinical priority areas in the Core20plus5 framework. Data about the service are published in the ‘Strategic Health Asset Planning and Evaluation (SHAPE)’ Atlas, which can be used to target users of community pharmacies that are located within the top 20% most-deprived areas, to identify gaps in hypertension case finding or blood pressure optimisation ​[45]​ . This is one way in which community pharmacy teams in England can reduce health inequalities.

Commissioners, local councils and public health professionals can identify local community pharmacies that are registered and actively providing the ‘NHS community pharmacy blood pressure check service’, as well as the number of patients seen monthly and cumulatively since the service launched.

The data enable users to identify the prevalence of hypertension within defined populations and to understand the demographics of the population served by that pharmacy. Community pharmacy teams can work with their local pharmaceutical committee, cardiovascular disease prevention lead or community pharmacy clinical leads to understand the prevalence of hypertension in their neighbourhoods through the ‘SHAPE’ Atlas . 

Fingertips , a collection of national public health profiles data, is a useful resource for pharmacy teams. It allows them to view indicators across a range of health and wellbeing categories, such as child and maternal health, musculoskeletal health and respiratory disease. Support is also available from the local knowledge and intelligence service , which can provide answers to specific questions and information about local public health intelligence across regions. Finally, the Healthcare Inequalities Improvement Dashboard provides strategic indicators relating to healthcare inequalities and covers data relating to the five clinical areas in the Core20Plus5 framework.

Data may not always be available or complete, but this should not hinder efforts to improve the health and wellbeing of local populations. In the meantime, data quality can be improved by making efforts to ensure accurate and comprehensive data entry into patients’ records, such as age, ethnicity, gender and deprivation (via postcode).

Health inequalities are unfair and create avoidable differences in health and access to healthcare. Community pharmacy teams can play an important role in reducing health inequalities and improving access to good quality healthcare in the community through the provision of clinical services.

However, success will require pharmacy teams to avoid silo working, go beyond clinical services provision, and fully integrate with other stakeholders in the provision of health and social care services within integrated neighbourhood teams and ICSs.

Strong professional leadership is required to improve workplace culture and the experience of the pharmacy workforce. Finally, population health data are a useful tool for identifying priority areas for intervention. 

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• Research article
• Open access
• Published: 21 July 2011

Public health in community pharmacy: A systematic review of pharmacist and consumer views

• Claire E Eades 1 ,
• Jill S Ferguson 2 &
• Ronan E O'Carroll 1  

BMC Public Health volume  11 , Article number:  582 ( 2011 ) Cite this article

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The increasing involvement of pharmacists in public health will require changes in the behaviour of both pharmacists and the general public. A great deal of research has shown that attitudes and beliefs are important determinants of behaviour. This review aims to examine the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health in order to inform how best to support and improve this service.

Five electronic databases were searched for articles published in English between 2001 and 2010. Titles and abstracts were screened by one researcher according to the inclusion criteria. Papers were included if they assessed pharmacy staff or consumer attitudes towards pharmaceutical public health. Full papers identified for inclusion were assessed by a second researcher and data were extracted by one researcher.

From the 5628 papers identified, 63 studies in 67 papers were included. Pharmacy staff: Most pharmacists viewed public health services as important and part of their role but secondary to medicine related roles. Pharmacists' confidence in providing public health services was on the whole average to low. Time was consistently identified as a barrier to providing public health services. Lack of an adequate counselling space, lack of demand and expectation of a negative reaction from customers were also reported by some pharmacists as barriers. A need for further training was identified in relation to a number of public health services. Consumers: Most pharmacy users had never been offered public health services by their pharmacist and did not expect to be offered. Consumers viewed pharmacists as appropriate providers of public health advice but had mixed views on the pharmacists' ability to do this. Satisfaction was found to be high in those that had experienced pharmaceutical public health

Conclusions

There has been little change in customer and pharmacist attitudes since reviews conducted nearly 10 years previously. In order to improve the public health services provided in community pharmacy, training must aim to increase pharmacists' confidence in providing these services. Confident, well trained pharmacists should be able to offer public health service more proactively which is likely to have a positive impact on customer attitudes and health.

Peer Review reports

Promotion of healthy lifestyles is one of the five core roles of a pharmacist, as defined by the Royal Pharmaceutical Society of Great Britain, (RPSGB) [ 1 ]. Although pharmacists have always had some involvement in health improvement, the focus on this aspect has greatly increased over recent years [ 2 ]. This changing role was formalised by the introduction of the new pharmacy contract in 2005 in England and Wales and 2006 in Scotland which outlined the public health service pharmacists would be required to provide. These services include provision of advice on healthy living and self care and involvement in health promotion campaigns in Scotland, England and Wales with the additional requirement to provide a smoking cessation and sexual health service in Scotland [ 3 , 4 ].

Community pharmacy holds a number of benefits as a setting for public health activities. With extended opening hours and no appointment needed for advice, community pharmacy can be more accessible than other settings. An estimated 600,000 people visit community pharmacies in Scotland every day and approximately 94% of the Scottish population visit a community pharmacy at least once in a year [ 5 ]. This gives community pharmacies access to a range of individuals in both good and poor health, and to those that may not have contact with any other health professionals. Reviews of evidence assessing public health initiatives in community pharmacy have confirmed the potential of pharmacy in this area and suggest that pharmacists can indeed make a positive contribution to public health [ 6 , 7 ].

Although there is clear potential for pharmacy to contribute in a unique way to public health, changes in the behaviour of both pharmacists and pharmacy customers are likely to be required for the service to be successful. Pharmacists must accept their role in public health and make the necessary changes in behaviour to carry out the service. Similarly, the general public must accept pharmacists as providers of public health services and be willing to seek advice on some health issues from pharmacists rather than other sources.

The factors that affect and predict behaviour have been the subject of a great deal of research. The theory of planned behaviour (TPB) is a model that has been widely used to predict and change behaviour across a range of settings [ 8 ]. The model states that voluntary behaviours are largely predicted by our intentions regarding the behaviour. Intentions are in turn determined by our attitude towards the behaviour (our judgement of whether the behaviour is a good thing to do), subjective norms (our judgement of what important others think of the behaviour), and perceived behavioural control (our expectation of how successful we will be in carrying out the behaviour). A review by Sutton found that on average the TPB predicted between 40 and 50% of the variance in intention and between 19 and 38% of the variance in behaviour [ 9 ]. While theories such as the TPB cannot entirely predict behaviour, these findings demonstrate the important role of beliefs in understanding behaviour.

Therefore, in order to understand and assist the behaviour changes associated with providing a public health service in community pharmacy, it is important to establish the beliefs of the general public and pharmacists regarding this role. Three systematic reviews have previously been carried out in this area. One assessed pharmacist views and another general public views towards various public health services [ 10 , 11 ]. The third reviewed papers on the provision of emergency hormonal contraception (EHC) in pharmacy and included public and pharmacist views [ 12 ]. The review of pharmacists' perceptions of public health covered literature published up to 2001 and found that although pharmacists valued the health improvement role they were more comfortable with medicine related health improvement work [ 10 ]. The review also found that pharmacists had concerns about being intrusive and believed they needed more support to provide public health services. Training was found to positively affect pharmacists' attitudes and behaviours in relation to health promotion [ 10 ].

The review on consumer views covered literature up to 2002 and found that pharmacists were perceived as 'drug experts' rather than experts on health and illness. Although consumers were generally satisfied with health advice given by pharmacists, they primarily used pharmacies for dispensing prescriptions and buying over the counter medication [ 11 ]. The final review summarised literature on the provision of EHC in pharmacy up to the end of 2004. The review reported that the service was largely viewed positively by both pharmacists and service users but that some concerns were raised by consumers regarding privacy [ 12 ].

Since these reviews were conducted, the introduction of the new pharmacy contract has brought about a great deal of change in community pharmacies. In order to continue to improve the public health service provided in community pharmacies, up to date information is needed regarding the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health. Beliefs about the public health role may or may not be similar to those found in the previous review. Establishing current views would allow potential barriers to the public health service to be established and appropriately tackled. The objective of this review is to summarise and evaluate quantitative and qualitative evidence published since the previous reviews were conducted on the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health.

The electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL and Dissertation Abstracts International were searched for articles published in English from February 2001 to February 2010. The following combination of search terms was used with each database: (pharm* or pharmacy staff or community pharmacy or consumer or public or customer) and (attitud* or belie* or perce* or knowledge or view or opinion) and (public health or health improvement or health promotion or self care or self management or smoking cessation or sexual health or prevent* or diet or healthy diet or healthy eating or exercise or physical activity or weight or health education or chlamydia testing or emergency contraception or alcohol or needle exchange or methadone or injecting equipment or drug misuse).

Titles and abstracts were screened against the inclusion criteria outlined in table 1 . Full text papers were retrieved for studies considered relevant and for those with titles and abstracts that contained insufficient information to allow judgement of relevance. The full text papers were assessed against the inclusion criteria by one researcher and those identified as relevant were checked again by a second researcher. Data were extracted from included studies using a data extraction form based on the example provided by the Centre for Reviews and Dissemination [ 13 ]. In order to assess methodological quality, studies were assessed against the checklist outlined by Crombie which is suitable for use with descriptive surveys [ 14 ]. The methodological quality of qualitative studies was assessed against the Critical Appraisal Skills Programme checklist for qualitative studies [ 15 ].

Literature Search

A total of 5628 abstracts were reviewed and 122 full text papers were assessed against the inclusion criteria outlined in Table 1 . A second researcher assessed the 71 papers shortlisted for inclusion and 63 studies published in 67 papers were included for review. Figure 1 shows the flow of studies identified by the searches.

Flow diagram of searches and inclusion assessment of studies .

Description of Included Studies

The characteristics of the studies included in the review are presented in additional file 1 . The majority of studies assessed the views of pharmacists (n = 29), support staff (n = 3) or both (n = 1). Three studies investigated both pharmacist and general public views and the remaining studies assessed the views of the general public or pharmacy customers (n = 27). The most common topics investigated were sexual health services (n = 17), smoking cessation (n = 14), general health promotion/screening (n = 12), and services for drug misusers (n = 10). The majority of studies were carried out in Europe (n = 31) and North America (n = 23). The most commonly employed methodology was surveys (n = 50). Eight studies used structured or semi-structured interviews, two used focus groups and two studies used both focus group and survey methods. Table 2 outlines the country of publication of papers included in the review sorted by topic area. It shows the proportion of UK and non-UK papers published after the introduction of the new pharmacy contract in the UK (2006 to 2010).

Quality of Included Studies

Quality varied across the studies included. The quality of reporting was often poor with 16 studies not reporting any information on the age of participants [ 16 – 35 ], 8 not reporting age or gender [ 36 – 43 ] and 2 not reporting gender [ 44 , 45 ]. Fifteen studies did not report response rates [ 17 , 25 , 29 , 43 , 46 – 56 ] and two only reported the response rates for part of the sample [ 57 , 58 ]. Only three studies followed up a sample of non-responders [ 59 – 61 ]. Response rates where reported were generally average to good with the majority (71%) achieving response rates of 50% and over. The way participants were recruited was not clearly reported in one study [ 50 ] and the results were not adequately explained in another [ 62 ]. In the latter case, the names of themes arising from the analysis of interviews were stated with little explanation of the direction of opinion of pharmacists in relation to these themes. The majority of studies included in the review employed convenience sampling (n = 29), 5 used purposive sampling [ 41 , 56 , 62 – 64 ] and only 13 used random sampling methods [ 16 , 18 , 32 – 38 , 47 , 50 , 58 , 65 – 68 ]. Of the 12 studies included that used qualitative methodologies only one employed respondent validation [ 62 ] or made a statement of how the personal characteristics of the researchers may have influenced analysis [ 69 ]. Methods and analysis were not adequately described in one study [ 43 ], data was not transcribed verbatim in another study [ 70 ] and multiple coding was not used in two further studies [ 41 , 51 ].

• Pharmacy Staff

The attitudes and beliefs of pharmacists and pharmacy staff investigated in the papers included in this review related to four main topics: perceptions of role, competence/confidence, barriers and training.

Perceptions of Role

The majority of participants in a survey in Scotland agreed (63%) or strongly agreed (16%) that public health is important to their practice and a little over half agreed (48%) or strongly agreed (8%) that they were public health practitioners [ 21 ]. A survey in Nigeria also reported that the majority of participants (94%) thought it was acceptable for pharmacists to be involved in health promotion activities [ 71 ]. Pharmacists and support staff taking part in focus groups in Sweden on the whole welcomed their role as a health promoter [ 56 ]. However, it was noted that not all participants felt this way and preferred to develop activities in areas in which they received their basic training. Consistent with this, a study in Moldova found that participants rated public health activities significantly lower in importance than all other aspects of professional practice assessed (e.g. dispensing activities) [ 65 ]. Furthermore, a survey in Scotland offering participants a choice of hypothetical jobs found that participants would rather provide a minor illness service than health promotion advice and would forgo £2798 of income to do this [ 72 ].

Perceptions regarding the pharmacists' role in smoking cessation counselling were generally favourable. Nearly all pharmacists surveyed in Thailand, Finland and the USA agreed that they should play a role in smoking cessation [ 45 , 37 , 16 ]. The majority of participants (83%) in another survey in the USA believed that pharmacists should be more active in assisting with smoking cessation [ 55 ]. However, in a survey in Turkey only 57% of participants thought that pharmacists should warn patients about the harmful effects of smoking [ 50 ]. A study in Canada found that pharmacists rated medicine related aspects (e.g. advising on the use of NRT) of their smoking cessation role as more important than other aspects (e.g. assessing patients' dependence on nicotine) [ 34 ]. Another paper based on the same sample found that participants were significantly more likely to carry out smoking cessation interventions with customers if they scored above the median in ratings of importance of various smoking cessation roles [ 32 ].

Perceptions about the pharmacist's role in sexual health services were generally positive. The majority of pharmacists (98%) surveyed in a study in Scotland agreed that they would be willing to offer free Chlamydia postal testing kits [ 26 ]. In a survey in the USA 55% of pharmacists were interested in providing emergency hormonal contraception (EHC) [ 68 ]. Pharmacists interviewed in a study in the UK [ 69 ] were found to hold largely positive views about providing EHC. However, around one quarter of pharmacists in another study in the USA were opposed to providing EHC largely due to religious and moral beliefs [ 67 ]. Pharmacists in the latter two studies also reported concerns that the service may be overused and lead to increases in unprotected sex and sexually transmitted diseases [ 67 , 69 ]. The benefits of providing this service that were highlighted by pharmacists in these two studies included increasing access to EHC, confidentiality, reducing unwanted pregnancies and improving status of the pharmacy profession [ 67 , 69 ].

Attitudes towards providing services for drug misusers have become more favourable over recent years. Surveys in England and Scotland in 2007 reported that attitudes were significantly more positive since assessed in a similar survey in 1995 [ 38 , 60 ]. Similarly, a study in the USA reported an increase in the number of pharmacists who agreed that sterile needles should be made available through community pharmacy [ 39 ].

Despite a shift in attitudes, views towards providing services for drug misusers are still mixed. Pharmacists taking part in focus groups in Estonia and a survey in the USA highlighted a number of concerns about the effect of selling sterile needles on customers and business [ 58 , 41 ]. Support staff in a survey in Scotland also reported similar concerns [ 30 ]. Only half of support staff (52.6%) in this study thought that their pharmacy should provide services to drug misusers [ 31 ]. The possibility of providing free injecting equipment to drug misusers was met with strong resistance in the study in Estonia. The majority of pharmacists in a survey in Scotland disagreed or neither agreed or disagreed that HIV/hepatitis prevention is an important role for pharmacists [ 73 ].

However pharmacists supplying sterile needles for purchase in the USA and UK reported few problems providing this service and little detrimental effect on customers or their business [ 41 , 42 ]. Pharmacists selling sterile injecting equipment in Vietnam reported that they felt a responsibility to prevent blood borne infection and were willing to provide health education to customers that were drug misusers [ 43 ]. More positive views were also reported in a study in the USA with nearly all pharmacists (98%) reporting that they felt they should play a part in helping prevent the spread of blood borne infections such as HIV and over two thirds supporting the availability of sterile needles for purchase in community pharmacies [ 41 ].

Competence/Confidence

Findings regarding confidence and competence in providing health promotion services were mixed. A survey of pharmacists in Scotland found that around one third of participants did not feel that they were competent in promoting and protecting the populations' health or encouraging behavioural change [ 21 ]. Around two thirds felt they lacked the underpinning knowledge and one third felt they could not apply their knowledge. Pharmacists taking part in a survey in Moldova rated their competence in health promotion activities at between 2.9 and 3.6 (0 = low competence and 5 = high competence) which was lower than competence scores for all other aspects of professional practice [ 65 ]. In contrast, the majority of pharmacists (95%) in a survey in Nigeria felt confident in advising patients on health promotion [ 71 ].

Pharmacists in Australia were reasonably confident in providing a smoking cessation service, with a mean confidence score of 3.7 (1 = not confident and 5 = extremely confident), and did not report confidence as a major barrier to smoking cessation activity [ 19 ]. Nearly all participants (92%) in a study in Canada [ 33 ] agreed that pharmacists can be effective in promoting smoking cessation with most customers. In another study in the USA around two thirds of pharmacists thought that the effectiveness of pharmacist counselling was average or good [ 55 ]. In two of these studies confidence was found to be the greatest predictor of the amount of smoking cessation activity reported and in one perceived effectiveness was also a significant predictor [ 19 , 55 ].

Confidence in advising on the prevention HIV/hepatitis was fairly low in pharmacists in a survey in Scotland [ 73 ]. Around half of pharmacists felt confident in advising customers on prevention of HIV and around a third on Hepatitis B/C. Confidence in advising on safer sex was higher with the majority of pharmacists reporting that they would be able to give advice on this to any customer or a drug misuser (78% and 72% respectively). However, only around one third were confident in advising a gay man on safer sex (35%) [ 73 ]. Support staff in a similar survey in Scotland reported lower confidence for advising on safer sex than pharmacists [ 74 ]. Only half of support staff felt able to give accurate advice to any customer (51%) and one third a drug misuser (34%) or a gay man.

Pharmacists' confidence in achieving positive outcomes in weight management counselling was low in one study. Pharmacists in a study in the USA reported mean confidence (1 = not at all confident and 5 = extremely confident) scores of only 3.0 for achieving weight loss in patients as a result of pharmacist counselling and 2.8 for achieving consumption of a calorie controlled diet in patients [ 18 ]. Mean confidence scores for medicine related aspects of obesity counselling (e.g. minimisation of adverse effects of anti-obesity medication) were higher at between 3.3 and 3.4. Self reported frequency of obesity counselling was found to be positively correlated with confidence in achieving positive outcomes. Confidence in providing brief alcohol screening and interventions was also low with over half of pharmacists in a study in New Zealand feeling neutral or disagreeing that they could appropriately advise patients about drinking [ 61 ].

A number of common barriers to public health practice were highlighted across the different services. These included availability of a private counselling area, time, customer demand/reaction and reimbursement for public health services.

The findings regarding a lack of private counselling area were mixed. This was identified as a main barrier to providing advice on health promotion in focus groups in Sweden and advice on prevention of HIV/hepatitis in pharmacists and support staff in Scotland [ 56 , 73 , 74 ]. Nearly two thirds of pharmacists in a survey in Canada felt that having a designated space in pharmacy was very or somewhat important in facilitating smoking cessation practice and nearly half of participants in a study in Thailand (43%) thought the pharmacy setting was barrier to smoking cessation counselling [ 35 , 45 ]. Pharmacists' perception of having adequate facilities was found to be a significant predictor of frequency of smoking cessation counselling in one study [ 55 ]. Although a predictor of service provision, the majority of pharmacists (71.7%) in this study did not view the pharmacy setting was an important barrier to smoking cessation counselling. Similarly, pharmacists in Nigeria (93.1%) did not think facilities were a barrier to patient interaction in relation to health promotion generally [ 71 ]. Pharmacists interviewed in England also felt they had adequate facilities to provide a Chlamydia testing and treatment service [ 22 ].

Lack of time was identified as a main barrier to providing advice on prevention of HIV/hepatitis by pharmacists and support staff in Scotland and for health promotion activities by the majority (75%) of pharmacists in a study in Malaysia [ 73 – 75 ]. Between 50 and 70% of participants in two studies in the USA and one in Thailand agreed that time was a barrier to providing smoking cessation counselling and over half in one of the USA studies felt that they were not adequately staffed for providing smoking cessation services [ 15 , 55 , 45 ]. Similarly, around 70% of participants in a study in New Zealand thought that being too busy was a barrier to carrying out brief alcohol screening [ 61 ]. Time was reported as a barrier to providing EHC by 67% of pharmacists surveyed in a study in the USA [ 67 ]. However, a study on health promotion in Nigeria and another on Chlamydia testing in England reported that time was not an issue in providing these services [ 71 , 22 ].

Views on patient demand for public health services in community pharmacy and patient reactions to being offered these services were mixed. Around 60% of pharmacists in a survey in Thailand reported that lack of patient demand was a barrier to providing smoking cessation services [ 45 ]. Focus group participants in Sweden also perceived that patients had low expectations of receiving health promotion advice from pharmacists [ 56 ]. Furthermore, over half of pharmacy assistants in a survey in Scotland felt that client embarrassment was a barrier to offering advice on HIV/hepatitis prevention and a similar proportion of pharmacists in a study in New Zealand felt that patients would resent being asked about their alcohol consumption [ 74 , 61 ]. Pharmacists interviewed in the USA reported that they viewed this as a sensitive topic and were hesitant to initiate conversations about smoking as they expected to receive a negative response from customers [ 62 ].

In contrast, the majority of participants in surveys on health promotion and smoking cessation in Nigeria, the USA and Finland did not think that lack of demand was a barrier and thought that patients were motivated to seek health advice from pharmacists, welcomed and valued this advice and were not discouraged from returning to the pharmacy as a result of being offered advice [ 71 , 33 , 55 , 37 ]. Pharmacists in a survey carried out in the USA agreed that customers are becoming more willing to discuss health problems and more accepting of counselling provided by pharmacists, but did not agree as strongly that customers were more accepting of pharmacists managing chronic disease [ 76 ]. Finally, pharmacists involved in offering a Chlamydia testing service reported that client reactions were to being offered the service were mixed but that they were predominantly satisfied as long as discretion was used [ 22 ].

Reimbursement for providing public health services does not seem to be a barrier for most pharmacists. The majority of participants (63.7%) in a study in Malaysia felt neutral or disagreed that a lack of reimbursement was a barrier to their involvement in health promotion and most pharmacists (87.6%) in a survey in Nigeria agreed that it is alright to be involved in health promotion whether there is reimbursement or not [ 75 , 71 ]. Studies in the USA, Thailand, and Canada also reported similar findings in relation to smoking cessation [ 55 , 45 , 33 , 34 ].

A need for training was identified in a number of surveys on different public health services. Over half of pharmacists in a study in Scotland reported that attaining additional pharmaceutical public health knowledge was a priority for their practice now and two thirds thought it would be a priority in the future [ 21 ]. Between one third and one half of pharmacists in three studies felt that lack of training or lack of knowledge and skills was a barrier to their smoking cessation practice [ 15 , 50 , 55 ]. Pharmacists and support staff in Scotland also felt that lack of training was a main difficulty in providing advice on prevention of HIV/hepatitis and over 80% of pharmacists in a study in New Zealand felt it was a barrier to providing alcohol screening and brief interventions [ 73 , 74 , 61 ]. Over 70% of pharmacists in a survey in Scotland reported that they would like further training on drug misuse [ 59 ]. The majority of pharmacists in Nigeria felt that they had good knowledge on health promotion (86.9%) but also agreed that they would be willing to retrain on health promotion (93.2%) [ 71 ].

Pharmacists taking part in a smoking cessation training needs assessment in Canada reported that training would be helpful on all aspects of smoking cessation practice but rated training on behavioural techniques for quitting smoking and motivating patients as most helpful [ 34 ]. Pharmacists in Scotland taking part in a survey on training needs for working with drug misusers most often cited motivational and counselling skills as areas they would like more training on [ 77 ]. No clear area for future training was identified in a survey in Scotland with the majority of pharmacists agreeing (79.3%) that training should focus on generic knowledge and skills but also with the statement that training should focus on priority health issues such as chronic heart disease (77.2%) [ 21 ]. Training for pharmacy technicians on smoking cessation was found to significantly increase knowledge, confidence and perceptions of the effectiveness of smoking cessation counselling in a study in the USA [ 24 ].

The attitudes and beliefs of the general public and pharmacy customers towards pharmaceutical public health investigated in the papers in this review related to four topics: use of community pharmacies, appropriateness of pharmacists' involvement in public health, satisfaction with pharmaceutical public health and perceptions of pharmacists' ability.

Use of community pharmacies

A survey of pharmacy customers in Australia found that the majority had never received advice on diet and exercise (88.2%) or on preventing health problems (65.1%) from a pharmacist [ 47 ]. The majority of smokers (57.8%) in the sample also reported having never received advice on smoking from a pharmacist.

Most pharmacy customers in a survey in Sweden expected to receive information from pharmacists on drugs (80.5%), while only around a third (36%) expected information on general health issues and less than a quarter expected advice on diet (24%), smoking cessation (21%) or disease/illness (20.5%) [ 78 ]. Users of nicotine replacement therapy in a survey in the USA found it most useful and were most likely to discuss medicine related smoking cessation topics (e.g. side effects of smoking cessation medication) with a pharmacist and were least likely and found it least useful to discuss behavioural topics (e.g. how to cope with difficulties encountered) [ 52 ]. A survey of pharmacy customers in Nigeria found that satisfaction was lower for the availability of public health services than other medicine related services [ 20 ].

Appropriateness of pharmacists' involvement in public health

The majority of participants in studies on smoking cessation (83%), health screening and promotion (71% and 74% respectively), EHC (65%), services for drug misusers and Chlamydia testing (75%) thought that pharmacists were appropriate providers of these services [ 17 , 56 , 49 , 64 , 70 ]. Users of nicotine replacement therapy in a study in the USA on average rated the appropriateness of pharmacists taking an active role in smoking cessation as 6.9 out of 10 (1 = not at all appropriate and 10 = extremely appropriate) [ 52 ]. However, less than one quarter (22%) of participants surveyed at a medical centre thought that pharmacists should monitor long term conditions such as asthma [ 59 ].

Satisfaction with pharmaceutical public health

Although it seems that customers often do not expect or receive advice from pharmacists on public health topics, satisfaction in those that have experienced pharmacy public health services is high. A survey in Australia found significantly more positive attitudes in those that had experience of pharmacy health screening or promotion than those that did not [ 57 ]. Attitudes in those with no experience of public health services were also found to be significantly more positive compared to a similar survey carried out around seven years previously.

Nearly all individuals receiving community pharmacy osteoporosis screening and education in two surveys in the USA reported that the information provided increased awareness (98%), that they were satisfied with the interaction (92%) and found the advice valuable or highly valuable [ 79 , 53 ]. The majority of participants receiving self management interventions from community pharmacists for asthma (89%) and diabetes (97.5%) were also satisfied with the care they received from the pharmacist [ 54 , 80 ]. Only 71% and 61% of those receiving the asthma self management interventions were satisfied by the education and counselling provided by physicians and nurses respectively [ 54 ].

Participants in a survey in the USA reported very positive experiences of community pharmacy based smoking cessation services [ 40 ]. Patients' agreement with ten statements about their satisfaction with the service (1 = lowest satisfaction and 10 = highest satisfaction) was high with mean scores between 8.5 and 9.9 for all of the statements. Intravenous drug users taking part in focus groups in Estonia reported that pharmacies were more convenient and easier to access than other needle exchange services, but that they experienced discomfort and embarrassment as a result of perceived negative attitude of the pharmacist and other customers towards them [ 58 ].

Women who received EHC from community pharmacy reported largely positive experiences of this service. The majority of women participating in surveys, interviews and focus groups in the USA, Canada and England reported that they were satisfied with their consultation with the pharmacist [ 81 , 82 , 27 , 48 , 69 ]. Over 80% of women in the survey conducted in the USA and another in Canada were satisfied with the amount of privacy in the pharmacy [ 81 , 27 ]. The flexibility and convenience of the pharmacy setting were viewed as benefits to this setting and were the primary reason for attending pharmacy over than other settings such as family planning clinics [ 63 , 82 , 69 ]. Indeed the majority of women (65%) sampled for a study in Sweden reported that they would prefer to purchase EHC from a pharmacy over visiting a clinic with availability selected as the motive for this choice by most women (64%) [ 66 ].

Despite largely positive views towards the service, concerns were reported by women in some studies. Some participants in focus groups in Europe, interviews in England and interviews in the UK felt that there were issues with privacy in the community pharmacy setting [ 51 , 48 , 63 ]. Significantly more women who obtained EHC from other services (e.g. family planning clinics) in the survey in England reported that they felt comfortable, had adequate privacy, adequate advice, and had discussed future contraception than those attending pharmacy [ 48 ]. Participants in the focus groups in Europe and Sweden also expressed mixed views on their interaction with the pharmacists [ 51 , 25 ]. Some participants perceived that the pharmacist was judgemental towards them in the consultation [ 51 , 25 ].

The majority of women surveyed after taking a postal Chlamydia testing kit from a pharmacy in Amsterdam reported that it was a good method of screening (68%) [ 23 ]. In a similar study in England, the majority of customers taking a Chlamydia testing kit were very satisfied with the service (80%), found the consultation sufficiently private (95%) and were comfortable discussing sexual health with the pharmacist (100%) [ 70 ]. In telephone interviews participants commented on the excellent communication skills of the pharmacist and the short waiting times and anonymity at the pharmacy. However, the interviews also revealed that while customers were satisfied with the confidentiality of the consultation, there were concerns regarding confidentiality at the counter [ 70 ].

Perceptions of pharmacists' ability

Around one third of pharmacy customers in a survey in the UK were unsure if the pharmacist was qualified to issue advice on sexual health issues or had enough experience or knowledge to deal with sexual health related issues [ 44 ]. Approximately three quarters of patients surveyed at a medical centre in the USA were undecided, disagreed or strongly disagreed with the statement that pharmacists are trained to provide smoking cessation services [ 17 ]. Those that reported a greater frequency of discussing medications with their pharmacists were more likely to agree or strongly agree with the statement. In a sample of the general public in the USA, 82% and 94.2% of participants respectively thought that pharmacists and physicians would be a very good or somewhat good source of advice on quitting smoking [ 36 ]. Nicotine replacement therapy users in a survey in the USA rated pharmacists' smoking cessation knowledge as highest in relation to prescription medicines at an average of 8.1 out of a maximum score of 10 and lowest in relation to knowledge of non-drug strategies to help tobacco users to quit at an average of 4.0 [ 52 ].

Patients with type 2 diabetes in a study in the United Arab Emirates showed a significant increase in their perceptions of pharmacists' ability to help them to reduce their blood sugar after receiving a pharmacist led self management intervention [ 46 ]. At baseline 32% of participants agreed or strongly agreed that their pharmacist can help decrease their blood sugar and 92% agreed or strongly agreed with the same statement for their doctor. Over half of participants (56%) agreed or strongly agreed that the pharmacist could help after receiving the intervention. A survey in Sweden found that around three quarters of pharmacy customers thought that pharmacy could influence people's willingness to improve their health [ 78 ].

Pharmacy staff

The majority of pharmacists in the review were positive about providing public health services and felt that this was an important role. This suggests that the changing role of community pharmacy from traditional dispensing activities to greater involvement in health improvement is largely accepted, and the importance of providing these services is understood. However, the review indicates that the public health role is still considered secondary to medicine related roles. Pharmacists viewed public health activities as less important than traditional roles and were less confident in providing these. Less positive views were also held by some pharmacists in relation to certain public health services, particularly services for drug misusers. These findings are consistent with those of the previous systematic reviews on this topic [ 6 , 7 , 12 ].

Reported levels of confidence in providing public health services varied from service to service in the current review, but on the whole were average to low. Confidence in our ability to perform a behaviour (known as self efficacy) has been found to be crucial in predicting whether we engage in the behaviour [ 83 ]. A review found that self efficacy can predict as much as 35% of the variance in behaviour [ 84 ]. This link between confidence and behaviour was supported in the current review with two studies reporting that confidence was the greatest predictor of self reported smoking cessation activity in pharmacists [ 19 , 55 ].

This review and the previous review identified a need for further training for a number of different public health services. Encouragingly, training was found to have a positive effect on pharmacists' attitudes in the previous reviews [ 6 , 7 , 10 ]. Although very few studies in the current review assessed specific areas for future training, the findings of the review do suggest how training may be best targeted. A study on drug misuse and another on smoking cessation indicated that training on motivating patients and behavioural techniques would be most useful [ 77 , 34 ]. Training for health professionals often devotes time to explaining the importance of the health issue in question and what part the professional can play in tackling this. However, the findings of this review suggest that pharmacists understand this and that tackling pharmacists' self efficacy may have a much greater impact on practice. Although self efficacy is an important determinant of behaviour, there is limited evidence on interventions to increase self efficacy [ 85 ]. Therefore, further research is needed to investigate interventions to increase pharmacists' self efficacy for providing public health services.

Although most studies found that a lack of patient demand and negative customer reactions were not a barrier to public health practice, some pharmacists did perceive these to be a problem. Similarly, the previous review found that pharmacists were concerned about being intrusive when offering public health services. These beliefs could be addressed during training by outlining the results of research on customer experiences of pharmaceutical public health.

Time was fairly consistently identified in the current review as a barrier to a number of public health services. Similarly, the previous review reported that dispensing duties were a barrier to public health activities. Findings in the current review were more mixed regarding availability of an adequate counselling space as a barrier to public health practice, which may reflect differences in availability of counselling areas rather than differences in perceptions of their importance. Remuneration for providing public health services was not reported to be a barrier in the current review suggesting that current levels of remuneration are perceived to be adequate.

Only three studies in the current review reported the attitudes of support staff separately from those of pharmacists [ 22 , 56 , 30 ]. Fewer support staff reported that they were confident in providing accurate advice on prevention of HIV and hepatitis [ 22 ] than pharmacists in another similar survey [ 18 ]. Support staff are often the first point of contact for pharmacy customers and can play a vital role in alleviating the time pressures on pharmacists by offering public health services and carrying out initial screening. Research is needed to establish the attitudes of support staff to allow support and training to be appropriately targeted for this group.

Customer attitudes towards pharmaceutical public health were on the whole quite positive. Customers found the pharmacy a convenient setting and felt that pharmacists should provide public health services. Those that had experienced public health services in community pharmacy, such as self management interventions, emergency hormonal contraception and Chlamydia screening, were largely satisfied with their experience of these. However, two studies revealed that most customers did not expect, and had never been offered, public health advice from a pharmacist [ 47 , 78 ]. This suggests that pharmacists' perceptions of low demand for public health services are accurate. However, the expectation of a negative customer reaction to pharmaceutical public health services held by some pharmacists seems to be unfounded. These findings are also consistent with those of the previous systematic reviews in the area [ 6 , 7 , 12 ]. Customers in the previous review valued the pharmacists input in public health services, but perceived pharmacists as drug experts and did not often use pharmacies for general health advice.

Customers' perceptions of pharmacists' ability to provide public health services were mixed in the current review, with some perceiving pharmacists as good sources of advice on health and other not. One study found a significant increase in customers' perceptions of pharmacists' ability after receiving a diabetes self management intervention from pharmacist. Similarly another study reported significantly more positive attitudes in members of the public who had experienced pharmacy health screening or promotion than those that had not.

Issues with privacy were raised in four studies investigating sexual health services in community pharmacy and were also highlighted in the previous review on customer attitudes [ 48 , 51 , 63 , 70 , 11 ]. Although private counselling areas are becoming more common in pharmacy, these studies highlight that there are still issues with privacy, particularly at the pharmacy counter. The nature of the pharmacy setting can make complete privacy difficult to achieve, but future projects involving sensitive topics such as sexual health must make attempts to remedy this issue.

Pharmaceutical public health services are clearly well received by those that experience them and result in high levels of satisfaction. Considering the findings of this review, it seems likely that the more these services are offered and experienced by the general public, the more positive attitudes will become. Successfully changing the public's perception of pharmacist in this way will require pharmacists to be proactive in offering public health services. As discussed, pharmacists may need additional support and training in order to feel confident about doing this.

Limitations of the review

Heterogeneity in the included studies reduced the ability of the review to summarise trends and may have accounted for some of the inconsistencies in findings. Studies were conducted in a variety of countries across the world with differing health care systems and it is not known how these different cultures and systems may affect customer and pharmacy staff attitudes. A number of factors increased the risk of bias within the included studies. Response rates were generally average, with the majority of studies achieving rates of 50% and over. One quarter of studies did not report response rates and only three studies followed up and assessed non-respondents. Convenience sampling was used in the majority of studies included in the review. These factors may mean that the views of those sampled were not representative of the population as a whole and therefore limit the generalisability of the findings.

The consistency of the findings of the current review with the previous reviews is striking. Despite the introduction of public health services to the pharmacy contract in the UK, current attitudes of pharmacists and the public appear to be largely similar to before these changes. Although this is discouraging it is perhaps not surprising considering the magnitude of the changes pharmacists have experienced in their role. Around half of non-UK papers and one third of UK papers in the present review were published prior to the introduction of the new pharmacy contract in the UK (See table 2 ). This fact considered with the possible lag between research being conducted and published may also partly explain why there was little difference found in attitudes between the current and previous systematic reviews.

It is important that the positive attitudes of pharmaceutical public health users and pharmacists found in both reviews are extended and built upon. Appropriate training and support is needed in order increasing pharmacists' confidence in providing public health services. Future research needs to investigate the effectiveness of strategies for increasing pharmacists' confidence and changing their public health practice. If pharmacists can be supported to offer public health services more proactively, it is likely that increased exposure to public health services will have a positive effect of the attitudes and health of the general public.

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Acknowledgements

Funding to undertake this review was provided by Pharmacy Services, NHS Forth Valley and NHS Education for Scotland.

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Claire E Eades & Ronan E O'Carroll

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Authors' contributions

CE conducted the design, screening, data abstraction, data analysis, and drafted the manuscript. JF assisted in the design of the study and helped draft the manuscript. RO assisted in the design of the study, assessing papers for inclusion and drafting the manuscript. All authors read and approved the final manuscript.

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Additional file 1: Characteristics of included studies. Excel table showing characteristics of studies included in the review. (XLS 100 KB)

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Eades, C.E., Ferguson, J.S. & O'Carroll, R.E. Public health in community pharmacy: A systematic review of pharmacist and consumer views. BMC Public Health 11 , 582 (2011). https://doi.org/10.1186/1471-2458-11-582

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• Community Pharmacy Practice and Experience

Community Pharmacy Practice and Experience - Essay Example

• Subject: Sociology
• Type: Essay
• Level: High School
• Pages: 2 (500 words)
• Downloads: 4

Extract of sample "Community Pharmacy Practice and Experience"

The least enjoyable and most boring part of the Internship was the re-counting of tablets or pills, bagging, shelving, and doing the inventory. I kept on thinking that I can do other things that were more important. Now, looking back I realize that I was doing an important task. I was being part of the team. If I didn’t do the work well, the pharmacy would suffer. I also realized that the tasks of making the inventory; and, shelving or returning medicine bottles to its proper shelves were only boring because I was already familiar with the generic and brand names.

The knowledge I learned through the Listing of the Top Medicines distributed in Classes of POP 4-6. As to the re-counting of controlled medications before bagging; I had no difficulty identifying the controlled medications. I now realize that I enjoyed the entire experience basically because I came prepared. Our school prepared me well—class discussions, lectures, and handouts. I will forever be grateful to the school administrators, lecturers, curriculum designers, and staff who were all instrumental in preparing me for the internship.

Perhaps another additional course should be offered -- Pharmacy Set-Up and Management. Exposure through the learning of the basic Pharmacy set-ups will enable the student to devise means and ways to facilitate customer care, dispensing of medicines, and other services that a Pharmacy can offer to its customers. I saw how the Rite Pharmacy rose to the challenge of catering to the needs of its customers. The success of a working Pharmacy is also dependent on how it is run. Varying Management Styles may be studied, compared, and contrasted.

I would rate the experience from 1-10; 10 being the highest---definitely a 10! 

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It’s time for the Legislature to take steps to protect pharmacy care

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All Minnesotans deserve access to trusted, local and accessible health care. Minnesotans average visits to their local pharmacy 18 times a year, but may only see their doctor once a year. As pharmacists, our job is to consult and assist patients with various health concerns through medicinal practices, tests, screenings and advising on patient health. It’s why quality community pharmacy care is so critical.

Supporting the health and wellness of our community members is the top priority, but without legislative action this session, many of the key services we provide could be lost, and patients and public health will pay the price of inaction. 

At the end of this year, the COVID-era Public Readiness and Emergency Preparedness (PREP) Act will expire, and with it will go numerous vaccination and testing services that Minnesotans have come to expect from their local pharmacy. Pharmacists played a significant role in not just vaccinating for COVID-19, but also stepped up with additional testing for influenza, strep, A1C and numerous other everyday ailments. The state needs to act to ensure pharmacists can continue to provide those important services to patients. 

In addition, the Legislature must act to secure stable Medicaid reimbursement for local pharmacies and ensure that patient services are covered by their health insurance. We will be unable to stop the tide of pharmacy closures that have plagued communities and underserved parts of our state. 

Since 2018, Minnesota has lost more than 34% of its independently-owned pharmacies, and almost 20% of franchise pharmacies — more than any other state in the country. These closures have left over two dozen Minnesota cities without a local pharmacy. Without increasing reimbursement rates for low-income Minnesotans utilizing our services, as well as ensuring pharmacies are paid at the same rate for services in comparison to other health care providers, more pharmacies will be forced to close their doors.

What does this mean for Minnesotans? Next year, when your local pharmacy cannot continue to operate under exhaustive financial strain, you and your family may find it more difficult to find localized, accessible health care. Minnesotans are falling victim to “pharmacy deserts” — underserved areas in the state in which, due to pharmacy closings, patients are forced to travel more than 30 minutes away for basic healthcare needs. Pharmacy deserts exacerbate inequitable health outcomes for low-income, rural and BIPOC communities.

In 2020, Minnesota pharmacies were at the forefront of fighting COVID-19, providing fast and effective testing and life-saving vaccinations to patients across the state. We played an essential role in stopping the spread and advocating for preventative measures, all while maintaining our patients’ health in our local community. At a time when office jobs, schools and stores were shut down, pharmacies worked tirelessly to provide our communities with top quality care. Now is the time to demand the Legislature act to protect accessible pharmacy patient care for Minnesotans. It will save lives.

John Hoeschen is a pharmacist and the owner of St. Paul Corner Drug.

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People are having to play "pharmacy bingo" - going from shop to shop to find stocks - as medicine shortages are worsening, experts have said.

Health leaders say some patients are even having to "ration" their drugs, with a new poll suggesting shortages are a "daily occurrence" for many of England's pharmacies.

Treatments for ADHD, diabetes and epilepsy are among those affected this year, according to trade body Community Pharmacy England.

Its survey of more than 6,000 pharmacies and 2,000 staff found shortages are "wreaking havoc" on patients.

Nearly all (97%) of staff said patients were being inconvenienced, while 79% said health was being put at risk.

Some 98% said they were also giving out more "I owe yous" - where they can only fulfil part of the prescription.

Nearly all (99%) pharmacies reported supply problems at least weekly, and 72% said they were having "multiple issues a day".

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Another survey last month, by the Nuffield Trust thinktank, said drug shortages had more than doubled between 2020 and 2023 and that Brexit was likely to "significantly weaken" the UK's ability to deal with the issues.

Shortages have also been a growing problem in Europe and the US in recent years.

However, the UK leaving EU supply chains is said to have added complications such as custom checks at borders and drug makers facing extra regulation.

The falling value of the pound after Brexit has also made it more expensive for the NHS to buy medicines.

Community Pharmacy England boss Janet Morrison said the supply problems were "beyond critical" and had become an "ongoing battle" for pharmacies.

"Patients with a wide range of clinical and therapeutic needs are being affected on a daily basis and this is going far beyond inconvenience, leading to frustration, anxiety and affecting their health," she added.

"For some patients, not having access to the medicines they need could lead to very serious consequences, even leaving them needing to visit A&E."

Ms Morrison said the survey was "yet another stark warning which must not be ignored".

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Read more: Pharmacies closing at a rapid rate - with deprived areas worst affected Seven things pharmacies will be able to treat without GP appointment

William Pett from Healthwatch England called it an "ongoing issue that continues to wreak havoc on patients".

"Healthwatch England hears about how shortages can lead to rationing and desperate instances of 'pharmacy bingo', where patients must travel from pharmacy to pharmacy looking for stock," he said.

Paul Rees, head of the National Pharmacy Association, urged the government "to sort out the UK's fragile medicines supply system, so that pharmacies can do their job and patients can get their lifesaving medicines in time".

A Department of Health and Social Care spokesperson said: "There are around 14,000 licensed medicines and the overwhelming majority are in good supply. Supply issues can arise for a wide range of reasons and are not specific to the UK.

"Our priority is to mitigate risks posed by those issues and to help ensure that patients continue to get the treatments they need. Thankfully most issues can be managed with minimal impact to patients.

"We recognise the vital role pharmacies play in our healthcare system and that's why they are backed by £2.6 billion a year in government funding. Deliberate violence or abuse directed at healthcare staff, is unacceptable and all staff, including pharmacists and their teams, deserve to work in a safe and secure environment."

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• Address: 803 S. Main St. Suite 120 Moscow, ID 83843
• Phone: 208.848.8300
• Toll Free Phone: 866.729.8258
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Monday – Friday** | 7:30 am* – 6:00 pm

Monday – Friday | 7:30 am* – 6:00 pm

*Opens at 9 am on the third and last Wednesday of every month, for continuing education for staff so they can better serve our patients. **The pharmacy closes for lunch from 12:30 pm – 1:00 pm

CHAS Health is a non-profit community health center that provides high quality healthcare services to families and individuals of all ages, regardless of insurance status. Opening its doors in 2013, our Latah clinic primary care team has been meeting the needs of individuals and their families located in Moscow, Pullman, and surrounding areas. Our facility includes a convenient, in-clinic pharmacy to allow for easy prescription pick-up and expert pharmacy staff to answer any of your questions. CHAS Health’s Latah Clinic expanded in 2017 to include Dental. Our experienced and professional dentists and hygienists offer exams, cleanings, extractions, restorative care, wisdom teeth consulting, and more.

Walk-In Clinic Services

Our Latah Community Health clinic offers walk-in hours from 1:00 pm – 5 pm Monday – Friday. Walk-in visits are first-come-first-served and available to both new and established patients. Some of the services we offer for walk-in patients include:

• Sore throat
• Sinus Congestion
• Rashes & Allergies
• Nausea, vomiting, & diarrhea
• Minor injuries: cuts & burns
• Urinary/bladder infections
• Sprains & Strains

Video Visits on the CHAS Health App

Call to schedule with your provider, and  tell your scheduler you want a video visit.

Learn more about using the CHAS Health App for a convenient video visit from the comfort of your home.

Behavioral Health

• Adult Psychiatry
• Medication Management
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• Substance Abuse Treatment
• Specialized Therapies for Children & Adolescents

Our dentists & hygienists offer:

• Root Canals

Our Dietitians offer nutrition counseling that includes individualized nutrition evaluations and interventions, to help patients make positive lifestyle changes and improve their overall health and well-being.

Our pediatricians offer services for children through age 18 including:

• Well Child Exams
• Immunizations
• Sports Physicals

Our pharmacists work side by side with our providers to bring a collaborative approach providing coordinated care for our patients.

Primary Care

CHAS Health employs the best primary care physicians and general practitioners that can help you and your family with all of your medical needs. Our care team care about your overall health and are trained in family medicine.

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We are trained to help you with specialty care, such as:

• Hepatitis C
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Our providers care for a comprehensive range of women’s health services including:

• Annual Gynecological Exams
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• Access to Midwives
• Complete Pregnancy Care

IPC helps pharmacy owners run smooth businesses

Ipc is changing community pharmacies – now and in the future..

Pharmacists who join Independent Pharmacy Cooperative aren’t just members – they are owners who share in the operating profits and direction of the company.

As a leading expert for independent pharmacy owners, IPC is uniquely positioned to serve community pharmacies. The company, founded in 1983, is future-ready – giving independent pharmacy owners the products, tools and knowledge to thrive in a rapidly changing industry.

IPC’s employees are key to the company’s continuing success. IPC has a high employee-retention rate, so employees thoroughly understand the challenges that independent pharmacies face. The employees’ many years of experience in the business provides pharmacists with trusted counsel and expertise when it comes to services, operations and marketing.

“We have such a quality team, and we respect each other and listen to each other,” said Michelle Johnson, executive vice president and chief human resources officer for IPC. “We are a very transparent organization. Many of our employees have been at IPC for many years, and we have a good mix of longevity – that breadth and experience we need – along with new ideas from those who have joined from other companies.”

Independent pharmacy owners rely on IPC both to open a new pharmacy and keep it running smoothly. As a part of a member-owned cooperative, pharmacists run their own business and can trust that the member-owners are guiding their best interests. The company leverages partnerships such as Pharmacy Select– a collaboration between IPC and PPSC, which represents more than 6,000 community pharmacies and brings competitive pricing to members.

Employees at IPC enjoy knowing that they work for an innovative company that is making an impact on the way that pharmacies serve patients.

One such innovation is Telehealth, a growing area for pharmacists and health care providers. IPC offers two options: Digital Health for businesses and iCare+ for consumers.

Digital Health, powered by IPC provides pharmacies a comprehensive integrated solution including Telehealth, Telepharmacy Lite, Home Health Kits and much more. Enrolling in iCare+, patients gain critical access to healthcare. iCare+Telehealth provides access to providers and offers a hybrid platform that also includes home health kits and testing options. iCare+ uniquely provides consumers with transportation, prescription delivery and a prescription savings program ScriptPass. 

IPC is the leading secondary wholesaler for independent pharmacies – and it’s the best way for independent pharmacists to optimize their purchases and keep costs down. IPC serves more than 2,000 cooperative members across the country with low-order minimums for free shipping and no set monthly ordering schedule.

The company – which employs 95 full-time and 105 part-time employees –– offers more than 4,000 prescription products, and its Warehouse Edge program provides a greater savings on brands.

“We are a top workplace because of our culture,” Johnson said. “IPC is very family oriented, and I believe our staff really enjoys working here. We encourage a work-life balance and offer a very robust benefits package including a highly competitive health insurance plan; our agency is always telling me how rich our benefits are compared to other similar companies in the area.”

In addition to generous paid time off, employees receive an employer-matching 401(k) plan that on average has a 7% contribution every year.

During holiday weeks, employees work full-time from home. They also receive eight hours of paid time off each year for volunteering. On-site employees use that time to do team volunteering at organizations such as Second Harvest Food Bank of Southern Wisconsin, the River Food Pantry and Habitat for Humanity of Dane County.

Work and professional development opportunities are a focus at IPC.

Each month, employees receive Bonusly points that they can give to each other to recognize great work. These points can be traded in for IPC merchandise or gift cards.

In addition to offering tuition reimbursement, the company has an emerging leaders group that identifies and develops the next group of leaders.

Johnson, who started at IPC 21 years ago, is proud to be part of an organization that has allowed her to grow.

“I have had a great career here that’s had progression,” she said. “I went from HR manager to CHRO, and in the pharmacy industry you’re constantly learning. I truly have fun every day at work, and I love my coworkers and the executive team. This is a great place to work.”

To learn more about employment opportunities at Independent Pharmacy Cooperative, visit ipcrx.com .