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1.  Patient self-management and pharmacist-led patient self-management in Hong Kong: A focus group study from different healthcare professionals' perspectives 
Background
Patient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong.
Methods
Participants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly.
Results
The majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients.
Conclusions
An effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.
doi:10.1186/1472-6963-11-121
PMCID: PMC3127980  PMID: 21609422
patient self-management; pharmacist-led patient self-management; chronic disease; health policy; Hong Kong
2.  Public perception on the role of community pharmacists in self-medication and self-care in Hong Kong 
Background
The choices for self-medication in Hong Kong are much diversified, including western and Chinese medicines and food supplements. This study was to examine Hong Kong public knowledge, attitudes and behaviours regarding self-medication, self-care and the role of pharmacists in self-care.
Methods
A cross-sectional phone survey was conducted, inviting people aged 18 or older to complete a 37-item questionnaire that was developed based on the Thematic Household surveys in Hong Kong, findings of the health prorfessional focus group discussions on pharmacist-led patient self management and literature. Telephone numbers were randomly selected from residential phone directories. Trained interviewers invited eligible persons to participate using the "last birthday method". Associations of demographic characteristics with knowledge, attitudes and beliefs on self-medication, self-care and role of pharmacists, and spending on over-the-counter (OTC) products were analysed statistically.
Results
A total of 1, 560 phone calls were successfully made and 1, 104 respondents completed the survey which indicated a response rate of 70.8%. 63.1% had adequate knowledge on using OTC products. Those who had no formal education/had attended primary education (OR = 3.19, 95%CI 1.78-5.72; p < 0.001), had attended secondary education (OR = 1.50, 95%CI 1.03-2.19; p = 0.035), and aged ≥60 years (OR = 1.82, 95% CI 1.02-3.26; p = 0.042) were more likely to have inadequate knowledge on self-medication. People with chronic disease also tended to spend more than HKD100 on western (OR = 3.58, 95%CI 1.58-8.09; p = 0.002) and Chinese OTC products (OR = 2.94, 95%CI 1.08-7.95; p = 0.034). 94.6% believed that patients with chronic illnesses should self-manage their diseases. 68% agreed that they would consult a pharmacist before using OTC product but only 45% agreed that pharmacists could play a leading role in self-care. Most common reasons against pharmacist consultation on self-medication and self-care were uncertainty over the role of pharmacists and low acceptance level of pharmacists.
Conclusions
The majority of respondents supported patients with chronic illness to self-manage their diseases but less than half agreed to use a pharmacist-led approach in self-care. The government should consider developing doctors-pharmacists partnership programs in the community, enhancing the role of pharmacists in primary care and providing education to patients to improve their awareness on the role of pharmacists in self-medication and self-care.
doi:10.1186/1472-6904-11-19
PMCID: PMC3252282  PMID: 22118309
3.  Pharmacists’ Recommendations to Improve Care Transitions 
The Annals of pharmacotherapy  2012;46(9):1152-1159.
Background
Increasingly, hospitals are implementing multi-faceted programs to improve medication reconciliation and transitions of care, often involving pharmacists.
Objective
To help delineate the optimal role of pharmacists in this context, this qualitative study assessed pharmacists’ views on their roles in hospital-based medication reconciliation and discharge counseling. We also provide pharmacists’ recommendations for improving care transitions.
Methods
Eleven study pharmacists at two hospitals who participated in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study completed semi-structured one-on-one interviews, which were coded systematically in NVivo. Pharmacists provided their perspectives on admission and discharge medication reconciliation, in-hospital patient counseling, provision of simple medication adherence aids (e.g., pill box, illustrated daily medication schedule), and telephone follow-up.
Results
Pharmacists considered medication reconciliation, though time-consuming, to be their most important role in improving care transitions, particularly through detection of errors in the admission medication history that required correction. They also identified patients with poor understanding of their medications, who required additional counseling. Providing adherence aids was felt to be highly valuable for patients with low health literacy, though less useful for patients with adequate health literacy. Pharmacists noted that having trained administrative staff conduct the initial post-discharge follow-up call to screen for issues and triage which patients needed pharmacist follow-up was helpful and an efficient use of resources. Pharmacists’ recommendations for improving care transitions included clear communication among team members, protected time for discharge counseling, patient and family engagement in discharge counseling, and provision of patient education materials.
Conclusion
Pharmacists are well-positioned to participate in hospital-based medication reconciliation, identify patients with poor medication understanding or adherence, and provide tailored patient counseling to improve transitions of care. Additional studies are needed to confirm these findings in other settings, and to determine the efficacy and cost-effectiveness of different models of pharmacist involvement.
doi:10.1345/aph.1Q641
PMCID: PMC3575733  PMID: 22872752
pharmacist; health literacy; care transitions; medication reconciliation; qualitative research
4.  The future of pharmaceutical care in France: a survey of final-year pharmacy students' opinions 
Background
In the last decades, the provision of pharmaceutical care by community pharmacists has developed in OECD countries. These developments involved significant changes in professional practices and organization of primary care. In France, they have recently been encouraged by a new legal framework and favored by an increasing demand for health care (increase in the number of patients with chronic diseases) and reductions in services being offered (reduction in the number of general practitioners and huge regional disparities).
Objectives: This study aimed to investigate final-year pharmacy students' opinions on 1/expanding the scope of pharmacists' practices and 2/the potential barriers for the implementation of pharmaceutical care. We discussed these in the light of the experiences of pharmacists in Quebec, and other countries in Europe (United Kingdom and the Netherlands).
Methods
All final-year students in pharmaceutical studies, preparing to become community pharmacists, at the University Paris-Descartes in Paris during 2010 (n = 146) were recruited. All of them were interviewed by means of a questionnaire describing nine "professional" practices by pharmacists, arranged in four dimensions: (1) screening and chronic disease management, (2) medication surveillance, (3) pharmacy-prescribed medication and (4) participation in health care networks. Respondents were asked (1) how positively they view the extension of their current practices, using a 5 point Likert scale and (2) their perception of potential professional, technical, organizational and/or financial obstacles to developing these practices.
Results
143 (97.9%) students completed the questionnaire. Most of practices studied received a greater than 80% approval rating, although only a third of respondents were in favor of the sales of over-the-counter (OTC) drugs. The most significant perceived barriers were working time, remuneration and organizational problems, specifically the need to create a physical location for consultations to respect patients' privacy within a pharmacy.
Conclusions
Despite remaining barriers to cross, this study showed that future French pharmacists were keen to develop their role in patient care, beyond the traditional role of dispensing. However, the willingness of doctors and patients to consent should be investigated and also rigorous studies to support or refute the positive impact of pharmaceutical care on the quality of care should be carried out.
doi:10.1186/1472-6904-11-6
PMCID: PMC3115856  PMID: 21612642
5.  Ideal and actual involvement of community pharmacists in health promotion and prevention: a cross-sectional study in Quebec, Canada 
BMC Public Health  2012;12:192.
Background
An increased interest is observed in broadening community pharmacists' role in public health. To date, little information has been gathered in Canada on community pharmacists' perceptions of their role in health promotion and prevention; however, such data are essential to the development of public-health programs in community pharmacy. A cross-sectional study was therefore conducted to explore the perceptions of community pharmacists in urban and semi-urban areas regarding their ideal and actual levels of involvement in providing health-promotion and prevention services and the barriers to such involvement.
Methods
Using a five-step modified Dillman's tailored design method, a questionnaire with 28 multiple-choice or open-ended questions (11 pages plus a cover letter) was mailed to a random sample of 1,250 pharmacists out of 1,887 community pharmacists practicing in Montreal (Quebec, Canada) and surrounding areas. It included questions on pharmacists' ideal level of involvement in providing health-promotion and preventive services; which services were actually offered in their pharmacy, the employees involved, the frequency, and duration of the services; the barriers to the provision of these services in community pharmacy; their opinion regarding the most appropriate health professionals to provide them; and the characteristics of pharmacists, pharmacies and their clientele.
Results
In all, 571 out of 1,234 (46.3%) eligible community pharmacists completed and returned the questionnaire. Most believed they should be very involved in health promotion and prevention, particularly in smoking cessation (84.3%); screening for hypertension (81.8%), diabetes (76.0%) and dyslipidemia (56.9%); and sexual health (61.7% to 89.1%); however, fewer respondents reported actually being very involved in providing such services (5.7% [lifestyle, including smoking cessation], 44.5%, 34.8%, 6.5% and 19.3%, respectively). The main barriers to the provision of these services in current practice were lack of: time (86.1%), coordination with other health care professionals (61.1%), staff or resources (57.2%), financial compensation (50.8%), and clinical tools (45.5%).
Conclusions
Although community pharmacists think they should play a significant role in health promotion and prevention, they recognize a wide gap between their ideal and actual levels of involvement. The efficient integration of primary-care pharmacists and pharmacies into public health cannot be envisioned without addressing important organizational barriers.
doi:10.1186/1471-2458-12-192
PMCID: PMC3342160  PMID: 22420693
Community pharmacists; Cross-sectional study; Health promotion; Prevention; Public health
6.  Enhancing provision of written medicine information in Australia: pharmacist, general practitioner and consumer perceptions of the barriers and facilitators 
Background
Written medicine information can play an important role in educating consumers about their medicines. In Australia, standardised, comprehensive written information known as Consumer Medicine Information (CMI) is available for all prescription medicines. CMI is reportedly under-utilised by general practitioners (GPs) and community pharmacists in consultations, despite consumer desire for medicine information. This study aimed to determine consumers’, GPs’ and community pharmacists’ preferences for CMI provision and identify barriers and facilitators to its use.
Method
Structured questionnaires were developed and administered to a national sample of Australian consumers (phone survey), community pharmacists and GPs (postal surveys) surrounding utilisation of CMI. Descriptive and comparative analyses were conducted.
Results
Half of consumers surveyed wanted to receive CMI for their prescription medicine, with spoken information preferable to written medicine information for many consumers and healthcare professionals. GPs and pharmacists remained a preferred source of medicine information for consumers, although package inserts were appealing to many among all three cohorts. Overall pharmacists were the preferred provider of CMI primarily due to their medicine expertise, accessibility and perceived availability. GPs preferred CMI dissemination through both the GP and pharmacist. Some consumers preferred GPs as the provider of medicines information because of their knowledge of the patients’ medicines and/or medical history, regularity of seeing the patient and good relationship with the patient. Common barriers to CMI provision cited included: time constraints, CMI length and perceptions that patients are not interested in receiving CMI. Facilitators to enhance provision included: strategies to increase consumer awareness, longer consultation times and counseling appointments, and improvements to pharmacy software technology and workflow.
Conclusion
Medicine information is important to consumers, whether as spoken, written or a combination of both. A tailored approach is needed to ascertain individual patient preference for delivery and scope of medicine information desired so that appropriate information is provided. The barriers of time and perceived attitudes of healthcare practitioners present challenges which may be overcome through changes to workplace practices, adoption of identified facilitators, and education about the positive benefits of CMI as a tool to engage and empower patients.
doi:10.1186/1472-6963-14-183
PMCID: PMC4000453  PMID: 24754890
Written medicine information; Patient education; Information-sharing; Barriers; Facilitators; Community pharmacists; General practitioners
7.  The stigma of mental illness in Southern Ghana: attitudes of the urban population and patients’ views 
Purpose
Stigma is a frequent accompaniment of mental illness leading to a number of detrimental consequences. Most research into the stigma connected to mental illness was conducted in the developed world. So far, few data exist on countries in sub-Saharan Africa and no data have been published on population attitudes towards mental illness in Ghana. Even less is known about the stigma actually perceived by the mentally ill persons themselves.
Method
A convenience sample of 403 participants (210 men, mean age 32.4 ± 12.3 years) from urban regions in Accra, Cape Coast and Pantang filled in the Community Attitudes towards the Mentally Ill (CAMI) questionnaire. In addition, 105 patients (75 men, mean age 35.9 ± 11.0 years) of Ghana’s three psychiatric hospitals (Accra Psychiatry Hospital, Ankaful Hospital, Pantang Hospital) answered the Perceived Stigma and Discrimination Scale.
Results
High levels of stigma prevailed in the population as shown by high proportions of assent to items expressing authoritarian and socially restrictive views, coexisting with agreement with more benevolent attitudes. A higher level of education was associated with more positive attitudes on all subscales (Authoritarianism, Social Restrictiveness, Benevolence and Acceptance of Community Based Mental Health Services). The patients reported a high degree of experienced stigma with secrecy concerning the illness as a widespread coping strategy. Perceived stigma was not associated with sex or age.
Discussion
The extent of stigmatising attitudes within the urban population of Southern Ghana is in line with the scant research in other countries in sub-Saharan Africa and mirrored by the experienced stigma reported by the patients. These results have to be seen in the context of the extreme scarcity of resources within the Ghanaian psychiatric system. Anti-stigma efforts should include interventions for mentally ill persons themselves and not exclusively focus on public attitudes.
doi:10.1007/s00127-010-0290-3
PMCID: PMC3192946  PMID: 20872212
Stigma; Mental illness; Ghana; Population attitudes; Patients’ perceptions
8.  Factors influencing pharmacists’ adoption of prescribing: qualitative application of the diffusion of innovations theory 
Background
In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services.
Methods
Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations.
Results
Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges.
Conclusions
Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours.
doi:10.1186/1748-5908-8-109
PMCID: PMC3847669  PMID: 24034176
9.  Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study 
BMJ Open  2012;2(3):e000939.
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
doi:10.1136/bmjopen-2012-000939
PMCID: PMC3358628  PMID: 22586286
10.  A role for pharmacists in community-based post-discharge warfarin management: protocol for the 'the role of community pharmacy in post hospital management of patients initiated on warfarin' study 
Background
Shorter periods of hospitalisation and increasing warfarin use have placed stress on community-based healthcare services to care for patients taking warfarin after hospital discharge, a high-risk period for these patients. A previous randomised controlled trial demonstrated that a post-discharge service of 4 home visits and point-of-care (POC) International Normalised Ratio (INR) testing by a trained pharmacist improved patients' outcomes. The current study aims to modify this previously trialled service model to implement and then evaluate a sustainable program to enable the smooth transition of patients taking warfarin from the hospital to community setting.
Methods/Design
The service will be trialled in 8 sites across 3 Australian states using a prospective, controlled cohort study design. Patients discharged from hospital taking warfarin will receive 2 or 3 home visits by a trained 'home medicines review (HMR)-accredited' pharmacist in their 8 to 10 days after hospital discharge. Visits will involve a HMR, comprehensive warfarin education, and POC INR monitoring in collaboration with patients' general practitioners (GPs) and community pharmacists. Patient outcomes will be compared to those in a control, or 'usual care', group. The primary outcome measure will be the proportion of patients experiencing a major bleeding event in the 90 days after discharge. Secondary outcome measures will include combined major bleeding and thromboembolic events, death, cessation of warfarin therapy, INR control at 8 days post-discharge and unplanned hospital readmissions from any cause. Stakeholder satisfaction will be assessed using structured postal questionnaire mailed to patients, GPs, community pharmacists and accredited pharmacists at the completion of their study involvement.
Discussion
This study design incorporates several aspects of prior interventions that have been demonstrated to improve warfarin management, including POC INR testing, warfarin education and home visits by trained pharmacists. It faces several potential challenges, including the tight timeframe for patient follow-up in the post-discharge period. Its strengths lie in a strong multidisciplinary team and the utilisation of existing healthcare frameworks. It is hoped that this study will provide the evidence to support the national roll-out of the program as a new Australian professional community pharmacy service.
Trial Registration
Australian New Zealand Clinical Trials Registry Number 12608000334303.
doi:10.1186/1472-6963-11-16
PMCID: PMC3040704  PMID: 21261998
11.  Factors affecting pharmacists’ recommendation of complementary medicines – a qualitative pilot study of Australian pharmacists 
Background
Complementary medicines (CMs) are widely used by the Australian public, and pharmacies are major suppliers of these medicines. The integration of CMs into pharmacy practice is well documented, but the behaviours of pharmacists in recommending CMs to customers are less well studied. This study reports on factors that influence whether or not pharmacists in Australia recommend CMs to their customers.
Methods
Data were collected from semi-structured interviews with twelve practicing pharmacists based in Brisbane, Australia. The qualitative data were analysed by thematic analysis.
Results
The primary driver of the recommendation of CMs was a desire to provide a health benefit to the customer. Other important drivers were an awareness of evidence of efficacy, customer feedback and pharmacy protocols to recommend a CM alongside a particular pharmaceutical medication. The primary barrier to the recommendation of CMs was safety concerns around patients on multiple medications or with complex health issues. Also, a lack of knowledge of CMs, a perceived lack of evidence or a lack of time to counsel patients were identified as barriers. There was a desire to see a greater integration of CM into formal pharmacy education. Additionally, the provision of good quality educational materials was seen as important to allow pharmacists to assess levels of evidence for CMs and educate them on their safe and appropriate use.
Conclusions
Pharmacists who frequently recommend CMs identify many potential benefits for patients and see it as an important part of providing a ‘healthcare solution’. To encourage the informed use of CMs in pharmacy there is a need for the development of accessible, quality resources on CMs. In addition, incorporation of CM education into pharmacy curricula would better prepare graduate pharmacists for community practice. Ultimately, such moves would contribute to the safe and effective use of CMs to the benefit of consumers.
doi:10.1186/1472-6882-12-183
PMCID: PMC3511229  PMID: 23051066
Pharmacy and complementary medicine; Pharmacists’ attitude towards complementary medicine; Pharmacy practice; Companion selling; Qualitative study
12.  Attitude and perception of patients and health care practitioners toward oral sustained release dosage forms in Palestine 
Aim
To evaluate the knowledge of health professionals in Palestine regarding the advantages of sustained release dosage forms (SRDFs) over conventional therapy.
Methods
Data were gathered from a questionnaire that was handed out to community pharmacists, physicians and patients. Pharmaceutical industry decision makers were enrolled in this study. Data were analyzed using the SPSS.
Results
Pharmacists (92.9%) and 89.2% of physicians thought that SRDFs improve patient compliance. 81.5% of pharmacists and 77% of physicians were in agreement regarding the capacity of SRDFs to maintain therapeutic activity during night. In this study, 81.5% of pharmacists and 81% of physicians believed that SRDFs provide further advantage with psychiatric patients who forget to take their medications. Pharmacists (63.1%) and only 63.5% of physicians believed that SRDFs yield a time saving for nurses who use SRDFs in hospital. Only 45.3% of physicians and 43.4% of pharmacists thought that SRDFs result in cost saving due to better disease management. Pharmacists (95.2%) and 95.9% of physicians agreed that SRDFs could be the right choice for faith patient’s who must take their medication during the month of Ramadan. Pharmacists (66.7%) and 50.7% of physicians recognize that SRDFs may be unsafe if they are improperly formulated. Bad swallowing was also recognized as inconveniences of SRDFs by 67.9% of pharmacists and 57.3% of physicians. Given the above advantages, 75% of patients showed economical problems regarding the cost of the single course therapy of SRDFs and 100% of interviewed patients were enthusiastic about the advantage of SRDFs during Ramadan.
Conclusion
The advantages of SRDFs are not completely understood by Palestinian health professionals. Pharmaceutical industries should pay more attention to the development and advertising of SRDFs due to the valuable advantages of these dosage forms.
doi:10.1016/j.jsps.2010.07.005
PMCID: PMC3731029  PMID: 23960735
Sustained release dosage forms; Ramadan; Patient compliance
13.  Health problems and help-seeking activities of methadone maintenance clients at Auckland Methadone Service (AMS): potential for community pharmacy service expansion? 
Background
In general the health of methadone clients has been found to be poorer than that of the general population. In New Zealand specialist drug services are not funded to provide primary healthcare services. Many health conditions could potentially be managed by community pharmacists who have frequent contact with this client group. This study sought to explore the health problems suffered by methadone clients, who they sought help from, and the potential for greater involvement of pharmacists.
Methods
Self-completion questionnaire of methadone maintenance clients managed in specialist care in Auckland, New Zealand.
Results
The most common health problem experienced by these clients in the past three months was sweating (70.0%), and more than half of the respondents also reported experiencing headache, fatigue and depression. The least frequently experienced conditions were hay fever (12.9%) and abscesses (12.1%). Respondents indicated that the top three choices from whom they would seek help were GP (56.7%), the client's partner (31.6%) and community pharmacists (27.9%). Barriers to seeking help from pharmacists included issues around cost, perceptions of pharmacist knowledge and skills, privacy and confidentiality.
Conclusion
Methadone clients in this study indicated that they suffered a number of general health problems, and in many cases were likely to seek help from a GP or their own partner, before seeking help from pharmacists. However, for over one quarter of respondents the pharmacist was in the top three from whom they would seek advice. Any barriers towards consulting pharmacists, in the main seem to be resolvable.
doi:10.1186/1477-7517-2-25
PMCID: PMC1334178  PMID: 16283944
14.  Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment. 
BACKGROUND: There have been calls for greater collaboration between general practitioners (GPs) and community pharmacists in primary care. AIM: To explore barriers between the two professions in relation to closer interprofessional working and the extension of prescribing rights to pharmacists. DESIGN OF STUDY: Qualitative study. SETTING: Three locality areas of a health and social services board in Northern Ireland. METHOD: GPs and community pharmacists participated in uniprofessional focus groups; data were analysed using interpretative phenomenology. RESULTS: Twenty-two GPs (distributed over five focus groups) and 31 pharmacists (distributed over six focus groups) participated in the study. The 'shopkeeper' image of community pharmacy emerged as the superordinate theme, with subthemes of access, hierarchy and awareness. The shopkeeper image and conflict between business and health care permeated the GPs' discussions and accounted for their concerns regarding the extension of prescribing rights to community pharmacists and involvement inextended services. Community pharmacists felt such views influenced their position in the hierarchy of healthcare professionals. Although GPs had little problem in accessing pharmacists, they considered that patients experienced difficulties owing to the limited opening hours of pharmacies. Conversely, pharmacists reported great difficulty in accessing GPs, largely owing to the gatekeeper role of receptionists. GPs reported being unaware of the training and activities of community pharmacists and participating pharmacists also felt that GPs had no appreciation of their role in health care. CONCLUSION: A number of important barriers between GPs and community pharmacists have been identified, which must be overcome if interprofessional liaison between the two professions is to be fully realised.
PMCID: PMC1314673  PMID: 14601335
15.  Public health in community pharmacy: A systematic review of pharmacist and consumer views 
BMC Public Health  2011;11:582.
Background
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.
Methods
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.
Results
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.
doi:10.1186/1471-2458-11-582
PMCID: PMC3146877  PMID: 21777456
16.  Older Patient, Physician and Pharmacist Perspectives about Community Pharmacists’ Roles 
Objectives
To investigate older patient, physician and pharmacist perspectives about the pharmacists’ role in pharmacist-patient interactions.
Methods
Design
Eight focus group discussions.
Settings
Senior centers, community pharmacies, primary care physician offices.
Participants
Forty-two patients aged 63 and older, 17 primary care physicians, and 13 community pharmacists.
Measurements
Qualitative analysis of focus group discussions.
Results
Participants in all focus groups indicated that pharmacists are a good resource for basic information about medications. Physicians appreciated pharmacists’ ability to identify drug interactions, yet did not comment on other specific aspects related to patient education and care. Physicians noted that pharmacists often were hindered by time constraints that impede patient counseling. Both patient and pharmacist participants indicated that patients often asked pharmacists to expand upon, reinforce, and explain physician-patient conversations about medications, as well as to evaluate medication appropriateness and physician treatment plans. These groups also noted that patients confided in pharmacists about medication-related problems before contacting physicians. Pharmacists identified several barriers to patient counseling, including lack of knowledge about medication indications and physician treatment plans.
Conclusions
Community-based pharmacists may often be presented with opportunities to address questions that can affect patient medication use. Older patients, physicians and pharmacists all value greater pharmacist participation in patient care. Suboptimal information flow between physicians and pharmacists may hinder pharmacist interactions with patients and detract from patient medication management. Interventions to integrate pharmacists into the patient healthcare team could improve patient medication management.
doi:10.1111/j.2042-7174.2012.00202.x
PMCID: PMC3442941  PMID: 22953767
pharmacist-patient interactions; provider-patient communication; prescription medication; qualitative research methods
17.  Meeting user needs in national healthcare systems: lessons from early adopter community pharmacists using the electronic prescriptions service 
Background
The Electronic Prescription Service release Two (EPS2) is a new national healthcare information and communication technology in England that aims to deliver effective prescription writing, dispensing and reimbursement service to benefit patients. The aim of the study was to explore initial user experiences of Community Pharmacists (CPs) using EPS2.
Methods
We conducted nonparticipant observations and interviews in eight EPS2 early adopter community pharmacies classified as ‘first-of-type’ in midlands and northern regions in England. We interviewed eight pharmacists and two dispensers in addition to 56 hours recorded nonparticipant observations as field notes. Line-by-line coding and thematic analysis was conducted on the interview transcripts and field notes.
Results
CPs faced two types of challenge. The first was to do with missing electronic prescriptions. This was sometimes very disrupting to work practice, but pharmacists considered it a temporary issue resolvable with minor modifications to the system and user familiarity. The second was to do with long term design-specific issues. Pharmacists could only overcome these by using the system in ways not intended by the developers. Some felt that these issues would not exist had ‘real’ users been involved in the initial development. The issues were: 1) printing out electronic prescriptions (tokens) to dispense from for safe dispensing practices and to free up monitors for other uses, 2) logging all dispensing activities with one user’s Smartcard for convenience and use all human resources in the pharmacy, and, 3) problematic interface causing issues with endorsing prescriptions and claiming reimbursements.
Conclusions
We question if these unintended uses and barriers would have occurred had a more rigorous user-centric principles been applied at the earlier stages of design and implementation of EPS. We conclude that, since modification can occur at the evaluation stage, there is still scope for some of these barriers to be corrected to address the needs, and enhance the experiences, of CPs using the service, and make recommendations on how current challenges could be resolved.
doi:10.1186/1472-6947-14-16
PMCID: PMC3984715  PMID: 24612966
User-centric approaches; Healthcare ICT; Usability; User experience; Social informatics in healthcare; Electronic prescription service release two
18.  Pharmacists and harm reduction: A review of current practices and attitudes 
Canadian Pharmacists Journal : CPJ  2012;145(3):124-127.e2.
Background: Injection drug use and other high-risk behaviours are the cause of significant morbidity and mortality and thus have been the focus of many health promotion strategies. Community pharmacists are considered underutilized health providers and are often thought to be more accessible than other health professionals. The purpose of this review is to provide an overview of community pharmacists' practices as well as pharmacists' attitudes and identified barriers toward providing harm reduction services. We will highlight the major harm reduction services being offered through community pharmacies, as well as identify barriers to implementing these services.
Methods: A review of the literature from 1995 to 2011 was conducted using the electronic databases MEDLINE, PubMed and Scopus, encompassing pharmacists' involvement in harm reduction services. Keywords included pharmacist, harm reduction, disease prevention, health promotion, attitudes, competence and barriers. References of included articles were examined to identify further relevant literature.
Results: Pharmacists are primarily involved in providing clean needles to injection drug users, as well as opioid substitution. Pharmacists generally have a positive attitude toward providing health promotion and harm reduction programs and express some interest in increasing their role in this area. Common barriers to expanding harm reduction strategies in community pharmacists' practice include lack of time and training, insufficient remuneration, fear of attracting unruly clientele and inadequate communication between health providers.
Conclusion: As one of the most accessible health care providers, community pharmacists are in an ideal position to provide meaningful services to injection drug users. However, in order to do so, pharmacists require additional support in the form of better health team and system integration, as well as remuneration models.
doi:10.3821/145.3.cpj124
PMCID: PMC3567507  PMID: 23509527
19.  Ask, advise and refer: hypothesis generation to promote a brief tobacco-cessation intervention in community pharmacies 
Objectives
To conduct a preliminary qualitative study identifying key facilitators and barriers for pharmacists' adoption of a brief tobacco-cessation protocol, Ask-Advise-Refer (AAR).
Methods
Ten community pharmacists were interviewed using semi-structured, face-to-face interviews with open-ended questions. Purposive and saturation sampling techniques were applied to identify participants and determine sample size respectively. Interviews were audio-recorded and transcribed. Using thematic analysis, two reviewers independently coded all transcripts to identify prominent themes. Appropriate measures were taken to ensure study rigor and validity.
Key findings
All facilitators and barriers identified were grouped into nine distinct themes. Pharmacists' fear of negative patient reaction was the most prominent barrier to initiating tobacco-cessation discussions with patients. Other themes identified in decreasing order of prevalence were pharmacists perceiving a rationale for initiating tobacco cessation, pharmacy environment, pharmacists' perception of/prior knowledge of patients' willingness to discuss tobacco cessation/to quit, patient initiation of tobacco-cessation or worsening-health discussion, pharmacists' perceptions of AAR characteristics, length of pharmacist–patient relationship/rapport with patients, low expectations of pharmacy patrons and pharmacists' communication ability.
Conclusion
This study highlights the potential fear among pharmacists about negative reactions from patients in response to initiating tobacco cessation. Based on the results of this study it is hypothesized that the following strategies would facilitate adoption of AAR: (1) train pharmacists to initiate cessation discussions; (2) initially target discussions with patients who have a disease or medication adversely affected by tobacco use; (3) encourage patient enquiry about pharmacy cessation services through visual cues; and (4) help pharmacists set up a workflow system compatible with the AAR protocol.
doi:10.1211/ijpp/17.04.0005
PMCID: PMC2801921  PMID: 20161528
community pharmacist; health promotion; pharmaceutical care; public health; smoking cessation; tobacco cessation
20.  Prostate cancer education in the Washington, DC, area. 
Pharmacists are key members of the healthcare team, especially in minority and urban communities. This study was developed to assess pharmacists' ability and willingness to counsel the public on prostate cancer in the community pharmacy setting. A mail survey was sent to all 192 community pharmacies in Washington, DC, and Prince George's County, Maryland. A total of 90 pharmacists responded to the questionnaire, providing a 46.9% response rate. One third of the pharmacists indicated a willingness to participate in a prostate cancer training program. Perceived benefits and perceived barriers were each measured through five questionnaire items using Likert-style statements with responses ranging from "strongly agree" to "strongly disagree." The most significant predictor of perceived benefits of providing prostate cancer information was gender; male pharmacists perceived greater benefits for providing prostate cancer information than female pharmacists. Similarly, black pharmacists perceived greater benefits of providing prostate cancer information to their patients than non-black pharmacists. Also, pharmacists in stores that offered disease state management programs had a significantly lower perceived benefit of providing prostate cancer information. These findings indicate that gender and race may play a role in health promotion in health disparities. There were no significant barriers to providing prostate cancer information. Thus, many pharmacists are willing to participate in health education on prostate cancer.
PMCID: PMC2594186  PMID: 12442999
21.  An overview of Ghana’s mental health system: results from an assessment using the World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) 
Background
This survey provides data on the Mental Health System in Ghana for the year 2011. It supplies essential planning information for the implementation of Ghana’s new Mental Health Act 846 of 2012, a renewal of the Ghana 5 year plan for mental health and it contributes to international knowledge base on mental health. It provides a baseline from which to measure future progress in Ghana and comparison data for use in other countries. In addition to reporting our findings we describe and analyse deficiencies and strengths of the Ghana mental health system.
Methods
We used the World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) to collect, analyse, and report data on the mental health system and services for all districts of the ten regions of Ghana. Data was collected in 2012, based on the year 2011.
Results
In 2011, Ghana was a lower middle income country with a population of approximately 25 million. A mental health policy, plan and legislation were in place. Mental health legislation was outdated and no longer in line with best practice standards. Services were significantly underfunded with only 1.4% of the health expenditure going to mental health, and spending very much skewed towards urban areas. There were 123 mental health outpatient facilities, 3 psychiatric hospitals, 7 community based psychiatric inpatient units, 4 community residential facilities and 1 day treatment centre, which is well below what would be expected for Ghana’s economic status. The majority of patients were treated in outpatient facilities and psychiatric hospitals and most of the inpatient beds were provided by the latter. There were an estimated 2.4 million people with mental health problems of which 67,780 (ie 2.8%) received treatment in 2011. The were 18 psychiatrists, 1,068 Registered Mental Nurses, 19 psychologists, 72 Community Mental Health Officers and 21 social workers working in mental health which is unbalanced with an unbalanced emphasis on nurses compared to what would be expected.
Conclusions
The main strength of the mental health system was the presence of a long established service with staff working across the country in outpatients departments and hospitals. The main weakness was that government spending on mental health was very low and the bulk of services, albeit very sparse, were centred around the capital city leaving much of the rest of the country with almost no provision. Service provision was dominated by nurses with few other professions groups present.
doi:10.1186/1752-4458-8-16
PMCID: PMC4016652  PMID: 24817908
Mental health; Ghana; WHO-AIMS
22.  Improving pharmacy practice through public health programs: experience from Global HIV/AIDS initiative Nigeria project 
SpringerPlus  2013;2:525.
Background
The use of medicines is an essential component of many public health programs (PHPs). Medicines are important not only for their capacity to treat and prevent diseases. The public confidence in healthcare system is inevitably linked to their confidence in the availability of safe and effective medicines and the measures for ensuring their rational use. However, pharmacy services component receives little or no attention in most public health programs in developing countries. This article describes the strategies, lessons learnt, and some accomplishments of Howard University Pharmacists and Continuing Education (HU-PACE) Centre towards improving hospital pharmacy practice through PHP in Nigeria.
Method
In a cross-sectional survey, 60 hospital pharmacies were randomly selected from 184 GHAIN-supported health facilities. The assessment was conducted at baseline and repeated after at least 12 months post-intervention using a study-specific instrument. Interventions included engagement of stakeholders; provision of standards for infrastructural upgrade; development of curricula and modules for training of pharmacy personnel; provision of job aids and tools amongst others. A follow-up hands-on skill enhancement based on identified gaps was conducted. Chi-square was used for inferential statistics. All reported p-values were 2-tailed at 95% confidence interval.
Results
The mean duration of service provision at post-intervention assessment was 24.39 (95% CI, 21.70–27.08) months. About 16.7% of pharmacies reported been trained in HIV care at pre-intervention compared to 83.3% at post-intervention. The proportion of pharmacies with audio-visual privacy for patient counseling increased significantly from 30.9% at pre-intervention to 81.4% at post-intervention. Filled prescriptions were cross-checked by pharmacist (61.9%) and pharmacy technician (23.8%) before dispensing at pre-intervention compared to pharmacist (93.1%) and pharmacy technician (6.9%) at post intervention. 40.0% of pharmacies reported tracking consumption of drugs at pre-intervention compared to 98.3% at post-intervention; while 81.7% of pharmacies reported performing periodic stock reconciliation at pre-intervention compared to 100.0% at post-intervention. 36.5% of pharmacies were observed providing individual counseling on medication use to patients at pre-intervention compared to 73.2% at post-intervention; and 11.7% of pharmacies had evidence of monitoring and reporting of suspected adverse drug reaction at pre-intervention compared to 73.3% at post-intervention. The institution of access to patients’ clinical information by pharmacists in all pharmacies at post-intervention was a paradigm shift.
Conclusion
Through public health program, HU-PACE created an enabling environment and improved capacity of pharmacy personnel for quality HIV/AIDS and TB services. This has contributed in diverse ways to better monitoring of patients on pharmacotherapy by pharmacists through access of pharmacists to patients’ clinical information.
doi:10.1186/2193-1801-2-525
PMCID: PMC3824707  PMID: 24255831
Pharmaceutical care; HIV/AIDS; Public health programs; Patients; Nigeria
23.  Management of childhood diarrhoea by pharmacists and parents: is Britain lagging behind the Third World? 
BMJ : British Medical Journal  1991;302(6774):440-443.
OBJECTIVE--To investigate the role of community pharmacists in providing advice and treatment for children with diarrhoea; to investigate mothers' responses to diarrhoea in their children. DESIGN--Cross sectional questionnaire study of a random selection of community pharmacists and of mothers attending child health clinics. Pharmacists were interviewed and given a questionnaire and a separate group was visited by a researcher posing as a parent; mothers were interviewed at the clinic. SETTING--Newcastle upon Tyne. SUBJECTS--20 pharmacists were interviewed and visits by a researcher posing as a parent were carried out to 10 different pharmacists; 58 mothers were interviewed. MAIN OUTCOME MEASURES--Advice given by pharmacists was contrasted with standard advice on management of diarrhoea in children. RESULTS--Half of the pharmacists interviewed and 70% of pharmacists visited by a researcher posing as a parent recommended inappropriate treatment of childhood diarrhoea (such as antidiarrhoeal drugs and withholding breast milk), and only 30% at interview stated that they would ask for the age of the child. Mothers' knowledge of home treatment was inadequate. All pharmacists in the posed visits recommended a purchased treatment. CONCLUSION--Pharmacists are widely used by parents for consultation for children's ailments but their advice is not always appropriate; hence they should be given more consistent training in recognising and managing clinical problems. Medical advice on management of diarrhoea is also inconsistent and should be modified to conform to the guidelines of the World Health Organisation.
PMCID: PMC1669340  PMID: 2004171
24.  A qualitative study exploring public perceptions on the role of community pharmacists in Dubai 
Pharmacy Practice  2014;12(1):363.
Background
The role of community pharmacists is very important due to their access to primary care patients and expertise. For this reason, the interaction level between pharmacists and patients should be optimized to ensure enhanced delivery of pharmacy services.
Objective
To gauge perceptions and expectations of the public on the role of community pharmacists in Dubai, United Arab Emirates (UAE).
Methods
Twenty five individuals were invited to participate in 4 separate focus group discussions. Individuals came from different racial groups and socio-economic backgrounds. Interviews were audio-recorded and transcribed. Using thematic analysis, two reviewers coded all transcripts to identify emerging themes. Appropriate measures were taken to ensure study rigor and validity.
Results
All facilitators and barriers that were identified were grouped into 5 distinct themes. The pharmacist as a healthcare professional in the public mind was the most prominent theme that was discussed in all 4 focus groups. Other themes identified were, in decreasing order of prevalence, psychological perceptions towards pharmacists, important determinants of a pharmacist, the pharmacy as a unique healthcare provider, and control over pharmacies by health authorities.
Conclusions
This study provided insight into the way that the public looks at the role of community pharmacists in Dubai. Determinants that influence their perception are the media, health authorities, pharmacist’s knowledge level, attire, nationality, age, and pharmacy location.
PMCID: PMC3955864  PMID: 24644519
Community Pharmacy Services; Pharmacies; Professional Practice; Consumer Satisfaction; Focus Groups; United Arab Emirates
25.  Exploring successful community pharmacist-physician collaborative working relationships using mixed methods 
Background
Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.
Objective
To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.
Methods
A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.
Results
On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.
Conclusions
The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.
doi:10.1016/j.sapharm.2009.11.008
PMCID: PMC3004536  PMID: 21111388
Pharmacists; Physicians; Collaborative working relationships; Pharmacist-physician collaborative index; Community

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