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The contribution of community pharmacy to improving the public's health. Report 1, Evidence from the peer-reviewed literature 1990–2001

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Abstract

The modernisation of the NHS has highlighted the Government's intent to improve the public’s access to health services, information on preventing ill health and support for self-care. Community pharmacies are in a strong position to contribute to this agenda with around 12 000 dedicated premises in the UK creating an informal network of ‘drop in’ access points for health care services, medicines and advice on health and well-being. It has been estimated that over six million people visit pharmacies every day. Many pharmacy staff work in premises that are sited within local communities and shopping precincts where they provide easy access to the public without the need for an appointment. The informal nature of contact with a pharmacy creates an experience for users which is more similar to a ‘consumer’ than as a ‘patient’. Visitors to pharmacies come from all sectors of the population and research has shown that local pharmacy services are particularly valued by those without easy access to a car or public transport. In recognition of this potential the recent Health Committee Inquiry into Public Health5 recommended that ‘the Government takes steps for community pharmacists to play a more active role in public health’. As a result of these characteristics there is an opportunity for pharmacy staff to give advice and support on health or medicines to a significant proportion of the population on a regular or ad hoc basis. Much of this advice is given with prescriptions and the treatment of minor illnesses, however, some pharmacies also provide other services to improve health, such as help with smoking cessation, dietary advice, and testing of blood pressure and cholesterol. The provision of these latter services, however, is not universal and there has been no systematic evaluation of the evidence on their contribution to public health. To help assess the value of these services delivered through pharmacy, the Royal Pharmaceutical Society of Great Britain (RPSGB)and the charity PharmacyHealthLink commissioned a review of the UK and international evidence-base health improvement in order to determine which activities are most likely to be effective in a pharmacy setting and how they might best be provided. The review demonstrates that certain services are both sufficiently well-researched and well-received by pharmacy users at an international level, for example in smoking cessation, lipid management in the prevention of coronary heart disease, immunisation and emergency contraception, that recommendations for their widespread implementation in the UK can be made. Other services also show promise but are less wellresearched and require more evaluation before an assessment of their effectiveness and suitability in a pharmacy setting can be determined. This review can help to shape the contribution of community pharmacists to a modernised health service. It provides useful evidence to those involved in the planning and provision of health services to prevent illness and maintain health. Funding bodies and commissioners may wish to use its findings to develop pharmacy services to contribute further to their health improvement plans and local targets.
The
contribution
of community
pharmacy to
improving the
public’s health
REPORT 1
Evidence
from the
peer-reviewed
literature
1990 –2001
Claire Anderson
Alison Blenkinsopp
Miriam Armstrong
The
contribution
of community
pharmacy to
improving the
public’s health
REPORT 1
Evidence
from the
peer-reviewed
literature
1990 –2001
Claire Anderson
Director of Pharmacy Practice
and Social Pharmacy,
The Pharmacy School,
University of Nottingham
Alison Blenkinsopp
Professor of the Practice of
Pharmacy, Department of
Medicines Management,
Keele University
Miriam Armstrong
Chief Executive,
PharmacyHealthLink
There are three reports in this series:
Report 1 Evidence from the peer-reviewed literature 1990-2001
Report 2 Evidence from the non peer-reviewed literature 1990-2002
Report 3 An overview of the evidence-base from 1990-2002 and
recommendations for action
Limited copies are available from PharmacyHealthLink at
1 Lambeth High Street, London SE1 7JN.
Tel: 020 7572 2265
E-mail: pharmacyhealthlink@rpsgb.org.uk
Registered charity no: 1021335
Registered company no: 2768032
Published by the charity PharmacyHealthLink (formerly known as the
Pharmacy Healthcare Scheme) and the Royal Pharmaceutical Society of
Great Britain, 1 Lambeth High Street, London SE1 7JN
First published 2003.
© PharmacyHealthLink and the Royal Pharmaceutical Society of Great
Britain 2003
Printed in Great Britain
ISBN 0-9538505-1-X
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form by any means,
without prior written permission of the copyright holder.
The publisher makes no representation, express or limited, with regard
to the accuracy of the information contained in this document and
cannot accept any legal responsibility or liability for any errors or
omissions that may be made.
The views expressed in this document are those of the authors and are
not intended necessarily to reflect the current policies of the Royal
Pharmaceutical Society of Great Britain or PharmacyHealthLink.
CONTENTS
Joint Foreword by Yve Buckland, Chair of the Health
Development Agency and Marshall Davies, President of
the Royal Pharmaceutical Society of Great Britain
Executive summary 1
1 Introduction 7
Aim of the review 8
Scope of the review 8
Criteria for inclusion of evidence 9
Health Development Agency’s standards:
Evidence Base 2000 9
National Service Frameworks: categorisation
of evidence 10
2 Methods 11
Search strategy and selection of evidence 11
Search strategy 11
Quality assessment 12
Abstraction of data 12
3 Results 13
Health topics 13
Smoking cessation 13
Coronary heart disease 14
Obesity and weight reduction 19
Skin cancer prevention 19
Drug misuse 20
Emergency hormonal contraception 21
Folic acid and pregnancy 23
Asthma 23
Diabetes 24
Immunisation 24
Head lice 26
Oral health 26
Nutrition and physical activity 27
Multi-topic health promotion programmes 27
iii
Factors affecting the effectiveness of community
pharmacy-based activities to improve health 28
Facilitators 28
Training 29
Stakeholder views 30
Pharmacy users 30
Pharmacists 32
External stakeholders 34
4 Discussion 37
Generalisability of the findings 37
Key discussion points 37
5 Conclusions 41
References 43
Appendices
1Search terms used for MEDLINE, EMBASE and
International Pharmaceutical Abstracts 49
2Search terms used for Cochrane Library database 50
3National Service Frameworks: categorisation of
evidence 51
4Details of reviewed evidence 52
iv
ACKNOWLEDGEMENTS
Principal authors
Dr Claire Anderson, Director of Pharmacy Practice and
Social Pharmacy, The Pharmacy School, University of
Nottingham
Professor Alison Blenkinsopp, Professor of the Practice of
Pharmacy, Department of Medicines Management, Keele
University
Miriam Armstrong, Chief Executive, PharmacyHealthLink
Peer reviewer
Dr Alison Hill, Director of the Public Health Resource Unit,
Institute of Health Sciences, Oxford
Steering Group
Christine Gray, Head of Practice Directorate, RPSGB (until
July 2001)
Nigel Graham, Head of Practice Directorate, RPSGB (from
July 2001)
Emma Richards, Practice Co-ordinator, RPSGB
Dr Sue Ambler, Head of Practice Research Directorate,
RPSGB
Zoe Whittington, Practice Research Manager, RPSGB
v
FOREWORD
The modernisation of the NHS has highlighted the
Government's intent to improve the public’s access to
health services, information on preventing ill health and
support for self-care.1Community pharmacies are in a
strong position to contribute to this agenda with around
12 000 dedicated premises in the UK2creating an informal
network of ‘drop in’ access points for health care services,
medicines and advice on health and well-being.
It has been estimated that over six million people visit
pharmacies every day.3Many pharmacy staff work in
premises that are sited within local communities and
shopping precincts where they provide easy access to the
public without the need for an appointment. The
informal nature of contact with a pharmacy creates an
experience for users which is more similar to a ‘consumer’
than as a ‘patient’. Visitors to pharmacies come from all
sectors of the population and research has shown that
local pharmacy services are particularly valued by those
without easy access to a car or public transport.4In
recognition of this potential the recent Health
Committee Inquiry into Public Health5recommended that
‘the Government takes steps for community pharmacists
to play a more active role in public health’.
As a result of these characteristics there is an opportunity
for pharmacy staff to give advice and support on health
or medicines to a significant proportion of the
population on a regular or ad hoc basis. Much of this
advice is given with prescriptions and the treatment of
minor illnesses, however, some pharmacies also provide
other services to improve health, such as help with
smoking cessation, dietary advice, and testing of blood
vii
1 Department of Health (2000). The NHS Plan: A Plan for Investment. A Plan for Reform. London:
The Stationery Office.
2 Source: Royal Pharmaceutical Society of Great Britain (2001). Statistics of pharmacists and
registered premises. http://www.rpsgb.org.uk/pdfs/registerstats.pdf (This figure excludes
hospital and primary care-based pharmacies.)
3 Royal Pharmaceutical Society of Great Britain (1993). Pharmaceutical Care: The Future for
Community Pharmacy. A Report of the Joint Working Party on the Future Role of the
Community Pharmaceutical Services. London: RPSGB.
4 Royal Pharmaceutical Society of Great Britain (1996). Baseline Mapping Study to Define Access
and Usage of Community Pharmacy. London: RPSGB.
5 House of Commons Health Committee (2001). Second Report on Public Health, vol I:
Recommendation: xvii. London: The Stationery Office.
pressure and cholesterol. The provision of these latter
services, however, is not universal and there has been no
systematic evaluation of the evidence on their
contribution to public health. To help assess the value of
these services delivered through pharmacy, the Royal
Pharmaceutical Society of Great Britain (RPSGB)6and the
charity PharmacyHealthLink7commissioned a review of
the UK and international evidence-base health
improvement in order to determine which activities are
most likely to be effective in a pharmacy setting and how
they might best be provided.
The review demonstrates that certain services are both
sufficiently well-researched and well-received by
pharmacy users at an international level, for example in
smoking cessation, lipid management in the prevention
of coronary heart disease, immunisation and emergency
contraception, that recommendations for their
widespread implementation in the UK can be made.
Other services also show promise but are less well-
researched and require more evaluation before an
assessment of their effectiveness and suitability in a
pharmacy setting can be determined.
This review can help to shape the contribution of
community pharmacists to a modernised health service. It
provides useful evidence to those involved in the
planning and provision of health services to prevent
illness and maintain health. Funding bodies and
commissioners may wish to use its findings to develop
pharmacy services to contribute further to their health
improvement plans and local targets.
Yve Buckland Marshall Davies
Chair President
Health Development Royal Pharmaceutical
Agency Society of Great Britain
viii
6 RPSGB is the regulatory and professional development body for pharmacy in England, Scotland
and Wales. It has responsibility for the registration of pharmacists and pharmacy premises as
well as overseeing the development of pharmacy practice.
7 PharmacyHealthLink is an independent charity with the principal aim of developing the public
health contribution of pharmacy through research, training and education.
EXECUTIVE SUMMARY
Aim
The purpose of this literature review is to provide a
critical and comprehensive overview of the peer-reviewed
evidence relating to the contribution of pharmacy to
improving the public’s health both in the UK and
internationally from 1990 to 2001.
Background
Community pharmacies and pharmacists have the
potential to contribute to the public’s health and there is
a history of over two decades of developmental work in
this setting in the UK. The position of community
pharmacies straddles both public and private sectors, the
former primarily through a nationally-negotiated NHS
contract to dispense prescriptions. Pharmacies’ dual
health and commercial roles offer a unique opportunity
to target activities towards healthy people as well as
those with existing health problems. For this to occur in
the most effective way, service commissioners need access
to the evidence of potential benefit, hence the current
literature review.
Method
The electronic databases, searched from 1 January 1990
to 1 February 2001 were: MEDLINE; EMBASE; Cochrane
Library; and International Pharmaceutical Abstracts. Hand
searches for the same period were undertaken of specific
journals including the Health Education Journal,
International Journal of Pharmacy Practice, Journal of
Social and Administrative Pharmacy, Pharmaceutical
Journal, Scanner, and abstracts of the British
Pharmaceutical Conference and Health Services &
Pharmacy Practice Research Conference.
Data abstracted from publications included:
participants/setting; intervention; outcome measures; key
findings; training.
1
Results
The review covers 35 trials/experimental studies
presented in 40 papers (18 UK; 14 US and Canada; 8
other Europe) and 34 descriptive studies (14 UK; 12 US
and Canada; 8 other). The studies were heterogeneous in
terms of design and outcome measures. The robustness
of study design was variable.
Most of the trials and experimental studies demonstrate a
positive effect from pharmacists’ input, although many are
small in scale. There is good clinical and cost-effectiveness
evidence from UK randomised controlled trials (RCTs) in
smoking cessation, and from US and Canadian RCTs in
lipid management in the prevention of heart disease.
This evidence supports the wider provision of these
services through community pharmacies.
In RCTs for smoking cessation, community pharmacists
were trained in the use of specific behaviour change
models applied to the use of nicotine replacement
therapy in smoking cessation.
Evidence from RCTs in the US and Canada supports the
wider provision of lipid management services through
community pharmacies. The trials involved pharmacists in
case finding, provision of specific advice on diet and
exercise, referral for medication where needed, and
regular consultation and interaction with clients.
A UK trial of supervised methadone administration in
drug misuse achieved an attendance rate of 95.2% by
clients and high levels of satisfaction with the service
among providers and clients. An economic analysis of
different methods of provision of needle–syringe
exchange programmes in the US demonstrated
pharmacy-based services to be the least costly.
The first UK schemes for community pharmacy supply of
emergency hormonal contraception began in late 1999. A
previous study conducted in the US showed that almost
12 000 supplies were made from 140 pharmacies over a
16-month period. Surveys of users of this service in the
2
3
US, and latterly in the UK, consistently show high levels
of satisfaction.
Intervention studies from Sweden and the UK provide
some evidence of benefit of pharmacist-provided patient
education and monitoring activities in diabetes. Further
research is warranted.
US research has evaluated the provision of immunisation
services from community pharmacies. Patient use of these
services increased rapidly after their introduction in 1998
and service user surveys show high levels of satisfaction
with the service and its accessibility. A trial in the
Netherlands demonstrated that use of pharmacy
medication records (PMRs) to target ‘at risk’ clients and
to invite them to attend their physician for vaccination
against influenza resulted in 75.5% uptake.
The studies reviewed generally showed pharmacists to be
positive about their potential contribution to health
development, although the constraining effects of
current working practices of pharmacists, existing
remuneration arrangements and some community
pharmacy premises are well-described. Training appears
to be a key factor in changing community pharmacists’
practice to incorporate health development activities and
embedding a more holistic approach.
Research suggests that pharmacists are currently more
likely to engage in health improvement activities that are
linked to medicines use in some way. Furthermore, the
literature indicates that, at present, pharmacists tend to
take a reactive rather than proactive approach to health.
There is some evidence that this may result from
pharmacists’ concerns that unsolicited advice about non
medicine-related subjects may be rejected by users.
While surveys have shown that pharmacy users generally
do not perceive the pharmacist as an adviser on general
health issues, feedback following uptake of health
improvement activities appears to be positive.
Discussion
The peer-reviewed literature from 1990 to 2001
demonstrates that pharmacists can make a positive
contribution to health improvement. The generalisability
of the findings of smaller studies is, however, limited. For
most health topics the review revealed groups of small
studies indicating positive impact.
The evidence from the reviewed literature is sufficiently
comprehensive in the areas of smoking cessation, lipid
management, emergency contraception and
immunisation that recommendations for their
widespread implementation in pharmacies can be made.
Other activities look promising – for example, diabetes
and anti-coagulation monitoring and weight-reduction
programmes, but would benefit from further research.
Better quality research is also needed in other areas – for
example, to test the effectiveness of pharmacy-based
interventions, such as advice on folic acid or skin cancer
prevention, on pharmacy users’ subsequent attitudes and
behaviour.
Public response to the role of pharmacists in health
improvement appears, at times, to be contradictory.
When asked in a theoretical way about whether they
perceive the pharmacist to have a role in providing
general health advice, the public’s response tends to be
cautious. However, when such advice and services are
offered the uptake is generally good, suggesting that the
public currently has low expectations of the community
pharmacist.
Some members of the public are undoubtedly willing to
take up the advice and services offered, and it appears
that those currently most likely to do so are already
regular pharmacy clients for prescribed medicines. This
creates a paradox that while community pharmacies are
visited by the healthy as well as the sick, the former
group may be the most difficult to engage. Endorsement
of pharmacists’ involvement in health improvement by
other stakeholders (including referrals to pharmacies),
4
5
and changes to remuneration arrangements could allow
and encourage pharmacists to become more proactive in
their approach to healthier users thus also increasing
public awareness of advice and services available.
The reviewed evidence highlights the value of training to
help pharmacists change their behaviour in order to
deliver effective health improvement interventions.
Conclusions
The published literature clearly demonstrates the potential
of pharmacists to contribute to improving the public’s
health.
The review identified a number of areas where further
research is needed; for example, in diabetes monitoring
and education. In particular the lack of strategic research
is a weakness that needs to be addressed, for example,
research on pharmacy’s role in neighbourhood
regeneration and renewal would complement this work
but is not available. Funding also needs to be provided to
address specific research questions in relation to pharmacy
involvement with health improvement and any ensuing
training needs.
There was relatively little published research into users’
views of services being tested, and little evidence of user
involvement in the development of the services
themselves. Future research needs to have both greater
user input into intervention and service design, and allow
more feedback from users.
From the pharmacy profession’s perspective, the
development areas lie in encouraging greater proactivity
through opportunistically offering advice and improving
pharmacists’ training in dealing with health improvement
topics that are not directly related to medicines use. It
will also be necessary to consider and address existing
constraints of community pharmacy practice,
remuneration arrangements, and premises where
appropriate.
From other stakeholders’ perspectives endorsing the use
of pharmacies and thus extending the public’s awareness
of the pharmacist’s role in giving health advice is key.
Health commissioners and planners can use the findings
of this review to incorporate community pharmacy-based
health improvement activities into local health services.
6
7
1 INTRODUCTION
During the last decade there has been considerable
interest and activity in research into the public health role
of community pharmacies. In the UK a number of local
initiatives have helped to shape thinking, for example the
programmes developed in Barnet (Anderson 1998b),
Somerset (Ghalamkari et al 1997a,b) and Glasgow
(Coggans et al 2001). A recent European Commission
project (2001) ‘Health Promotion in Primary Care: General
Practice and Community Pharmacy’ was set up to develop
a database of quality-assured European health promotion
initiatives of Member States.1
Despite an increasing number of initiatives and the
growing published literature there were no recent reviews
of the strength of the evidence for wider implementation
of public health programmes in community pharmacies.
For example, although the European initiative considered
the quality of initiatives submitted and made
recommendations for action, the project did not
systematically review the quality of initiatives according to
a set of evidence-based standards. In addition there was a
broader need to clarify definitions used to describe public
health activities in pharmacy, to identify which activities
were most suited to a pharmacy setting and to determine
which activities warranted further research investment.
To help address these issues the Royal Pharmaceutical
Society of Great Britain and the charity PharmacyHealthLink
commissioned a critical review of the UK and international
literature relating to the contribution of community
pharmacy to improving the public’s health as part of a
wider work programme to determine which activities are
most likely to be effective in a pharmacy setting and how
they might best be provided.
The first report reviews the findings of the peer-reviewed
literature, which includes peer-reviewed journals and
conference proceedings. The second report reviews the
non peer-reviewed literature and examines aspects of
1 See www.univie.ac.at/phc for more details on this initiative.
implementation in more detail. The final report
summarises all the material reviewed and makes
recommendations for action.
Aim of the review
The aim was to review, summarise and evaluate the
evidence base of the literature from 1990 onwards
relating to the contribution of community pharmacy to
improving the public’s health both in the UK and
internationally.
Scope of the review
Definitions
The review includes activities defined under the
following widely used definitions of health promotion
and public health:
Health promotion
The Ottawa Charter for Health Promotion (WHO,
1986)2states that ‘Health promotion is the process of
enabling people to increase control over, and to
improve, their health’.
Public health
Public health has been defined as ‘the science and art
of preventing disease, prolonging life and promoting
health through the organised efforts of society’
(Acheson inquiry into the future development of the
public health function, 1988).3
Activities included/excluded
Specifically, the review included pharmacy activities for
both individuals and wider communities relating to:
Promoting health and well-being (e.g. nutrition,
physical activity).
Preventing illness (e.g. smoking cessation,
immunisation, travel health).
Identifying ill health (e.g. screening and case finding).
8
2 WHO (1986). Ottowa Charter for Health Promotion. First international conference on Health
Promotion, Ottowa, 21 November 1986. Geneva: World Health Organization.
3 Public health in England: the report of the Committee of Inquiry into the future development
of the public health function, Cm 289, 1988. London: The Stationery Office.
9
The maintenance of health for those with chronic or
potentially long-term conditions (e.g. diabetes,
asthma, hypertension).
The advice-giving role of the pharmacist in relation to the
treatment of acute self-limiting conditions, the
management of minor illness, prescribing and prescription
reviews was not included because it has been adequately
covered elsewhere.4
The literature review focused on activities taking place
within the community pharmacy setting or activities
carried out by community pharmacists and their staff in
other settings, for example, in nursing homes. The work
of pharmacists in primary care and strategic roles was
included where relevant.
Criteria for inclusion of evidence
The majority of dissemination of research is based on a
hierarchy of evidence with the randomised controlled trial
(RCT) as the ‘gold standard’. The literature in the field of
pharmacy practice/public health contains few RCTs, and a
substantial number of experimental studies and
descriptive work. This review used two approaches to
assess the quality of evidence: (1) the Health Development
Agency’s Evidence Base 20005for standards for transparency,
systematicity and relevance; and (2) the categorisation of
evidence according to the system used by the Department
of Health in its National Service Frameworks (NSF).6
Health Development Agency standards:
Evidence Base 2000
Transparency – evidence must include a clear and
transparent account of how it was collated, which
sources of information have been consulted, who was
involved in collating the evidence, how the work was
funded, and a full disclosure of any analysis and findings.
Systematicity – evidence identified must display clearly,
regardless of the individual study, report or review
4 See, for example, The Public's Use of Community Pharmacies as a Primary Health Care Resource (1998)
– research carried out by the University of Manchester School of Pharmacy and the National Primary
Care Research and Development Centre for the Community Pharmacy Research Consortium.
5 See, for example, the Health Development Agency's website: www.HDA-online.org.uk/evidence/eb2000:
Evidence base – quality standards for evidence.
6 See, for example, page 11 of the NSF on Services for Older People, Department of Health, March 2001.
methodology, the process through which the evidence
was gathered and assessed.
Relevance – evidence must be judged to be relevant
to pharmacy practice/public health, and in this
instance to the role of community pharmacy.
National Service Frameworks: categorisation of evidence
The Department of Health categorises individual studies
according to the standard classification set out in its
National Service Frameworks:
Evidence from research and other professional literature
A1 Systematic reviews which include at least one
randomised controlled trial (RCT) e.g. systematic
reviews from Cochrane or NHS Centre for Reviews
and Dissemination.
A2 Other systematic and high quality reviews which
synthesise references.
B1 Individual RCTs.
B2 Individual non-randomised,
experimental/intervention studies.
B3 Individual well-designed non-experimental studies,
controlled statistically if appropriate. Includes studies
using case control, longitudinal, cohort, matched
pairs or cross-sectional random sample
methodologies, and well-designed qualitative
studies, well-designed analytical studies including
secondary analysis.
C1 Descriptive and other research or evaluation not in B
(e.g. convenience samples).
C2 Case studies and examples of good practice.
DSummary review articles and discussions of relevant
literature and conference proceedings not otherwise
classified.
10
11
2 METHODS
The electronic databases, searched from 1 January 1990
to 1 February 2001, were: MEDLINE; EMBASE; Cochrane
Library; and International Pharmaceutical Abstracts. The
brief for this study was to consider papers from 1990
onwards only, to capture the most recent evidence.
Hand searches for the same period were undertaken of
the Health Education Journal, International Journal of
Pharmacy Practice, Journal of Social and Administrative
Pharmacy, Pharmacy World and Science, Annals of
Pharmacotherapy (1992 onwards; previously Drug
Intelligence and Clinical Pharmacy 1990–1991),
Pharmaceutical Journal, Scanner, and abstracts of the
British Pharmaceutical Conference and Health Services &
Pharmacy Practice Research Conference.
All searches included non-English language literature.
Those studies with English abstracts were assessed for
inclusion on the basis of the abstract.
Search strategy and selection of
evidence
Search strategy
Search terms for MEDLINE, EMBASE and International
Pharmaceutical Abstracts were: pharmacists; community
pharmacy; community pharmacy services; pharmacies;
pharmaceutical services; health education; health
promotion; public health; smoking cessation; diet; body
weight; coronary heart disease (see Appendix 1).
The Cochrane Library was searched using a combination
of the following terms: pharmacist; pharmacy;
community pharmacy; health education; health
promotion; smoking cessation; diet; body weight;
coronary heart disease (see Appendix 2).
The lists of titles and abstracts of papers from the
searches were examined separately by two of the authors
(AB and CA) of this review. The inclusion/exclusion lists
were then compared and any differences resolved by
discussion. Hard copies were obtained of all papers to be
considered for inclusion.
Quality assessment
Two approaches were used. Firstly, the Health
Development Agency’s Evidence Base 2000 for standards
for transparency, systematicity and relevance were
applied to each paper. Secondly, each study was allocated
an evidence grade according to those used by the
Department of Health in the National Service
Frameworks (see Appendix 3).
Abstraction of data
Data were abstracted and summarised under the
headings: authors and study; study quality; country; study
design and participants; interventions (including
training); outcome measures; results; conclusions. A sub-
sample of six papers was abstracted by each author and
the findings compared to identify any differences and
resolve them.
The summarised data in Appendix 4 was used as the basis
for a qualitative synthesis of the findings and interpretation,
taking into account the quality of evidence.
12
13
3 RESULTS
The searches generated 112 titles, 74 of which were
considered to fall within the scope of the review and
hard copies were obtained. The review covered 35
trials/experimental studies reported in 40 papers (18 UK;
14 US and Canada; 8 other Europe) and 34 descriptive
studies (14 UK; 12 US and Canada; 8 other).
The results are presented by health topic, with a set of
statements summarising the findings together with the
grading of the evidence. Full details of all studies are
provided in Appendix 4 with the page numbers on which
they appear cross-referenced in the text.
Health topics
Smoking cessation
Two RCTs (Scotland, Northern Ireland) and three non-
randomised experimental studies (Sweden, Germany,
Switzerland) were reviewed. Abstinence rates in the RCTs
were 14.3% intervention, 2.7% controls at one year
(P<0.001) (B11: Maguire et al 2001, p53) and 12%
intervention, 7% controls at nine months (B1: Sinclair et
al 1998, p53). Intervention customers in the Scottish RCT
were significantly more likely to report having discussed
stopping smoking with pharmacy personnel (85% vs 62%
controls; P<0.01). Self-reported abstinence was 33% at
one year in the Swedish study but no validation method
was used (B3: Isacson et al 1998, p55).
A health economic analysis of the Aberdeen trial showed
that the cost of producing one successful attempt to quit
smoking by using intensive rather than standard
pharmaceutical support was £300 or £83 per life year
saved (B1: Sinclair et al 1999, p53). In a health economic
evaluation of a pilot study prior to the Northern Ireland
trial the cost per life year saved through intervention
ranged from £196.76 to £351.45 for men and £181.35 to
£722 for women (B1: Crealey et al 1998, p54).
1 See Appendix 3 for an explanation of the grades used to classify studies reviewed.
Main findings:
Community pharmacists
trained in behaviour change
methods are effective in
helping clients stop smoking
(B1).
Community pharmacy-based
smoking cessation services
are cost effective (B1).
Analysis / discussion point:
Crealey
et al
(1998), Sinclair
et al
(1998a,1999), Isacson
et al
(1998), and Maguire
et al
(2001)
demonstrate the effectiveness and
cost-effectiveness of smoking
cessation services provided by
community pharmacists who have
received training in behaviour
change methods.
In a US survey of community pharmacists, 39.5% reported
counselling people on smoking cessation at least once
each week whereas only 7.5% reported routinely
checking pharmacy clients’ smoking status (B3: Williams
et al 2000, p54). The authors conclude that although
community pharmacists believe that they are qualified to
provide smoking cessation services, they do not routinely
identify smokers.
Studies in the UK (B1: Sinclair et al 1998, p53) and
Switzerland (B3: Wick et al 2000, p55) investigated the
effect of training on community pharmacists’ smoking
cessation advice. Intervention customers in the UK study
were more likely to have had discussions with pharmacy
staff about smoking cessation and to rate these
discussions more highly than usual care customers. In the
Swiss study, the intensity of counselling was predicted by
prior participation in training.
Coronary heart disease
Lipid management
Two RCTs (USA, Canada), two observational studies (both
USA) conducted in community pharmacies and one
uncontrolled intervention study in a single community
pharmacy (UK) were reviewed.
In the US RCT (B1: Nola et al 2000, p56) patients were
identified from the pharmacy’s computerised patient
medication records and invited to attend a screening day
at the pharmacy, where a nurse took blood samples
which were tested off-site. The pharmacist advised on
diet, exercise and treatment. At the end of the study (6
months) 32% of the intervention group and 15% of the
control group patients achieved target lipid levels. Risk
factor scores improved in the intervention but not the
control group.
The Canadian RCT tested the efficacy of community
pharmacist intervention on cholesterol risk management
in high risk coronary heart disease patients (B1: Tsuyuki
et al 1999, 2000, p56; B1: Simpson et al 2001, p57)
14
Analysis / discussion points:
Williams
et al
(2000) suggest that
pharmacists are more likely to
respond to smokers’ requests for
advice than to initiate
conversations about smoking.
Sinclair
et al
(1989
b
) and Wick
et
al
(2000) underline the role of
training in enabling community
pharmacists to provide effective
smoking cessation services.
Main findings:
Lipid management services
provided by community
pharmacists are effective in
helping clients to achieve
target lipid levels (B1).
Lipid management services
provided by community
pharmacists are effective in
enhancing the prescribing and
use of lipid-regulating
medications (B1).
Lipid management services
provided by community
pharmacists are effective in
reducing clients’ coronary
heart disease risk scores (B1).
Information routinely kept by
community pharmacies on
dispensed medication enables
case-finding of patients for
interventions in lipid
management (C1).
15
involving 44 community pharmacies. Patients included
were those at high risk of vascular events (those with
atherosclerotic valvular disease, or diabetes with another
risk factor). The primary endpoint was a composite
measure of a complete fasting cholesterol profile, or
addition of cholesterol-lowering medication or
modification of previous cholesterol medication.
Secondary outcomes were patient satisfaction and quality
of life. Pharmacists undertook training and participated
in investigator meetings. Patients involved in the
intervention were interviewed by the pharmacist, who
also conducted a cholesterol test, provided information
and education on risk factors and made recommendations
to the physician on medication changes. The external
data committee recommended early study termination
due to benefit, the primary endpoint being reached in
58% of intervention patients compared to 30% in usual
care (P=0.001).
In a before and after study in the US patients’ total lipid
and LDL (low-density lipoprotein) levels were significantly
decreased at 12 months compared with baseline of 6
months (P<0.02) (B3: Shibley & Pugh 1997, p57). Target
lipid levels were achieved by 62.5% of patients in a two-
year US study conducted in 26 community pharmacies
(B3: Bluml et al 2000, p58). Observed rates for persistence
and compliance (assessed through number of missed
doses and timing of prescription refill requests)2with
treatment were 93.6% and 90.1% in the same study.
In the UK uncontrolled intervention study in a single
community pharmacy, patient follow-up of total blood
cholesterol measurement was made after each of three
visits to the pharmacy (B3: Ibrahim et al 1990, p58). Of
241 people screened, 51 had elevated total blood
cholesterol and completed the study. There was a
significant decrease in total blood cholesterol between
the first and second pharmacy visits but not between the
second and third visits. In a US uncontrolled study with
patient follow-up of self-reported lifestyle behaviour
change of 539 participants, 78% were found to have
Analysis / discussion point:
The RCTs (Tsuyuki
et al
1999,
2000; Nola
et al
2000; Simpson
et
al
2001) provide convincing
evidence, supported by the other
studies (Ibrahim
et al
1990;
Madejski & Madejski 1996;
Shibley & Pugh 1997; Bluml
et al
2000), that community
pharmacists have an important
role to play in managing lipid
levels. Community pharmacies
offer the potential to improve the
use of the resources invested in
and the outcomes of lipid
management. Piloting of
programmes should commence as
soon as possible in the UK.
2 Measurement of the extent to which patients take treatment as intended is complex. Two
techniques commonly used are the number of doses missed and whether the patient collects further
supplies of the medicine such that continuous dosing can occur. The latter (‘Mistimed Refills’) can be
used by the pharmacist to monitor patterns and initiate a discussion with the patient where needed.
elevated cholesterol levels and 85% of these were
followed up. Lifestyle modifications were reported by
85% of patients and 23% accepted an offer of re-testing
(B3: Madejski & Madejski 1996, p58).
Identifying pharmacy users with risk factors for
coronary heart disease
A distinction is made in this section between the terms
‘screening’ and ‘case finding’ in a pharmacy setting. The
terms used are based on the definitions adopted by the
UK National Screening Committee:3
Screening – is a health service in which members of a
defined population, who do not necessarily perceive
they are at risk of a disease or its complications, are
asked a question or offered a test, to identify those
individuals who are more likely to be helped than
harmed by further tests or treatment.
Screening procedure – a systematic procedure to
select individuals from a given population at risk for
an impairment.
Case-finding – actively trying to diagnose individuals
for cascade screening (systematic identification and
testing of members in a family).
The published literature in this review uses the term
‘screening’ to describe the disease detection services that
are, or might be, provided from community pharmacies.
In practice most community pharmacy-based services are
‘case-finding’ where targeted groups identified from an
analysis of patient medication records are invited to
attend for testing.
Case-finding
In addition to the US RCT (B1: Nola et al 2000, p56)
patient medication records in four Canadian community
pharmacies were searched for a range of drugs that
would indicate heart disease, hypertension, diabetes or
smoking (B3: Gardner et al 1995, p59). The 426 patients
16
3 See UK National Screening Committee Glossary: www.doh.gov.uk/nsc/glossary/glossary_main.htm
Main findings:
Using pharmacy medication
records to identify clients at
‘high risk’ of coronary heart
disease is an effective method
of identifying those most at
risk and instigating health
promotion measures (B1).
17
were then invited to attend the pharmacy for a
cholesterol test, of whom 88 did so. An additional 97
‘walk-in’ patients were also tested. Cholesterol levels
were significantly higher in the targeted group.
Dispensing data from 138 community pharmacies in
Sydney, Australia was used to identify patients who had
apparently discontinued treatment with lipid lowering
drugs (B3: Simons et al 1996, p59). The main reasons
given for why patients had stopped their treatment
were: being unconvinced of the need for treatment
(32%); poor efficacy4(32%), and adverse effects (7%).
Half of the apparent discontinuations occurred within
three months of starting treatment.
Screening
In a city-wide survey of community pharmacies in the UK,
12% were offering testing services other than pregnancy
testing and 48% indicated that they might offer tests in
the future (B3: Allison et al 1994, p59). Owner-proprietors
were more likely to be providers of ‘screening’ services.
Allison et al (1994) concluded that community pharmacy-
based screening was unlikely to be commercially viable
unless local doctors contracted for such services.
A survey of community pharmacies in South Africa
investigated the provision of ‘screening’ services and
their operation (B3: Flobbe et al 1999, p60). Overall, 57%
of pharmacies provided at least one screening test, with
blood pressure measurement, serum cholesterol, capillary
glucose and pregnancy testing being the most common.
Blood pressure measurement was the most frequently
conducted test. Only 35% of pharmacists kept records of
test results. No pharmacists reported using quality control
procedures for their screening service, and pharmacists’
knowledge about the tests was found to be poor. These
findings indicated areas where improvement was
needed. In addition, the authors comment that
population coverage was insufficient for pharmacists to
play a meaningful role in screening for disease.
Analysis / discussion point:
The use of pharmacy medication
records and dispensing data to
target patients with risk factors
for coronary heart disease appears
to be effective in identifying those
at risk to provide follow-up on
lipid management and advice (see
also ‘Lipid management’).
Main findings:
There is insufficient evidence
to determine whether
‘screening’ activities, for
example blood pressure
measurement, carried out in
community pharmacies is an
effective use of resources
(B3).
4 How patients interpreted or evaluated efficacy is not clear.
In an evaluation of US cholesterol testing using the
community pharmacy premises as one of the locations,
community pharmacists were asked about their
experiences with the screening programme (B3:
Jungnickel & Wisehart 1997, p60). The results showed
little engagement of pharmacists in the programme,
indicating that simply locating the service in the
pharmacy setting did not result in increased pharmacist
involvement. Few pharmacists were aware of the process
for identifying high risk patients and in only 10% of
cases had the pharmacist received a list of patients who
had been recommended to contact their doctor.
In a study involving a single community pharmacy in a UK
inner city, free blood pressure checks were offered for six
weeks to people aged 30–64 years, with the pharmacist
inviting individuals to take part (B3: Hampton et al 1990,
p60). The client was given a copy of his or her blood
pressure reading to take to the doctor. Of 120 people
approached, 70 (58%) agreed. The GP records of 40
patients were checked for the inclusion of the pharmacy
blood pressure reading, 10 cases were found. GP response
to the scheme, explored at interview was ‘not enthusiastic’.
The authors concluded that pharmacist measurement of
blood pressure and referral to a GP was unlikely to be
accepted unless part of a co-ordinated programme.
Secondary prevention with aspirin
Two audits of aspirin purchases in UK community
pharmacies in 1996 and 1998 showed that 33% and 27%
of patients respectively appeared to be taking
prophylactic aspirin without their GP’s knowledge (B3:
Horne 1998, p61). The mean purchase rates were
approximately two patients per pharmacy per week in
the first audit and 2.5 in the second. Interviews with 128
patients purchasing low dose aspirin or receiving it on
prescription were used to identify information needs (B3:
Black et al 1998, p61). Community pharmacists were seen
as a highly acceptable source of information but there
was some concern about the level of privacy achievable
in a community pharmacy, with just over half believing
that the pharmacy was a suitable venue for such
information.
18
Analysis / discussion point:
It is unclear whether pharmacies
can play an effective part in
population screening for coronary
heart disease without further
research and training.
Main findings:
Community pharmacy audits
can identify self-initiated
aspirin treatment and
encourage referral for medical
advice (B3).
Community pharmacy-based
monitoring of the use of
prophylactic aspirin treatment
shows promise but more
evidence is needed (B3).
Analysis / discussion point:
Black
et al
(1998) and Horne
(1998) indicate that community
pharmacies could perform an
important role in ensuring the
appropriate use of prophylactic
aspirin treatment and intervening
to minimise potential harm from
self-initiated aspirin treatment in
people with contra-indications to
its use. Further research in
collaboration with local prescribers
is needed to test feasibility and
outcomes of such a programme.
19
Anticoagulation
Three community pharmacies in the US, with existing
‘health education centre’ and laboratory facilities,
provided an anticoagulation education and monitoring
programme for patients referred by two primary care
physicians (B3: Knowlton et al 1999, p62). In addition to
measuring international normalised ratio (INR)5the
pharmacists conducted regular patient assessment
covering adherence, medication use and diet. Of 26
patients referred to the service, data were available for
21 of them. Most patients’ INR values were within the
targeted range for over 60% of the study period.
Obesity and weight reduction
One study in Denmark reported the results of ‘slimming
courses’ held at 19 community pharmacies for 269 obese
clients (B3: Tubro 1999, p62). Average weight loss (self-
reported by clients measured on scales in the pharmacy)
was 5.3 kg for females and 6.2 kg for males. At one-year
follow-up, 20% of clients who completed the course had
maintained a weight loss of 5 kg or more.
Skin cancer prevention
A North American RCT was reviewed that tested the
effect of training, prompts and feedback on community
pharmacists’ unprompted counselling rates on skin cancer
prevention (B1: Mayer et al 1998, p62). Intervention-
group pharmacists scored higher on knowledge, and
‘mystery shopper’ visits showed some evidence of
increased counselling rates on skin cancer prevention
among intervention pharmacists.
In Sweden a kiosk with a touchscreen education public
programme was installed in one community pharmacy
and in one library, and usage was monitored (C1:
Lindholm et al 1998, p63). Usage was higher in the
pharmacy than in the library setting. Of the 274 users of
the programme, 29% (mainly young women) reported
they would change their sun exposure behaviour.
5 Patients taking anticoagulants are monitored using a blood test to ensure that the level of
anticoagulation is safe. Each patient is given a target INR range and if the test result is outside
that range, the dose of anticoagulant is increased or decreased. Testing of INR has generally
been done in hospital clinics, but local community-based testing is more convenient for patients.
Main findings:
Community pharmacy-based
monitoring of anticoagulant
therapy shows promise but
more evidence is needed (B3).
Analysis / discussion point:
Further research into community
pharmacy-based monitoring of
anticoagulant therapy is urgently
required to identify the potential
for minimising negative health
outcomes for this ‘high risk’
patient group.
Main findings:
Community pharmacy-based
weight reduction programmes
appear to show promise but
further evidence is needed (B3).
Analysis / discussion point:
Further research is required to
determine the potential for an
alternative effective community-
based programme for weight
reduction based in community
pharmacies.
Main findings:
Training in skin cancer
prevention enhanced
knowledge and increased the
opportunistic offering of advice
to clients by pharmacists (B1).
Analysis / discussion point:
Pharmacy-based information on
skin cancer prevention appears to
be effective in raising awareness
of ‘sun risks’ and trained
pharmacists are more likely to be
proactive in counselling clients.
However, the effects of this advice
on behaviour are unknown.
A community pharmacy-based skin cancer awareness
campaign in Canada tested pharmacists’ knowledge
before and after the scheme (B3: Leinweber et al 1995,
p63). Pharmacists’ knowledge about skin cancer was high
at baseline, with some improvement at follow up.
Pharmacists were positive about participation in the
scheme. However, no data were available on client
uptake or client-related outcomes.
Drug misuse
One UK study reported on the findings of a pilot for
supervised administration of methadone in community
pharmacies (B3: Luger et al 2000, p63). Seventeen
community pharmacists supervised a mean of five
methadone consumptions per week. The service was
acceptable to clients, with 68% rating it ‘reasonable’.
One in three pharmacists reported difficulty in coping
with this client group.
A survey of community pharmacist providers of
pharmacy-based needle exchange (PBNX) and local
needle exchange co-ordinators in the UK aimed to
characterise the service (B3: Sheridan et al 2000, p64).
The mean number of transactions per pharmacy per
month was 49 and pharmacies had a mean of 17 clients
(range 0–350). The return rate for injecting equipment
was 30%. Two-thirds of PBNX pharmacies also reported
dispensing oral methadone. Pharmacists reported further
training needs for themselves and their staff.
An economic analysis was undertaken in the US of the
relative cost in preventing HIV in different needle/syringe
provision programmes including PBNX (B3: Lurie et al
1998, p64). The estimated cost per syringe distributed
was found to be 37 cents US (approximately £0.24)
through PBNX compared with 97 cents (approximately
£0.63) through a standard needle exchange programme.
A national UK survey of community pharmacists found
that between 1988 and 1995 the percentage of
pharmacies providing needle exchange services increased
from 3.0% to 18.9% and that sales of injecting
20
Main findings:
Community pharmacy-based
supervised methadone
administration services can
achieve high attendance rates
and be acceptable to clients
(B3).
PBNX schemes are cost-
effective (B3).
Specific training needs have
been identified for
pharmacists participating in
PBNX schemes (C1).
21
equipment were being made by 34.5% compared with
28.0% in 1988 (B3: Sheridan et al 1996, p64).
A US study of pharmacists’ attitudes towards
needle/syringe exchange and sales of injecting
equipment found that while pharmacists stated support
for access to sterile injecting equipment, there was
diversity in their approaches to its sale (B3: Gleghorn et
al 1998, p65). One in three pharmacists would only sell
injecting equipment to identified diabetic patients, and
54% stated that they routinely asked for picture ID before
agreeing to make a sale. There are no similar studies of
UK pharmacists’ approaches to selling injecting equipment.
Analysis of queries received by a pharmacist during
sessions at a needle/syringe exchange service in a drug
counselling centre in the UK was used to identify training
needs (C1: Scott et al 1998, p65). Key areas of new
knowledge identified were: harm reduction strategies
and drug use-related health problems. Being able to
respond to drug users’ terminology was also found to be
a key need.
A survey of community pharmacists in the UK identified
the following as predicting pharmacist provision of
services: male gender; more recently registered; positive
attitudes towards drug misusers (B3: Matheson et al
1999, p65). Research has also identified geographical
variation in the provision of methadone supervision
services (B3: Matheson et al 1999, p66). Attitude was
found to be an independent predictor of participation in
needle/syringe sales, methadone dispensing and
supervised methadone administration (B3: Matheson
et al 1999, p66).
Emergency hormonal contraception
Community pharmacists worked with local prescribers to
produce Collaborative Drug Therapy Agreements
(CDTAs)6to enable the pharmacist to supply emergency
hormonal contraception (EHC) in a pilot project involving
140 pharmacies in Washington state (B3: Hayes et al
6 CDTA is a local agreement between pharmacists and physicians in the US to allow the supply of
certain medicines by pharmacists.
Analysis / discussion point:
The majority of studies show
increasing interest and
commitment by community
pharmacists towards the provision
of services for drug misusers. The
services evaluated in the
published literature have been
shown to be cost-effective and
acceptable to users. Training in the
needs of this target group is
necessary to ensure services are
safe and appropriate for both
users and staff.
Main findings:
Emergency contraception can
be effectively and appropriately
supplied by pharmacists (B3).
Users were generally satisfied
with the service pharmacists
provided (C1).
Pharmacists were positive
about their experience of
providing emergency
hormonal contraception (B3).
2000, p66). There were 145 CDTAs created and 11 969
supplies of EHC made over 16 months. Training was
undertaken by 1000 pharmacists for the scheme.
A questionnaire survey of providers and users of the
Washington EHC scheme was made (C1: Sommers et al
2001, p67). Pharmacists were highly rated by users for
their personal interactions and for the quality of
information supplied about EHC use. Ratings were lower
for information about side effects, recognition and
follow-up of EHC failure, and for information on regular
contraceptive methods. Most of the pharmacists and
prescribers (92%) were ‘satisfied’ or ‘very satisfied’ with
the prescribing arrangements.
From late 1999, EHC (at that time a prescription only
medicine) was made available through community
pharmacies in a small number of areas of the UK using
‘Patient Group Directions’ (PGDs).7Evaluation was
undertaken involving interviews with 44 provider
pharmacists from two areas (B3: Bissell et al 2001, p67).
Pharmacists were positive about their experiences of
supplying EHC although some expressed concerns about
the potential for repeated use being encouraged by
widening access to the treatment. Pharmacists believed
that the cost of EHC as an over the counter medicine was
likely to deter its use by women on lower incomes. Bissell
et al (2001) concluded that pharmacy supply of EHC
appeared to be a novel and beneficial method of
extending access within the timescale required for
effective treatment.
A study of the effect of using pharmacy window displays
was conducted in 20 community pharmacies in one area
of the UK to raise awareness of emergency contraception
(B3: Sharma & Anderson 1998, p67). Enquiries about EHC
increased two- to fourfold and leaflet uptake between
three- and 43-fold. Prescriptions for EHC rose threefold
and pregnancy tests fourfold.
A review of the UK literature (C1: Anderson 2000, p68)
described health development initiatives introduced by
22
7 PGD provides authorisation for the supply of a medicine to patients other than on a prescription
according to specified inclusion and exclusion criteria.
Pharmacy window displays
are effective in raising client
awareness, enquiries about
supply and the presentation
of prescriptions for emergency
contraception and pregnancy
tests (B3).
Analysis / discussion point:
Utilising community pharmacies to
widen timely access to EHC has
resulted in a service with high
levels of user satisfaction. Window
displays are effective in raising
awareness, and use, of pharmacies
for supplying emergency
contraception.
23
individual pharmacists, pharmacy multiples, and NHS
organisations. Use of the pharmacy premises (e.g.
window displays) increased both uptake of leaflets
about, and presentation of prescriptions for, EHC.
Community pharmacies in deprived areas in the US, were
identified as key access points in a discussion paper on
potential roles for pharmacists in the prevention and control
of sexually transmitted diseases (D: Stergachis 1999, p68).
Folic acid and pregnancy
A community pharmacy-based campaign was undertaken
in one area of the UK to promote the uptake of folic acid
in planned pregnancy (B3: Rajyaguru & Anderson 1999,
p68). Pharmacists and their staff took part in an evening
training session and were supplied with publicity
materials including leaflets, posters, and window display
items. Most pharmacists and assistants reported feeling
comfortable about advising on this topic, and the
evaluation showed they felt most comfortable advising
regular customers.
A postal questionnaire study examined the knowledge,
behaviour, and attitudes of Dutch community
pharmacists in relation to folic acid use by women of
childbearing age (B3: De Jong-Van den Berg et al 1999,
p69). Overall, 30% of respondents reported that they
were using an additional label about folic acid on oral
contraceptives. The two-thirds who were not using the
label said this was because of concerns about ‘imposing’
this information on women. Pharmacists’ perceptions of
the attitudes of local GPs appeared to influence their
willingness to proactively promote folic acid use.
Compared with the findings of a similar survey two years
earlier, De Jong-Van den Berg et al (1999) state that more
pharmacists appeared to be promoting folic acid use.
Asthma
One UK study reported the effects of a controlled trial of
educational intervention by pharmacists on primary school
teachers’ knowledge of asthma (B2: Bell et al 2000a, p69).
Pre-study knowledge scores were similar for the intervention
Main findings:
Pharmacy staff appear
positive about promoting the
role of folic acid in pregnancy
but there is no published
evidence of the effects of
intervention on behaviour
(B3).
Analysis / discussion point:
Further investigation is needed to
assess the impact of pharmacy-
based interventions on folic acid
use by women.
Main findings
An educational intervention
by pharmacists enhances
asthma knowledge of primary
school teachers (B2).
and control groups whereas post study scores were
significantly higher in the intervention-group teachers.8
Diabetes
In Sweden the effects of a one-year pharmacy-based
group education model for people with diabetes was
investigated (B3: Sarkadi & Rosenqvist 1999, p70). Thirty-
nine patients in eight study groups who had participated
in the programme for five months or longer were
included in the evaluation. Metabolic control, as
indicated by HBA1c,9was significantly improved at six but
not 12 months. More than half of the participants
reported that their perception of diabetes and its
treatment had changed as a result of the programme.
A Dutch consensus group study of community
pharmacists and pharmacy technicians was undertaken to
identify priorities for community pharmacists’
educational activities targeted at people with diabetes
(B3: Timmer et al 1999, p70). The study found that
priority should be given to adherence with treatment,
increasing awareness of side effects and improving
glucose monitoring through correct use of meters. A
lower priority was given by the pharmacists and
technicians to activities directed at lifestyle changes.
In a community pharmacy-based UK study, patients were
allocated to ‘quality control’ (QC) and ‘no quality control’
(NQC) groups with HBA1c levels as the outcome measure
(B2: Dixon et al 2000, p70). All patients were given
written information about diabetes, a new set of
instructions for their glucose meter, and a diary to record
their results. Patients in the QC group also received
written information about QC. Patients in this group
showed smaller increases in HBA1c.
Immunisation
In an experimental study in the US, 19 supermarket
pharmacies provided an immunisation service and also
administered vaccines at off-site locations (B3: Weitzel &
24
8 Most research detailing the involvement of pharmacists in the management of asthma fell
outside the scope of this literature review.
9 HBA1c is measured in a blood test and is the standard method of assessing how well blood
glucose levels are being controlled in diabetes.
Analysis / discussion point:
Further research is required into
whether pharmacist-led training
programmes can lead to improved
management of asthma in
schoolchildren by teachers.
Main findings:
Pharmacy-based group
education for people with
diabetes shows promise but
more evidence is needed (B3).
Community pharmacy-based
monitoring and information-
giving in diabetes shows
promise in improving diabetic
control but further research is
needed (B2).
Analysis / discussion point:
Further research is needed into
the effectiveness of pharmacy-
based programmes to improve the
management of diabetes.
Main findings:
Immunisation services can be
safely provided through
community pharmacies (B3).
User satisfaction with
pharmacy-based immunisation
services is high (C1).
25
Goode 2000, p71). The pharmacy service was offered
through clinics and walk-in centres from 1998 onwards.
In the first year, 5137 influenza and 613 pnuemococcal
vaccinations were provided, increasing to 18000 and 1200
in the next year. There were few adverse reaction reports
and no serious allergic reactions.
A survey of users of pharmacy-based immunisation
services was conducted in the US (C1: Grabenstein 2001,
p71). Many respondents stated a preference for
pharmacy immunisation based on access, convenience,
trust, and cost. Most users reported being satisfied with
the service received and said they would recommend it to
others. Patients’ acceptance of pharmacy-based
immunisation was investigated using a postal
questionnaire distributed through physician and
pharmacy outlets (C1: Ernst et al 2001, p71). Younger
patients and those in small towns were more likely to
report receiving immunisation from a non-physician.
There was greater support for non-physician
immunisation for adults than for children.
In a US review of the role of pharmacists as an advocate
for immunisation, 50–94% of people who receive a
pharmacist’s recommendation to be immunised accepted
the recommendation (D: Grabenstein 1998, p72). The
author reports that pharmacists were authorised to
administer vaccines in 25 states and that over 5 million
doses of influenza vaccine per year were administered in
pharmacies. More than 1000 pharmacists received
training in vaccine administration in 1997 in the US.
A national US survey of pharmacists found that 2.2% and
0.9% of respondents reported being involved in adult
and paediatric immunisations respectively (B3: Madhavan
2001, p72). However, the low response rate (25.3% after
three mailings) makes the robustness of the findings
questionable. The study also explored perceived barriers
to pharmacists’ future involvement and these findings
might be used in educational and promotional
programmes to extend pharmacist provision of
immunisation.
In the Netherlands, 27 community pharmacists worked
with 42 local family doctors to promote vaccination (B3:
Support for non-physician
immunisation is greater for
adult than for child
immunisation (C1).
Pharmacy patient medication
records can be used for
case-finding of ‘at risk’ clients
to be invited for immunisation
and can increase the
percentage of the target
group immunised (B3).
Analysis / discussion point:
While there has been no
community pharmacy-based
provision of immunisation services
in the UK to date, the data from
the US show that such services
can be safely provided by
community pharmacists and that
they increase convenience for the
public. The potential to use
pharmacy-based patient
medication records to target
people for influenza immunisation
is considerable and should be
piloted in the UK.
Davidse & Perenboom 1995, p72). Medication data from
the pharmacists’ computerised patient medication
records were used to create a list of ‘at risk’ patients. The
doctors used the lists to select patients to be invited for
the influenza vaccination. Coverage of vaccination
increased by over 50% to 75.5% in the intervention
group, compared with an increase of 18% for a group of
comparable non-participating family doctors.
Head lice
A study of community pharmacists’ self-reported
behaviours in advising about head lice was conducted in
the UK (B3: Adie & Anderson 1998, p72). Half of the 34
pharmacists interviewed said they had checked hair in
the pharmacy, mainly when asked, and a further 12 said
they would do so if asked. Half of the pharmacists said
they followed local policy on which product to
recommend, with locum pharmacists being less likely to
be aware of current local policy. Pharmacists’
recommendations about product use and the need for
repeat applications were variable.
Oral health
Two studies were reviewed that explored pharmacists’
perceptions of their role in oral health. In a survey of
pharmacists in Greater Belfast, 25% reported receiving
formal education on oral health (B3: McVeigh & Kinirons
1999, p73). A South African survey found that community
pharmacists received substantial numbers of customer
inquiries on a range of oral health topics (B3: Gilbert 1998,
p73). While pharmacists were positive about this role few
had received education on oral health and there was little
evidence of networking with other health professionals.
A campaign to increase the proportion of sugar-free
medicines prescribed, dispensed and sold for paediatric
use was conducted in two test and two control areas of
the UK (B2: Maguire et al 1999, p73). Information was
provided to GPs and community pharmacists and
quantities of sugar-free medicines dispensed and sold
were tracked. There was a substantial increase in sugar-
free medicines prescribed and dispensed but only a small
increase in sugar-free medicines sold over the counter.
26
Analysis / discussion point:
Members of the public see
pharmacists as an approachable
source of advice and treatment for
head lice. The provision of this
service, however, appears
unstructured and requires further
assessment of its effectiveness.
Main findings:
Pharmacists are asked by their
customers to give advice on
oral health but training
received on this topic is
variable and evidence of the
effectiveness of their
interventions is lacking (B3).
Analysis / discussion point:
Members of the public view
pharmacists as an acceptable
source of advice on oral health,
but pharmacists’ contribution
appears to be limited by their
training.
27
Nutrition and physical activity
The literature search identified no individual studies on
these topics, although they were covered in some multi-
topic community pharmacy programmes, and were part
of some studies on heart disease prevention.
Multi-topic health promotion programmes
A city-wide community pharmacy health promotion
programme was established in Glasgow (C1: Coggans et
al 2001, p74). Five facilitators were appointed to provide
support for the pharmacists and a resource manual and
training were provided. Pre- and post-programme surveys
were conducted with 410 customers in 32 pharmacies.
The results showed an increase in the percentage of
customers who reported gaining useful health
information from interactions with pharmacists or
assistants or from health leaflets. More customers
reported discussions about general health when
collecting prescription medicines or purchasing over the
counter medicines, indicating that the programme
changed pharmacists’ behaviour in two important ways.
Firstly, pharmacists became more proactive in initiating
health discussions and, secondly, they introduced general
health topics.
In the UK, 10 community pharmacies participated in a
health authority based health promotion scheme (B3:
Blenkinsopp et al 2000, p74). Pharmacists provided advice
based on the transtheoretical model10 with brief (Level 1)
and extended (Level 2, 20 minutes) interventions. Health
topics covered were: oral health; physical activity;
smoking cessation; and use of medicines. Intervention
numbers were lower than expected, with the exception of
smoking cessation. User feedback showed that prior
perception of pharmacists’ involvement in health advice
was low but that the pharmacist’s input was invariably
received positively. The feasibility of providing Level 2
interventions in the pharmacy setting was questioned.
Although the intention was for pharmacists to use their
Main findings:
Support from facilitators
was associated with
pharmacy-based health
development activities with
high public uptake (C1).
User feedback from
pharmacy-based health
development activities is
generally very positive (B3).
Users’ awareness of
community pharmacies as a
source of general health
advice is low (B3).
Training increases the
length of consultation
between pharmacist and
clients on health issues (B2).
10 The transtheoretical model was developed and trialled by Prochaska and DiClemente in the
1980s. It has been commonly referred to as the ‘stages of change’ model, although this reflects
only one of its three key components.
patient medication records to target individuals for
advice, this rarely occurred.
In a scheme in one area of the UK, 14 community
pharmacies were randomly allocated to test (training)
and control groups (B2: Ghalamkari et al 1997a, p74,b,
p76). A further control group was also included.
Pharmacists were asked to record, for eight months, their
health promotion consultations on: smoking cessation;
pregnancy; sun and skin protection; blood pressure
monitoring; peak flow measurement; and infestations.
The test group pharmacists recorded a higher number of
consultations, although the difference between test and
controls was not significant. Pharmacists in the test group
recorded higher numbers of longer consultations (six
minutes or more) and the control pharmacists higher
numbers of brief consultations (one minute or less).
The nature and frequency of the involvement of
community pharmacists in health promotion was studied
in 20 community pharmacies in one area of the UK (B3:
Thompson et al 1995, p75). Pharmacists reported a mean
of 124 consultations on health promotion topics (range
46–328). Smoking cessation was the most frequently
reported topic (23% of consultations), followed by
healthy eating (7%) pregnancy testing (7%), and oral
health (6%). Health promotion advice was associated
with the sale of a medicine or other product in only 20%
of consultations.
Factors affecting the effectiveness of
community pharmacy-based activities
to improve health
Facilitators
The literature review identified two programmes that
explicitly mentioned the use of facilitators in a pharmacy-
based health promotion programme (C1: Coggans et al
2001, p74). In this Glasgow-based programme, five
community pharmacists were appointed on a part-time
basis as facilitators and each were responsible for a
locally-defined group of 40–45 pharmacies, linked to a
28
Analysis / discussion point:
Pharmacists are willing to
participate in large-scale health
promotion programmes and
training positively increases their
level of involvement. User
feedback from programmes of this
kind is positive and most report
gaining useful health information,
although their expectations of the
service are initially low. There is
no evidence available yet linking
increased interaction with
pharmacy staff to changes in user
behaviour or health outcomes.
Main findings:
Support from facilitators
increases the number of health
improvement consultations made
by community pharmacists (B3).
29
hospital pharmacy practice base. A year after the
programme began, one of the facilitators was appointed
to a post at the local health promotion department, with
a remit that included the development of community
pharmacy-based health promotion. This person was
subsequently able to provide a direct and continuous link
between the facilitator network, the local pharmacists,
and the health promotion department.
In a multi-topic health promotion programme the
appointment of a pharmacist facilitator during the
scheme resulted in increased interventions by the
participating community pharmacists (B3: Blenkinsopp et
al 2000, p74).
Training
Four studies investigated the effect of training (B2:
Anderson 1995, p75; B3: Anderson & Alexander 1997,
p76; B2: Ghalamkari et al 1997a, p74, B3: 1997b, p76;
B1: Sinclair et al 1998, p53). All concluded that training
was a key component in changing pharmacists’ behaviour
during specific health promotion programmes. Advice
from pharmacists trained in smoking cessation advice
techniques produced significantly higher quit rates
among smokers than pharmacists without training
(B1: Sinclair et al 1998, p53). Training resulted in longer
consultations between pharmacists and clients
(B2: Anderson 1995, p75; B3: Ghalamkari et al 1997b,
p76) and increased opportunistic health promotion
involvement (B3: Ghalamkari 1997b, p76; B3: Coggans et
al 2001, p74). Training was positively received by
pharmacists in all studies reviewed. The involvement of
other health professionals in future training programmes
was recommended (B3: Anderson & Alexander 1997,
p76). A review of UK literature suggested that training
on health promotion for pharmacists may lead to a more
holistic view of health (C1: Anderson 2000, p68).
Evidence that training in health promotion changes
pharmacists’ behaviour is provided by the findings of two
studies (B2: Anderson 1995, p75; C1: Coggans et al 2001,
p74). Anderson (1995), a covert research study, used a
‘simulated patient’ who presented at a random sample of
both community pharmacies where the pharmacist had
received training and an equal number of control
Main findings:
Training in smoking cessation
techniques increases
pharmacists’ effectiveness in
achieving higher quit rates
(B1).
Training changes pharmacists’
behaviour during specific
health promotion programmes
(B2).
Training in health
improvement increases the
time that community
pharmacists spend in
consultation with pharmacy
users and also increases user
satisfaction and opportunistic
health promotion advice (B3).
pharmacies where no training had been received. The
‘simulated patient’ was blind to the status of the
pharmacies visited. Pharmacists who had participated in
training not only spent longer with the client and asked
more questions, but the client felt more able to ask
questions during the consultation and was more satisfied
with these consultations. Coggans et al (2001) found
that, clients of pharmacists who had participated in
training reported that the pharmacist initiated more
discussions on general health matters rather than solely
on medicines.
Stakeholder views
Pharmacy users
Of those clients who had consulted with community
pharmacists in a local health promotion scheme in the
UK, 105 (72%) responded to a follow-up survey four
weeks later (B3: Ghalamkari et al 1997b, p76). Nearly
70% reported that they had followed the advice they
had received and only 4% reported that they had not
followed any aspect of the pharmacist’s advice.
A survey completed by 430 users of community pharmacy
schemes supplying EHC in the UK found that 91% felt
‘comfortable’ or ‘very comfortable’ about discussing
emergency contraception with the pharmacist (B3:
Anderson et al 2001, p68). This study explicitly addressed
users’ perceptions of privacy in the pharmacy and found
that 86% said there was sufficient privacy to talk to the
pharmacist comfortably. A further 90% were ‘satisfied’ or
‘very satisfied’ with the manner in which their request for
emergency contraception was dealt with. A minority
(16%) indicated that they were ‘concerned’ or ‘very
concerned’ that information about their request for
emergency contraception would not be kept confidential
by the pharmacy. Overall these findings demonstrate a
high level of user satisfaction. Although concerns about
confidentiality were only expressed by a minority of
users, this finding suggests that it would be useful to
provide more information to the public about
pharmacists’ professional responsibilities regarding
confidentiality of patient information.
30
Analysis / discussion point:
Both training and the use of
facilitators increase the
effectiveness and participation of
pharmacists in health improvement.
Main findings:
Pharmacy users report having
followed the health advice
given by pharmacists with
positive views on the
pharmacist’s input (B3).
Most pharmacy users perceive
there is sufficient privacy in
the pharmacy to discuss even
sensitive subjects (B3).
Awareness of pharmacy-based
leaflets on health topics is
higher for those clients taking
prescribed medicines (B3).
31
A survey of the views of ‘established’ users of four
community pharmacies in Ireland on the pharmacist’s role
in health education and promotion was completed by
112 (72%) respondents (B3: Hamilton 1998, p77). The
majority considered that the pharmacist was qualified to
discuss health matters, with 12% disagreeing. The
pharmacist was seen as the first source of health
information by 18% of respondents.
An interview-based survey of 1000 members of the public
in Northern Ireland (B3: Bell et al 2000b, p77) examined
the attitudes towards current and future roles of
community pharmacists in health promotion and health
screening. Support for both health promotion and
‘screening’ activities was highest in those aged under 60
years. Just over half the respondents said they would be
willing to pay for cholesterol testing and blood pressure
measurement in the pharmacy, with older patients more
likely to do so. Around 40% said they would be willing to
make an appointment with their pharmacist for health
promotion or screening.
In a major UK study involving interviews with 592
community pharmacy users, 77% preferred their GP as a
source of advice for ‘staying healthy’ and 8% the
pharmacist (C1: Anderson 1998a, p77; B3: 1998b, p78).
Overall, 40% agreed it was the pharmacist’s ‘usual job’ to
advise on staying healthy (prescription users being most
likely to agree), 19% disagreed, and 41% said they did
not know. Over 90% had noticed health topic leaflets in
their pharmacy and 30% had taken one or more leaflets
to read. Most of the users who had taken leaflets
reported finding them useful.
In a survey of health information requests by pharmacy
customers in Spain (C1: Dominguez 2000, p77), the
commonest topic was medicines (20.8%) and the least
frequent was the only topic related to general health –
diet and nutrition (5.5%).
A UK consumer survey of 427 ‘high users’ of community
pharmacies and of 358 members of the general population,
asked participants whether they had noticed or read
leaflets on health matters in the pharmacy (B3: Jesson et
al 1994, p78). Those who reported having read leaflets
were asked if they had found them useful. Two-thirds of
high users and half of the general population had
noticed leaflets in the pharmacy. Leaflets had been taken
and read by 37% of high users and 23% of others. The
authors conclude that passive display of leaflets meant
they were missed by many pharmacy users.
Pharmacists
A qualitative interview-based study was undertaken in
the UK with six community pharmacists who participated
in the Barnet ‘High Street Health’ programme (B3:
Anderson 1998b, p78). Participants gave broader
definitions of health after, than before, the programme.
Dispensing duties were reported to be a major constraint
on health promotion activity. The needs of patients with
asthma were a recurrent theme during the interviews.
There was little evidence that participation in the Barnet
programme had led to networking with other primary
care team members.
Community pharmacists’ self-reported current levels of
health promotion activity in one area of the UK were
studied using structured interviews with a stratified
sample of pharmacists (B3: Moore et al 1995, p78). Advice
was 2.5 times more likely to be reactively responsive
rather than proactively offered. Pharmacists generally felt
isolated and excluded from local health promotion
activities.
An interview-based survey of 48 community pharmacists
from one area of the UK explored current and future
participation in health promotion activities and potential
barriers to further involvement (B3: Keene et al 1994,
p78). More than three-quarters of the participants
believed health promotion activity was beneficial. Most
pharmacists indicated that they needed further training
in health promotion and that remuneration would be a
pre-requisite for further activity. Lack of training, time,
and space within the pharmacy were considered as
barriers by one-third of those interviewed.
32
Analysis / discussion point:
The majority of pharmacy users
value advice on health and
medicines given by pharmacists
and the literature suggests there
is potential to develop this role
further, for example, through
pharmacists more proactively
offering advice and leaflets.
Main findings:
Pharmacists attach a high
degree of importance to
health improvement (B3).
Pharmacists are more
comfortable with health
improvement activities that
are related to medicines and
need support to extend their
portfolio of health-related
work (B3).
Pharmacists’ advice is more
likely to be reactive rather
than proactive (B3).
Pharmacists’ concerns about
being ‘intrusive’ in offering
potentially unwelcome health
advice predisposes to a
reactive stance (B3).
Dispensing duties and a lack
of training, time and space
within the pharmacy are
widely reported to be key
barriers to pharmacists’
greater involvement in health
improvement (B3).
33
Perceptions of pharmacists of their health education role
and the practicalities of implementation (including
barriers) were investigated in an in-depth interview study
with 10 community pharmacists in the UK (B3: Benson &
Cribb 1995, p79). Pharmacists were clear about their
health education role in relation to prescribed medicines
but less so for topics not involving medicines. The authors
concluded that these uncertainties were not only related
to the undergraduate training of pharmacists which was
primarily based on the biomedical model of health, but
also to their expressed concerns about ‘interfering’ in the
lifestyles of pharmacy users.
A postal questionnaire study of community pharmacists’
views and experience of the Pharmacy Healthcare
Scheme (PHS) was conducted in Wales (B3: Mullan et al
1999, p79). Overall attitudes to leaflets were positive, but
the response rate was only 46%. Sources of leaflets used
were: PHS (76%), commercial (59%), and local Health
Promotion Units (HPUs; 41%). Leaflets from commercial
sources were perceived to fill gaps on topics not covered
by PHS or HPUs, and to be quickly obtainable with
plentiful supplies. Most pharmacists (88%) reported that
they had never received training or guidance on using
health information leaflets. The authors concluded that
there is scope to increase the use of PHS and HPU
leaflets. While the pharmacists in this study saw handing
out leaflets personally as being more effective than
leaving them for people to pick up there were no data
on the relative frequency of these two methods of
distribution. Therefore the extent to which pharmacists’
behaviour in practice concords with their expressed views
is not known.
Two Canadian surveys of the participation of community
pharmacists in health promotion activities were
reviewed. Few community pharmacists were found to
routinely practise prevention activities in a proactive way,
although 90% perceived prevention as being important
(B3: O’Loughlin et al 1999, p79). Pharmacy owners, those
working in pharmacies with a history of prevention
activities, and those reporting moderate to high job
satisfaction were more likely to report being involved.
Expressed interest was highest in screening for
hypertension, raised lipids and diabetes, and in methods
of monitoring compliance with medication for coronary
heart disease. In a survey of the extent of participation in
specific activities, the lowest reported rates were for
speaking to community groups on health-related
matters, participating in screening programmes, querying
clients on their smoking and occupational status, and
counselling on HIV prevention (B3: Paluck et al 1994,
p80). In contrast, the study found that pharmacists
reported participation most often in health promotion
activities directly related to the dispensing or selling of
medicines.
In a US study of 609 community pharmacists’ smoking
cessation-related activities, 39.5% of respondents
reported counselling people on smoking cessation at
least once a week and 42% had attended an educational
programme on smoking (B3: Williams et al 2000, p54).
Pharmacists believed that they were qualified to perform
smoking cessation interventions. Only 7.5% reported
routinely ascertaining users’ smoking status.
External stakeholders
Little research has been conducted on the views of
external stakeholders on the contribution of the
pharmacists to health improvement. One small UK study
compared the views of community pharmacists with
those of ‘pharmaceutical policy makers’: health authority
Pharmaceutical Advisers and Directors of Public Health
(B3: Ursell et al 1999, p80). About 44% of community
pharmacists and 65% of policy makers responded. The
current role of the pharmacist in public health provision
was perceived as ‘very important’ by 11% of policy
makers and 50% of community pharmacists. Financial
issues were identified as the most important constraint
on pharmacists’ public health involvement by 41% of
policy makers and 14% of community pharmacists, with
the latter perceiving lack of time as most important.
A 1995 telephone survey of pharmaceutical advisers of
English health authorities quantified local initiatives in
34
Analysis / discussion point:
Pharmacists are generally very
positive about the need for health
improvement activities in the
pharmacy and their role in
delivering this. In practice,
however, their approach tends to
be reactive rather than proactive
and centred around the use of
medicines rather than a more
holistic view of health.
35
health improvement that involved community
pharmacists (B3: Anderson 1996, p80). The survey
achieved an 86% response rate and found that 57% of
health authorities reported one or more health
promotion activities involving pharmacists. The main
barriers perceived by the pharmaceutical advisers were
lack of funding and insufficient resources for local
development, support and facilitation. The strength and
nature of relationships between the health authority,
Local Pharmaceutical Committee and Health Promotion
Unit were seen as a critical success factor in enabling
local activity.
Analysis / discussion point:
Further investigation is needed
into the perceptions of the
pharmacy’s role in health
improvement by local health
service planners and
commissioners and pharmacy’s
contribution to local planning
processes. Insufficient resources
for development, support and
facilitation locally have been
suggested as possible barriers.
37
4 DISCUSSION
Generalisability of the findings
Published evidence demonstrates that pharmacists can
make a positive contribution to improving the public’s
health. While the generalisability of the findings of
smaller individual studies is limited, for most health
topics there were groups of small studies indicating
positive impact. The extent of any submission and
publication bias is not known.1
The review identified many published studies of the
effects of interventions by pharmacists in health
improvement. Although the number of RCTs was small,
there was a substantial number of intervention studies.
The studies were heterogeneous in terms of design and
outcome measures, and the robustness of study design
was variable. It is noteworthy, however, that a RCT design
would not have been appropriate to answer some of the
research questions addressed in these studies – a
perennial issue in public health research. This is
particularly true where the key issue was whether
widening access to a service could be achieved safely and
acceptably through pharmacies, as was the case, for
example, with the supply of emergency hormonal
contraception and provision of immunisation services.
Whilst there were multi-pharmacy trials in a number of
health topic areas, many of the intervention studies were
small in scale, with several involving a single pharmacist
delivering the intervention, therefore the generalisability
of these study findings is limited. The findings of this
review should therefore be considered together with the
evidence produced by the additional reports in this series
(see ‘Introduction’ for more details).
Key discussion points
The evidence from the peer-reviewed literature is
sufficiently comprehensive in the areas of smoking
1 In clinical medicine it is recognised that studies showing positive results are more likely to be
published while the converse is the case for those where results are neutral or negative. In
pharmacy health development there have been many local developmental and pilot studies, few
of which have resulted in publications.
cessation and lipid management, emergency
contraception and immunisation, that recommendations
for their widespread implementation in pharmacies can
be made. Further piloting in the UK may be desirable for
those activities for which only international data exists, in
particular, immunisation and lipid management.
Other activities look promising – for example, diabetes
and anti-coagulation monitoring and weight-reduction
programmes, but would benefit from further research.
Better quality research is also needed in other areas, for
example, to test the effectiveness of pharmacy-based
interventions, such as advice on folic acid or skin cancer
prevention, on pharmacy users’ subsequent attitudes and
behaviour.
Public response to the involvement of pharmacists in
health improvement appears, at times, to be
contradictory. When asked in a theoretical way about
whether they perceive the pharmacist to have a role in
providing general health advice, the public’s response
tends to be cautious. However, when such advice and
services are offered the uptake is generally good,
suggesting that the public currently has low expectations
of the community pharmacist in providing general health
advice.
There was relatively little published research into users’
views of services being tested, and little evidence of user
involvement in the development of the services
themselves. Future research needs to have both greater
user input to intervention and service design, and
incorporate more feedback from users.
Some members of the public are undoubtedly willing to
take up the advice and services offered by pharmacies,
and it appears that those currently most likely to do so
are already regular clients for prescribed medicines. This
creates a paradox that while community pharmacies are
visited by the healthy as well as the sick, the former
group may be the most difficult to engage.
38
39
Indeed, the results of research to date suggest that
pharmacists are currently more likely to engage in health
improvement activities that are linked to medicines use
in some way. The literature also indicates that, at
present, pharmacists tend to take a reactive rather than
proactive approach to health improvement. There is
some evidence that this may result from pharmacists’
concerns that unsolicited advice about non medicine-
related subjects may be rejected by pharmacy users.
Endorsement of pharmacists’ involvement in health
improvement by other stakeholders (including referrals
to pharmacies), and changes to remuneration
arrangements could allow and encourage pharmacists to
become more proactive in their approach to healthier
users thus also increasing public awareness of advice and
services available.
The studies reviewed showed most pharmacists to be
positive about their potential contribution to health
improvement, although the constraining effects of
pharmacists’ current working practices, existing
remuneration arrangements, and some community
pharmacy premises were well-described. Training appears
to be key in changing community pharmacists’ practice to
incorporate health improvement activities and
embedding a more holistic approach to client care. The
published evidence highlights the value of training in
helping pharmacists change their behaviour to deliver
effective health improvement activities.
41
5 CONCLUSIONS
The peer-reviewed literature clearly demonstrates the
potential of community pharmacists to contribute to
improving the public’s health.
The evidence from the reviewed literature is sufficiently
comprehensive in the areas of smoking cessation, lipid
management, emergency contraception, and
immunisation, that recommendations for their
widespread implementation in pharmacies can be made.
Further piloting in the UK may be desirable for those
activities for which only international data exists, in
particular, immunisation and lipid management, and this
research should commence as soon as possible.
The review identified a number of areas where further
research is needed; for example, in diabetes monitoring
and education. The lack of strategic research is a
weakness in the published evidence that needs to be
addressed – for example, research on the role of the
pharmacy in neighbourhood regeneration and renewal
would complement this work but is not available.
Funding also needs to be provided to address specific
research questions in relation to pharmacy involvement
with health improvement and any ensuing training needs.
From the pharmacy profession’s perspective, the
development areas lie in encouraging greater proactivity
through opportunistically offering advice, and improving
the training of pharmacists in dealing with health
improvement topics that are not directly related to
medicines use. It will also be necessary to consider and
address existing constraints of community pharmacy
practice, remuneration arrangements and premises
where appropriate.
From other stakeholders’ perspectives endorsing the use
of pharmacies and thus extending the public’s awareness
of the pharmacist’s role in giving health advice is key.
Health commissioners and planners can use the findings
of this review to incorporate community pharmacy-based
health improvement activities into local health services.
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47
49
Appendix 1. Search terms used for
MEDLINE, EMBASE and International
Pharmaceutical Abstracts
1. pharmacists ti,ab,sh
2. community pharmacy ti,ab,sh
3. community pharmacy services ti,ab,sh
4. pharmacies ti,ab,sh
5. pharmaceutical services ti,ab,sh
6. #1 or #2 or #3 or #4 or #5 and health education
ti,ab,sh
7. #1 or #2 or #3 or #4 or #5 health promotion ti,ab,sh
8. #1 or #2 or #3 or #4 or #5 public health ti,ab,sh
9. pharmac* and smoking cessation ti,ab,sh
10. pharmac* and diet ti,ab,sh
11. pharmac* and body weight ti,ab,sh
12. pharmac* and coronary heart disease ti,ab,sh
Appendix 2. Search terms used for
Cochrane Library database
(COMMUNITY and PHARMACY)
(COMMUNITY and PHARMACIST)
PHARMACY
PHARMACIST
PHARMACISTS
PHARMACIES
(((((#1 or #2) or #3) or #4) or #5) or #6)
HEALTH-EDUCATION *:ME
HEALTH-PROMOTION
PUBLIC-HEALTH
COMMUNITY-PHARMACIST
COMMUNITY-PHARMACY
(#8 or #9)
(((((#1 or #2) or #3) or #4) or #5) or #6)
(#12 and #13)
(((((#1 or #2) or #3) or #4) or #5) or #6)
SMOKING-CESSATION*:ME
(((((#1 or #2) or #3) or #4) or #5) or #6)
(#15 and #16)
DIET*:ME
(((((#1 or #2) or #3) or #4) or #5) or #6)
(#18 and #19)
BODY-WEIGHT*:ME
(((((#1 or #2) or #3) or #4) or #5) or #6)
(#21 and #22)
CORONARY-DISEASE*:ME
(((((#1 or #2) or #3) or #4) or #5) or #6)
(#24 and #25)
CORONARY-DISEASE
(((((#1 or #2) or #3) or #4) or #5) or #6)
(#27 and #28)
50
51
Appendix 3. National Service
Frameworks: categorisation of evidence
The Department of Health categorises individual studies
according to the standard classification set out in its
National Service Frameworks:
Evidence from research and other professional literature
A1 Systematic reviews which include at least one
Randomised Controlled Trial (RCT) e.g. Systematic
reviews from Cochrane or NHS Centre for Reviews
and Dissemination.
A2 Other systematic and high quality reviews which
synthesise references.
B1 Individual RCTs.
B2 Individual non-randomised,
experimental/intervention studies.
B3 Individual well-designed non-experimental studies,
controlled statistically if appropriate. Includes studies
using case control, longitudinal, cohort, matched
pairs or cross-sectional random sample
methodologies, and well-designed qualitative
studies, well-designed analytical studies including
secondary analysis.
C1 Descriptive and other research or evaluation not in B
(e.g. convenience samples).
C2 Case studies and examples of good practice.
DSummary review articles and discussions of relevant
literature and conference proceedings not otherwise
classified.
52
Appendix 4. Details of reviewed evidence
The abstracted papers are listed by health topic in the order the
findings are included in the ‘Results’ section of the report. Each paper
has an evidence grading (see ‘Introduction – Criteria for inclusion of
evidence’ and Appendix 3 for an explanation of the categorisation of
grades used). Abbreviations used: RCT, randomised controlled trial;
PAS, Pharmacist Action on Smoking; CP, community pharmacy; NRT,
nicotine replacement therapy; PMR, patient medication record; PCSQ,
pharmaceutical care satisfaction questionaire; N/A, not applicable;
CHD, coronary heart disease; CV, cardiovascular; QOL, quality of life;
TBC, total blood cholesterol; OTC, over the counter; INR, international
normalised ratio; NEP, needle exchange programme; ECP, emergency
contraceptive pill; CDTA, collaborative drug therapy agreements; EHC,
emergency hormonal contraception; PGD, patient group direction;
NIDDM, non-insulin dependent diabetes mellitus.
Contents
Smoking cessation 53
Coronary heart disease 56
Lipid management 56
Identifying pharmacy users with risk
factors for CHD 59
Secondary prevention with aspirin 61
Anticoagulation 62
Obesity and weight reduction 62
Skin cancer prevention 62
Drug misuse 63
Emergency hormonal contraception 66
Folic acid and pregnancy 68
Asthma 68
Diabetes 69
Immunisation 70
Head lice 72
Oral health 72
Multi-topic health promotion programmes 73
Factors affecting the effectiveness of community
pharmacy-based activities to improve health 74
Training 74
Stakeholder views 75
Pharmacy users 75
Pharmacists 77
External stakeholders 79
53
Study/authors Maguire TA, McElnay JC &
Drummond A. Addiction (2001) 96: 325–31.
A randomised controlled trial of a smoking cessation
intervention based in community pharmacies. B1 UK
Study design and participants RCT comparing
a structured intervention (PAS model) with usual
care. 100 CPs in N Ireland and 24 in London were
recruited and trained. Each CP was asked to recruit
12 smokers. 44% of pharmacists who were trained
recruited one or more smokers in approx. one year.
484 smokers were enrolled and randomised into
intervention (n=265) and control (n=219).
Interventions The PAS intervention involved a
structured counselling programme, an information
leaflet, weekly follow-up for the first 4 weeks and
monthly thereafter as needed. Pharmacists were
sent the PAS model and a literature review on
smoking cessation and asked to study the material
before attending a 3-hour workshop. The
pharmacists were subsequently visited by a
researcher.
Outcome measures Primary outcome: self-
reported smoking cessation at 12 months with
cotinine validation at the 12-month follow-up.
Results 14.3% (38) of PAS group were abstinent
at 12-month follow-up compared with 2.7% (6)
controls (P<0.001). Only a minority of the
pharmacists who expressed an initial interest took
part in the study and many of these could not
recruit patients at the desired rate. Lack of time
and remuneration were the major barriers.
Conclusions The CP-based PAS service can be an
effective method for smoking cessation when
delivered by pharmacists willing to adopt this
approach. Questions remain about the proportion
of pharmacists who will be interested in becoming
involved in interventions of this kind.
Study/authors Sinclair HK, Bond CM, Lennox AS,
Silcock J, Winfield AJ & Donnan PT. Tob Control
(1998) 7: 253–61.
Training pharmacists and pharmacy assistants in
the stage of change model of smoking cessation: a
randomised controlled trial in Scotland. B1 UK
Study design and participants RCT comparing
counselling for smoking cessation based on ‘stage
of change’ model with usual care. 62 (82%) non-
city pharmacies in Grampian – 54 pharmacists and
54 assistants – attended the training. 492 smokers
(224 intervention, 268 controls) over 12 months.
Interventions Pharmacists provided smoking
cessation advice based on the client’s ‘stage of
change’. Pharmacists and assistants participated in
a one-evening training session. The training aimed
to give participants an understanding of the ‘stage
of change’ model, and focused on brief
questioning which could enable counsellors to
assess the stage of individual customers and to
subsequently increase the frequency and
effectiveness of the counselling support by
tailoring their advice to the current stage of the
customer.
Outcome measures Self-reported smoking
cessation rates for the two groups of customers at
1, 4 and 9 months. Perceptions of customers and
pharmacy personnel of the pharmacy support and
advice received.
Results At 1 month, prevalence of abstinence
was claimed by 30% of intervention and 24% of
controls; at 9 months, 12% of intervention and 7%
of controls. Intervention customer respondents
were significantly more likely to have discussed
stopping smoking with pharmacy personnel – 85%
(113) compared with 62% (99) of controls
(P<0.001). Intervention customers also rated their
discussion more highly.
Conclusions The intervention was associated
with increased and more highly rated counselling
and a trend towards higher smoking cessation
rates, indicating that pharmacy personnel can
make a significant contribution to national targets.
SMOKING CESSATION
Study/authors Sinclair H, Silcock J, Bond CM,
Lennox S & Winfield AJ. Int J Pharm Pract (1999) 7:
107–12.
The cost-effectiveness of intensive pharmaceutical
intervention in assisting people to stop smoking.
B1 UK
Study/authors Williams D, Freeman Newson J &
Penick Brock T. J Am Pharm Assoc (2000) 40: 366–70.
An evaluation of smoking cessation-related
activities by pharmacists. B3 US
Study design and participants Postal
questionaire survey. Distributed to 541 CPs in
North Carolina and 946 in Texas in October 1997.
A random stratified sample extracted from
registers of CPs.
Outcome measures Types of smoking
interventions performed by community pharmacists;
smoking cessation knowledge and activities;
perceived barriers to providing these interventions.
Results Response rate 609 (41%); 396 (65.8%)
sold tobacco products at practice site. 235 (39.9%)
had control over whether tobacco was stocked.
North Carolina pharmacies more likely to sell
tobacco products. 42% had attended an
educational programme on smoking. Only 45
(7.5%) routinely checked people’s smoking status.
320 (39.5%) had counselled people regarding
smoking cessation on at least a weekly basis.
Exploratory factor analysis indicated that barriers
to interventions included pharmacists’ personal
characteristics, practice site considerations, patient
characteristics and financial considerations.
Conclusions Although pharmacists believe that
they are qualified to perform smoking cessation
interventions they do not routinely identify
Study design and participants RCT comparing
‘standard’ with ‘intensive’ pharmaceutical support
for smoking cessation. 62 community pharmacies
took part. Costs to the health service, pharmacies
and clients were recorded. Effectiveness of training
was assessed by comparing quit rates at 1, 4 and 9
months.
Interventions Smoking cessation advice tailored
to clients’ ‘Stage of Change’.
Outcome measures Cost of producing one
additional successful attempt to quit smoking
using intensive rather than standard
pharmaceutical support.
Results The cost of producing one additional
successful attempt to quit smoking was £300 or
£83 per life year.
Conclusions The intervention was associated
with higher smoking cessation rates. The key
determinants of the incremental cost-effectiveness
ratio were the number of quitters, the costs of
training and the costs of NRT. Comparable studies,
say the authors, show greater costs per quitter for
physician intervention and lesser costs per quitter
as a result of mass media campaigns.
54
Study/authors Crealey G, McElnay JC & Maguire
TA. Pharmacoeconomics (1998) 12: 323–33.
Costs and effects associated with a community
pharmacy-based smoking cessation programme.
B1 UK
Study design and Participants A before and
after study of pharmacist advice on smoking
cessation based on PAS model. Pilot study in two
Belfast pharmacies over a 2-year period, 52 people
entered a smoking cessation group (group 1), 48
people who bought NRT were also followed up
(group 2).
Interventions The PAS model was used. The 4
stage model involves a written contract between
the patient and pharmacist (including a stop date)
and a series of brief counselling meetings over
approximately 6 months.
Outcome measures The aim was to determine
costs and effects associated with the PAS
programme, using the perspective of the payer in
the main analysis.
Results The cost per life-year saved when using
the PAS programme ranges from £196.76 to
£351.45 for men and from £181.35 to £722 for
women (1997 values) depending on age. This
compares favourably with other disease prevention
medical interventions such as hypertension or
hypercholesterolaemia.
Conclusions These findings, the authors state,
provide an argument for adoption and
remuneration of the PAS model in the CP setting.
55
smokers. Pharmacists should strongly consider the
conflicting message communicated by selling
tobacco products in a health care facility.
Study/authors Wick M, Ackermann-Liebrich U,
Bugnon O & Cerise C. Soz praventivmed (2000) 45:
73–84.
Evaluation of the Swiss Society of Pharmacists’
campaign ‘Future non-smoker’. (German paper,
English abstract.) B3 Switzerland
Study design and participants A before and
after study of the effects of a smoking cessation
campaign. 616 Swiss pharmacies were invited to
participate.
Interventions Pharmacists provided smoking
cessation advice.
Outcome measures Documented smoking
cessation consultations 1 week before and 6 weeks
after the campaign. Pharmacists’ perceptions of
their smoking cessation counselling and attitudes
towards the campaign.
Results 32% of pharmacists completed activity
statistics, 58% completed the attitudinal survey.
Frequency of counselling was best predicted by
customer pattern. The highest frequency was
observed among pharmacies with a majority of
non-regular customers. Intensity of counselling was
predicted by prior training. Those who counselled
most frequently were most likely to have most
positive views of smoking cessation.
Conclusions Pharmacists can play a role in
offering low threshold smoking cessation
programmes. Important pre-requisites are
motivation with regard to prevention as well as
continuing education of pharmacists and pharmacy
personnel.
Study/authors Isacson D, Bingfors C & Ribohn M.
J Soc Admin Pharm (1998) 15: 164 –73.
Quit smoking at the pharmacy – an evaluation of a
smoking cessation programme in Sweden. B3
Sweden
Study design and participants A ‘before and
after’ study. 20 Pharmacies took part in an 8-week
smoking cessation programme. Clients paid 750
SEK (£70) to participate which included one free
week’s NRT. Postal questionnaire to participants at
end of course and at 2, 6, and 12 months. Those
who answered the questionnaire received a lottery
ticket.
Interventions There were six 1.5-hour meetings
in each pharmacy. Pharmacists received 2 days’
intensive training as group leaders and on group
dynamics with lectures, role plays and discussion
with other health care professionals involved in
smoking cessation.
Outcome measures Smoker or non-smoker at
the end of the intervention and at 3, 6 and 12
months.
Results 140 people participated, 126 answered
the first questionnaire, 114, 107, and 109 answered
the questionnaire at 3, 6, and 12 months. 60%
reported that they had stopped smoking during
the intervention, 45% at 3 months, 42% at 6
months and 33% at 1 year. 65% used NRT. 82%
had a good impression of the programme. They
thought the price of the course was high although
employers had paid for most of it.
Conclusions The programme was delivered in
collaboration with other health professionals and
provides a good example of how pharmacists can
work together with other primary health care
professionals.
Study/authors Tsuyuki RT, Johnson JA, Teo KK et
al. Ann Pharmacother (1999) 33: 91019.
Study of cardiovascular risk intervention by
pharmacists: a randomised trial design of the
effect of a community pharmacist intervention
programme on serum cholesterol risk.
B1 Canada
See also
Tsuyuki RT, Johnson JA, Teo KK, et al. Can J Cardiol
(2000) 16: 107.
A randomised trial of the effect of community
pharmacist intervention on cholesterol risk: the
study of cardiovascular risk intervention by
pharmacists. B1 Canada
Study design and participants RCT of
pharmacist intervention in patients at high risk of
vascular events. 54 community pharmacies in
Alberta and Saskatchewan.
Interventions Intervention and ‘usual care’
patients receive written information about
cardiovascular risk factors. In addition, the
pharmacist interviews the patients and completes
physician contact form listing patient’s risk factors,
medication, and any recommendations.
Pharmacists provided education on management
of risk factors identified. Pharmacist conducted
cholesterol test, measured blood pressure and
discusses findings with patient. Referrals to
physician based on protocol. Follow-up at 2, 4, 8,
and 16 weeks. Pharmacists took part in training
sessions to review management of heart disease
risk factors, especially hyperlipidaemia, and study
procedures. The study had a 24-hour helpline
available for pharmacists’ queries and to ensure
randomisation. Investigator meetings were held
every 5–6 weeks plus monthly study newsletter.
56
CORONARY HEART DISEASE
Lipid management
Study/authors Nola KM, Gourley DR, Portner TS,
Gourley GK, Solomon DK, Elam M & Regel B.
J Am Pharm Assoc (2000) 40: 166–73.
Clinical and humanistic outcomes of a lipid
management programme in the community
pharmacy setting. B1 US
Study design and participants RCT comparing
pharmacists’ intervention (advice on diet, exercise
and medication) with usual care (controls).
One independent community pharmacy took part.
Follow-up was at 6 months. Service provided by
‘Pharmacist investigator’ not the ‘Pharmacy owner’.
Interventions Patients identified using pharmacy
PMRs and self-referrals in response to publicity
about cholesterol screening at the pharmacy. PMRs
were searched to find patients with minimum
6-month history of use of specific medications in
hypertension and diabetes. A letter was sent to
these patients inviting them for cholesterol
screening. Patients attending one of five screening
days completed a CHD risk questionnaire. Blood
samples were taken by a nurse and sent for
testing. A follow-up visit by the patient was
arranged for 10 days later when the results were
discussed. Patients were referred to their doctor
according to guidelines. The pharmacist advised on
diet and exercise and provided information about
treatment. Food frequency charts and exercise
diaries were used. Patients were seen at 1–2 month
intervals depending on their progress.
Outcome measures Lipid levels at baseline, 3
and 6 months; achievement of target lipid levels.
CHD risk factor scores. Treatment adherence was
assessed through prescription refill data. Patient
satisfaction with pharmacy service assessed using
PCSQ administered by a pharmacy technician.
Results 191 patients were screened (105 ‘walk-
ins’ and 86 ‘invitees’) and 51 (25 intervention, 26
control) took part in the study. Response to the
letter of invitation was 19%. 32% of intervention
group and 15% control group patients achieved
target lipid levels. Risk factor scores improved in
the intervention group and worsened in controls.
Knowledge about hyperlipidaemia improved in the
intervention group but there were no significant
between-group differences. Patient satisfaction
data was difficult to interpret as baseline data
related to ‘pharmacist owner’ and post-study to
‘pharmacist investigator’.
Conclusions The follow-up period (6 months)
was short. Lipid levels may have been subject to
confounding by seasonal effect.
57
Outcome measures Lipid profiles; addition or
modification of lipid lowering therapy. Patient
satisfaction, quality of life.
Results Data were analysed for 565 patients.
Average age was 64 years and 39% were female.
The primary endpoint was reached in 58% of
Study/authors Simpson SH, Johnson JA & Tsuyuki
RT. Pharmacotherapy (2001) 21 (5): 627–35.
Economic impact of community pharmacist
intervention in cholesterol risk management: an
evaluation of the study of cardiovascular risk
intervention by pharmacists. B1 Canada
Study design and participants RCT of
pharmacist intervention was conducted in 54
community pharmacies in Canada.
Interventions Cost analysis of CP intervention was
carried out assuming improvement in CV risk factor
management would translate into reduction in
risk. Perspectives of government and community
pharmacy managers were adopted to identify
resource utilisation and costs. A decision analysis
framework was used to identify possible events
occurring as a result of the pharmacist–patient
interaction.
Outcome measures Change in CV risk
(quantified by the Framingham risk function) was
Study/authors Shibley CH & Pugh CB.
Ann Pharmacother (1997) 31: 713–19.
Implementation of pharmaceutical care services for
patients with hyperlipidaemias by independent
community pharmacy practitioners. B3 US
Study design and participants A ‘before and
after’ study involving two independent community
pharmacies. Pharmacists received knowledge-based
training on lipid disorders and therapy with case
studies. Training involved analysis of two patient
profiles from pharmacists’ own practice and
simulated patient interviews. Training on the study
protocol included guidelines for cholesterol
measurement, diet, exercise, and follow-up.
Pharmacists also received training on use of lipid
testing equipment.
Interventions Pharmacists measured lipids,
blood pressure and weight. Initial counselling was
on non-drug approaches. Referral for drug
intervention patients and 30% in ‘usual care’
(P=0.001). Each component of the primary
endpoint was also improved.
Conclusions Community pharmacist intervention
improves lipid management.
used to predict impact of the pharmacist’s
intervention on health outcomes. Patients
reported numbers of physician visits, nature and
frequency of adverse drug events and actions
taken to treat them.
Results Sufficient information was available to
calculate the change in the Framingham risk
estimate for the intervention group. Cost
identification was carried out for intervention and
control groups. Costs to government healthcare
funders were estimated to be Can. $6.40 per
patient per 4 months (covering physician visits and
tests). Costs to the community pharmacy manager
would be Can. $22 per 4 months. The 10-year risk
of CV disease for patients in the intervention
group decreased during the 4-month study period
by 5.2%, from 17.3% to 16.4% (P<0.0001).
Conclusions The 10-year risk of cardiovascular
disease was significantly reduced for patients in
the intervention group. Costs of providing the
service were calculated.
treatment if needed at 3 months for patients with
existing CHD, 6 months otherwise. Patients also
saw a dietitian. Follow-up was conducted by the
pharmacist. Summaries provided (with patients’
consent) at 6 and 12 months.
Outcome measures Lipid levels at baseline, 6
and 12 months; SF-36 survey; pre- and post-study
patient satisfaction (MacKeigan-Larson
questionnaire). Pre and post-study knowledge
assessment completed by pharmacists.
Results 25 patients completed the study, of
whom eight were taking lipid-regulating
treatment on entry but lipids were not adequately
controlled. At the end of the study 14 patients
were taking lipid-lowering treatment. Total lipid
and LDL were significantly decreased at 12 months
compared with baseline or 6 months (P<0.02).
Significant improvement in QOL and patient
satisfaction. Patients reported more positive
perceptions of pharmacist’s role. Pharmacists’
Study/authors Bluml BM, McKenney JM &
Cziraky MJ. J Am Pharm Assoc (2000) 40: 157–65.
Pharmaceutical care services and results in Project
ImPACT: hyperlipidaemia. B3 US
Study design and participants Observational
study with 2-year follow-up. 26 of an initial 32
community-based ambulatory care pharmacies in
12 states. Sites selected according to:
private/semiprivate consultation area; technician
suppport; documentation system for recording and
tracking interventions; experience with patient-
focused disease management programmes;
demonstrated communication skills; ability to
implement point-of-care lipid testing (US).
Pharmacists received a 2.5 day training programme
(later certificated by the American Pharmaceutical
Association).
Interventions ImPACT (Improve persistence and
compliance with therapy). Patients either newly
diagnosed or on treatment but dyslipidaemia not
controlled. ‘At risk’ patients referred by doctors
(15%), identified by pharmacists (60%), patient
self-referral (13%), or community screening events
(12%). Patients gave written consent for
pharmacists to receive medical information.
Appointment-based system. Pharmacists collected
data from patients to assess CHD risk, conducted
test for fasting lipid profile. Risk factors and
Study/authors Ibrahim OM, Catania PN, Mergener
MA & Supernaw RB. DICP (1990) 24: 817–21.
Outcome of cholesterol screening in a community
pharmacy. B3 UK
Study design and participants A ‘before and
after’ design. Six-month uncontrolled study based
in one community pharmacy.
Interventions Obtaining TBC levels, reporting
results to patients, patient education on lipids and
Study/authors Madejski RM & Madejski TJ. J Am
Pharm Assoc (1996) NS36: 243–8.
lifestyle changes discussed. Patients invited for
monthly follow-up for 3 months, then quarterly.
Patients and their doctors received information on
lipid test results, CHD risk and target lipid goals.
Outcome measures Rates of patient persistence
and compliance with lipid-regulating therapy;
achievement of target lipid levels. Compliance
assessed through number of missed doses and refill
timing. Defined as non-compliant if more than five
doses missed or more than 5 days late for refill.
End of study site survey to identify facilitating
factors and experiences with obtaining payment
for the service.
Results 397 of 574 patients completed the 2-year
study. 345 were treated with lipid-regulating
drugs; 52 (13.1%) used lifestyle modification only.
38.5% were newly diagnosed, 61.5% were poorly
controlled. 346 interventions were made of which
265 (76.6%) were implemented by the doctor.
Observed rates for persistence and compliance
with treatment were 93.6% and 90.1%. Target
lipid levels were achieved by 62.5% patients.
First visit, mean 45 mins (range 30–60); follow-ups,
mean 22 mins (range 10–30). 64 (53%) of 121 third
party funders paid an average of US $30 per visit.
Conclusions Pharmacists contributed to
improved management of dyslipidaemia.
health, explanation of heart disease risk factors,
follow-up.
Outcome measures TBC levels.
Results Of 241 people tested, 57 had elevated
TBC and 51 completed the study. There was a
significant decrease in TBC between visits one and
two but not between visits two and three.
Conclusions A community pharmacy-based
cholesterol screening program resulted in
decreased TBC levels.
Cholesterol screening in a community pharmacy.
B3 US
58
knowledge of lipid management improved
significantly.
Conclusions Non-drug measures had ‘a modest
impact’ on total lipids and LDL. Drug therapy
resulted in a greater reduction. Significant
improvements in lipid control, patient satisfaction
and patients’ perception of pharmacist’s role.
59
Study design and participants A ‘before and
after’ design. One community pharmacy
participated.
Interventions Free cholesterol screenings were
advertised in newspapers and the pharmacy.
Patients made an appointment by telephone and
were interviewed for risk factors.
Results A total of 539 patients participated, of
whom 78% had elevated cholesterol levels. About
Study/authors Gardner SF, Skelton DR, Rollins SD
& Hastings JK. Pharmacotherapy (1995) 15: 292–6.
Community pharmacy databases to identify
patients at high risk for hypercholesterolaemia. B3
Canada
Study design and participants Case-finding
using searches of pharmacy PMRs. Databases held
by four community pharmacies were searched.
Interventions Community pharmacy databases
were searched for patients prescribed beta
blockers, thiazide diuretics, oral hypoglycaemics,
insulin, sublingual nitrates, nicotine gum, nicotine
patches. These patients were invited to attend for
cholesterol screening. Testing was also available to
other pharmacy customers.
Study/authors Simons LA, Levis G & Simons J.
Med J Aust (1996) 164: 208 –11.
Apparent discontinuation rates in patients
prescribed lipid lowering drugs. B3 Australia
Study design and Participants Prospective
survey of 12 months dispensing data from 138
community pharmacies in Sydney.
Interventions Patients who stopped having their
prescription for a lipid lowering drug dispensed
were asked why they had stopped treatment.
Outcome measures Number of patients failing
to collect prescription refills.
85% of the latter group were followed up.
Lifestyle modifications were reported by 85%,
information on diet was requested by 81%, and
23% accepted the offer for re-screening.
Conclusions The community pharmacy is an
easily accessible site for cholesterol screening that
is acceptable to patients. Pharmacies may also
benefit financially from increased dispensing of
lipid lowering medication.
Outcome measures Cholesterol levels of
screened patients.
Results 426 patients were identified from the
pharmacy records. Of these, 88 attended for
cholesterol screening. An additional 97 ‘walk-ins’
were also tested. Cholesterol levels were
significantly higher in patients in the targeted
group. Borderline levels were found in 36% of the
invited and 30% of the walk-in groups. High levels
were found in 32% and 19% respectively.
Conclusions Targeting patients using data from
PMRs was an effective method for identifying
patients with raised lipid levels.
Results 610 patients were identified. 60%
apparently discontinued their statin during the
study period. Half of the apparent discontinuations
occurred within 3 months of starting treatment
and a quarter after 1 month. The relative risk of
discontinuation was higher in those showing early
evidence of poor compliance. The main reasons
given by patients for discontinuation were:
unconvinced of need for treatment (32%), poor
efficacy (32%) and adverse events (7%).
Conclusions Discontinuation rates for statins
were high and patients’ reasons for stopping
treatment indicate scope for intervention.
Identifying pharmacy users with risk factors for CHD
Study/authors Allison C, Page H & George S.
J Epidemiol Community Health (1994) 48: 178–81.
Screening for coronary heart disease risk factors in
retail pharmacies in Sheffield, 1992. B3 UK
Study design and participants Questionnaire
survey of all community pharmacies on the
Sheffield Family Health Services Authority list (102).
Outcome measures Numbers of pharmacies
currently offering screening tests and stated
future intent to do so.
Results Response rate was 75% (77). Nine (12%)
offered screening tests other than pregnancy
testing. Overall 37 (48%) indicated that they might
Study/authors Flobbe K, Ljsselmuiden CB,
Rheeder P, Gerber JJ & Lubbe M. S Afr Med J
(1999) 89: 980–6.
The pharmacy screening project – an evaluation of
pharmacy-based screening programmes. B3
South Africa
Study design and participants Cross-sectional
survey of pharmacists providing diagnostic testing
services. Survey of 198 community pharmacies in
three areas of South Africa. Pharmacies were
initially contacted by phone to identify those
providing ‘screening’ services. Those doing so and
who agreed to participate were visited and a
questionnaire was administered.
Outcome measures Proportion of community
Study/authors Jungnickel PW & Wisehart DA.
J Am Pharm Assoc (1997) NS37: 640–6.
Evaluation of community pharmacists’ experiences
with cholesterol screening programs. B3 US
Study design and participants Cross-sectional
survey of pharmacists. Postal questionnaire of
pharmacists in charge at all Nebraska community
pharmacies.
Interventions N/A
Outcome measures Number of pharmacists
reporting cholesterol test provision from their
offer tests in the future. Pharmacies offering or
likely to offer screening were more likely to be
owner proprietors. The most frequent comments
by respondents were about the commercial
viability of screening and lack of space to ensure
privacy/confidentiality.
pharmacies providing screening, types of test used,
costs to patients, criteria for selection of target
groups, pharmacists’ knowledge about the
screening tests they used and their attitudes
towards screening.
Results Overall 57% of pharmacies provided at
least one screening test. Blood pressure
measurement, serum cholesterol, capillary glucose
and pregnancy testing were the most commonly-
offered services. Screening tests were conducted
less than five times a week except for blood
pressure measurement, which was more frequent.
Only 35% of pharmacists kept records. No quality
control procedures were used. Pharmacists’
knowledge about the tests, e.g. false positive and
false negative results, was poor.
premises; involvement of pharmacists in patient
monitoring.
Results 308 pharmacists responded and cholesterol
screening had been undertaken on 83 of these
pharmacy premises. Where screening had taken
place only 61% of the pharmacists reported having
monitored the screening process. Few pharmacists
were aware of the process for identifying high risk
patients. Only eight pharmacists had received a list
of patients who had been recommended to
contact their doctor. Only 3 of 30 pharmacists had
reminded patients to do so.
60
Study/authors Hampton A, Wilson A & Hussain
M. Fam Pract (1990) 7(1): 52–5.
Measuring blood pressure in an inner city
pharmacy: an attempt at coordination with
general practice. B3 UK
Study design and participants Non-targeted
case finding through provision of blood pressure
measurement service. One community pharmacy
took part.
Interventions Free blood pressure checks were
offered for 6 weeks, targeted at those aged 30–64
years. The pharmacist invited 120 clients to take
part, of whom 70 (58%) agreed. Clients were given
a copy of the reading to take to their GP. GPs were
interviewed about the scheme.
Outcome measures Numbers of blood pressure
readings taken. Presence of readings in GP notes.
Attitudes of GPs towards the scheme.
61
Results The GP records of 40 patients were
checked, of which only 10 contained the pharmacy
reading. The records of higher readings were more
Study/authors Horne F. Pharm J (1998) 261: R44.
Community pharmacy audit: sales of aspirin in
community pharmacies in Ealing, Hammersmith
and Hounslow. B3 UK
Study design and participants Case finding
through survey of pharmacy customers. Two audits
of aspirin purchases in 21 and 26 community
pharmacies respectively. Patients purchasing aspirin
were asked to take part in the survey.
Interventions Audit 1: 21 pharmacies recorded
sales of ‘P’ aspirin over a 6-week period in
October–November 1996. Purchasers were asked
why they were buying the aspirin. classified as: for
first aid use (e.g. analgesia, colds) / cheaper than
prescription/ told to purchase by GP/ told to
purchase by hospital/ other member of family
taking aspirin/ read about in newspaper or
magaizne/ other. Purchasers were also asked if
their GP knew they were taking aspirin and what
dose they were taking; Audit 2: 26 pharmacies
recorded sales of 75mg aspirin over a 4-week
period in February 1998.
Study/authors Black PE, Blenkinsopp A &
Kinghorn I. Pharm J (1998) 261: R51.
An investigation into the information needs of
users of low dose aspirin. B3 UK
Study design and participants Cross-sectional
survey of patients taking prophylactic aspirin.
Telephone interviews with patients receiving 75 mg
aspirin on prescription or purchasing it over the
counter in six community pharmacies.
Interventions Six community pharmacists invited
patients with a prescription for 75 mg aspirin or
requesting to purchase the medicine to take part
in the survey.
Outcome measures Reasons for taking aspirin;
likely to be present. Most of the GPs interviewed
were not enthusiastic about the scheme.
Outcome measures Audit 1: patients’ reasons
for purchasing OTC aspirin Audit 2: GPs’ awareness
of aspirin-taking among their patients. Pharmacists
recorded pack size, product, if the purchaser was
the patient, if they were taking aspirin daily, if
their GP knew they were taking aspirin, if they had
ever been prescribed aspirin, and why they were
taking aspirin.
Results Audit 1: of 540 sales 341 (63%) were for
reasons other than ‘first aid’, mainly 75 mg
tablets. 12% said they took aspirin because
another family member did so and a further 11%
on the basis of newspaper or media reports. 21%
said their GP was unaware they were taking
aspirin. 271 leaflets were issued to purchasers.
Audit 2: of 277 sales 89% were for cardiovascular
indications or stroke. 73% of purchasers said their
GP knew they took aspirin, 16% (44) that their GP
did not know and 11% (30) could not confirm
whether their GP knew or not.
knowledge of aspirin’s use in CHD prevention.
Results 128/141 patients approached (91%)
agreed to take part of whom 108 were
subsequently contactable. 70 (65%) had received
aspirin on prescription and 38 (35%) had
purchased it. 89 were taking aspirin for secondary
prevention and 19 for primary prevention. 10%
showed ‘little’, 69% ‘some’ and 18% ‘good’
understanding of aspirin. Only 33% recalled
receiving any information about aspirin. 92 (85%)
said they would be willing to receive information
about aspirin from the pharmacist and 78% said
the pharmacist was qualified to give such advice.
However, only 57% thought that pharmacies were
a suitable venue to receive this sort of advice.
Secondary prevention with aspirin
Study/authors Knowlton CH, Thomas OV,
Williamson A, Gammaitoni AR, Kirchain WR,
Buttaro ML & Zarus SA. J Am Pharm Assoc (1999)
39: 368–74.
Establishing CP-based anticoagulation education
and monitoring programmes. B3 US
Study design and participants A before and
after design. Three CPs with existing health
education centre and laboratory facilities. Pilot
study with convenience sample of patients
referred by primary care physicians.
Interventions The pharmacists conducted regular
patient assessment including adherence to
treatment, medication use (including over the
counter medicines), dietary aspects including use
Study/authors Tubro S, Dahlger l, Hermansen l,
Herborg H & Astrup AV. Ugeskr Laeger (J Danish
Med Assoc) (1999) 161: 5308–13. (English abstract,
article in Danish.)
Dietary guidelines on obesity at Danish pharmacies.
Results of a 12-week course with 1-year follow-up.
B3 Denmark
Study design and participants Retrospective
uncontrolled study. Results of a 12-week slimming
course for obese subjects held at 19 Danish
pharmacies (8–20 subjects/ pharmacy) at 1-year
follow-up were evaluated. 269 obese subjects took
part in the study (259 females) (BMI >25 kg/m2)
paid DKr 550 each. Pharmacists participated in 2
days compulsory training for pharmacy team
leaders – (personal communication).
Study/authors Mayer JA, Slymen DJ, Eckhardt L,
Rosenberg C, Palmer RC, Elder JP, Graf G & Anderson
ST. Cancer Detect Prev (1998) 22(4): 367–75.
Skin cancer prevention counselling by pharmacists:
specific outcomes of an intervention trial B1 US
Study design and participants RCT of the effect
of training, practice prompts and counselling aids
on pharmacists’ advice about skin cancer
of vitamins, health foods, supplements and
changes in dietary and alcohol intake. Pharmacists
also measured INR.
Outcome measures Percentage of INR values
within therapeutic range compared with values
reported for anticoagulant clinics, major bleeding
events, and thrombotic events.
Results 26 patients were referred to the three
pharmacy clinics by two primary care physicians. Of
these, 21 charts were available for analysis. More
than 80% of patients had INR values within their
targeted range 60% or more of the time. Of the
235 INR values obtained during the study 75%
were within the indiviudalised targeted
therapeutic range.
Interventions Course included eight 1.5-hour
sessions. Education in nutrition and physiology
aiming for a dietary change toward a low fat high
carbohydrate diet.
Outcome measures Self-reported body weight
assessed on pharmacy scale before and after the
course and at 3, 6, and 12 month follow-up.
Results 191 (71%) completed programme.
Average weight loss was 5.3 kg females and 6.2 kg
males. 122 (45%) of participants were followed up
at 1-year was 4 and 6.7 kg in 118 females and 4
males respectively. At 1-year follow-up, 40 subjects
(20%) who had completed the course had
maintained a weight loss of >5 kg.
prevention. 54 chain community pharmacies (61%
of local total) randomly assigned to intervention /
control. 178 pharmacists took part. Pharmacies
selected by researchers based on census data. Sites
with higher proportion of non-Hispanic whites
were targeted. Video-based training developed for
the project and provided to the 27 intervention
sites. Content was acted scenarios modelling brief
interventions in practice. Written support material
62
Anticoagulation
SKIN CANCER PREVENTION
OBESITY AND WEIGHT REDUCTION
63
provided. Pharmacists received credit points for
continuing education.
Interventions Seven-week intervention period.
Intervention sites received: (1) video-based training
for pharmacists; (2) prompts installed in pharmacy
to promote discussion (mugs, badges, posters);
(3) leaflets and sunscreen samples placed behind
counter for staff to distribute; (4) group-based
feedback on previous week’s counselling rates
reported by mystery shoppers. Rates posted on
staff notice boards and in pharmacists’ mailboxes.
Outcome measures (1) Counselling rate
measured by ‘mystery shoppers’ (‘confederate’)
visited all pharmacies three times a week for 3
weeks and recorded whether, in response to an
unrelated OTC request, pharmacists counselled
Study/authors Lindholm LH, Isacsson A, Slaug B
& Moller TR. J Cancer Ed (1998) 13: 207–12.
Acceptance by Swedish users of a multimedia
programme for primary and secondary prevention
of malignant melanoma. C1 Sweden
Study design and participants Observational
study of effect of installing touchscreen information
kiosk. One community pharmacy, one library.
Interventions Kiosk with touchscreen public
Study/authors Leinweber CE, Campbell HS &
Trottier DL. Can J Public Health (1995) 86: 380–3.
Is a health promotion campaign successful in
community pharmacies? B3 Canada
Study design and participants Pre- and post-
campaign survey of community pharmacists for a
skin cancer awareness campaign.
Interventions A sun awareness campaign ‘Be Sun
Smart’ was run by a collaboration between
pharmacy and health development organisations
in Alberta, Canada.
about skin cancer prevention. (2) pharmacists’ self-
reported (a) knowledge of skin cancer,
(b) perceived expertise, and (c) attitudes to
counselling on skin cancer prevention. Measured
by pre- and post- project mail questionnaire.
Results 53% of pharmacists completed both pre-
and post-test questionnaires. Intervention
pharmacists scored higher on knowledge and self-
rated expertise on skin cancer. No differences in
attitude scores. In ‘mystery shopper’ visits counselling
on skin cancer was provided by intervention
pharmacists on 53 of 243 occasions (21.8%). Most
counselling (87%) was verbal. Some correlation
between mystery shopper reports and pharmacists’
self-reported counselling rates. Pharmacists
reported positive perceptions of the programme.
education programme on malignant melanoma.
Outcome measures Ease of use; ease of
understanding; recall of recommendations given;
worries/concerns following the programme; stated
intent to change behaviour.
Results 274 people used the programme, mostly
(224) at the pharmacy 29% (mainly young women)
said they would change their sun exposure
behaviour. 66% found the programme ‘worrying’.
Outcome measures Pre-campaign and post-
campaign: attitudes and knowledge about skin
cancer. Post-campaign: pharmacists’ self-reports
about the campaign.
Results Community pharmacists’ knowledge on
skin protection and skin cancer was high prior to
the campaign and was increased at the post-
campaign survey. There was a high degree of
pharmacist acceptance of community pharmacy
based public education campaigns.
DRUG MISUSE
Study/authors Luger L, Bathia N, Alcorn R &
Power R. Int J Drug Policy (2000) 11: 227–34.
Involvement of community pharmacists in the care
of drug misusers: pharmacy-based supervision of
methadone consumption. B3 UK
Study design and participants Longitudinal
follow-up of clients receiving methadone treatment
with pharmacy supervised administration. Pilot
project involving 17 CPs in Camden and Islington
over 9 months in 1998. A training day included
information on drug misuse, treatment of
addiction, dose assessment, methadone and
strategies to deal with difficult incidents.
Interventions Pharmacists supervised the
administration of methadone for clients in the
pharmacy and kept records of patients’
attendance.
Outcome measures Client attendance rates.
Acceptability and feasibility of the scheme from
perspectives of pharmacists, clients and key workers.
Study/authors Sheridan J, Lovell S, Turnbull P,
Parsons J, Stimson G & Strang J. Addiction (2000)
95: 1551–60.
Pharmacy-based needle exchange (PBNX) schemes
in south-east England: a survey of service
providers. B3 UK
Study design and participants Postal self-
completion survey to (1) all community pharmacists
participating in PBNX in south-east England and (2)
needle exchange co-ordinators in the same area.
Interventions Almost three-quarters of
pharmacists had undertaken training (unspecified)
on needle exchange and 80% reported satisfaction
with the training received. In contrast 40% of
pharmacists reported that their staff had received
no training.
Study/authors Lurie P, Gorsky R, Jones TS &
Shompe L. J Acquir Immune Defic Syndr Hum
Retrovirol (1998) 18: S126 –32.
An economic analysis of needle exchange and
pharmacy based programs to increase sterile
syringe availability for injecting drug users. B3 US
Study design and participants Economic analysis
comparing costs of different needle/syringe
provision schemes in a range of settings.
Results 2738 methadone consumption
supervisions took place, with an attendance rate of
95.2% for 79 registered clients. 45 of whom were
in the scheme throughout the study. Supervision
took less than 5 minutes, excluding paperwork. On
the whole experience of the pharmacists with the
clients were good. 67% of pharmacists found it
satisfying to work with methadone clients. 33% of
pharmacists found it difficult to cope with the
clients. 68% of clients found it to be a ‘reasonable
service’. Most key workers welcomed the scheme.
Outcome measures Business operation and
policies; day to day work of PBNX outlets (level of
exchange activity in the previous month); problems
encountered by PBNX providers.
Results Response rates were 86.7% for
pharmacists after telephone follow-up of non-
responders, and 88.9% for co-ordinators. The
mean number of transactions per pharmacy in the
previous month was 49 (range 0–1000).
Responding pharmacies had a mean of 16.7 clients
(range 0–350) of whom a mean of 14.1 were
regular clients using the service once a month or
more frequently. The return rate of injecting
equipment was 30%. Two-thirds of pharmacies
reported dispensing oral methadone. Pharmacists
reported further training needs for both
themselves and their staff.
Outcome measures Estimated cost per syringe
distributed for five syringe distribution strategies:
a NEP, pharmacy based NEP, free pharmacy
distribution of pharmacy kits, sale of such kits to
injecting drug users and sale of syringes in
pharmacies. Relative cost of these strategies in
preventing HIV infection in injecting drug users.
Results Costs were: NEP US $0.97, pharmacy NEP
US $0.37, pharmacy kit distribution US $0.64,
pharmacy kit sale US $0.43, syringe sale US $0.15.
64
Study/authors Sheridan J, Strang J, Barber N &
Glanz A. BMJ (1996) 313: 272– 4
Role of community pharmacies in relation to HIV
and drug misuse: findings from the 1995 national
survey in England and Wales. B3 UK
Study design and participants Cross-sectional
survey. Self-completion questionnaire distributed
to a random one in four sample of all community
pharmacists in England and Wales in 1995.
65
Outcome measures Current activity levels: (a)
dispensing of controlled drugs to drug misusers;
(b) sale of needles and syringes; (c) needle and
syringe exchange. Comparison with previous
survey conducted in 1988.
Results Response rate was 74.8% after four
Study/authors Gleghorn AA, Gee G & Vlahov D.
J Acquir Immune Defic Syndr Hum Retrovirol
(1998) 18: S89–93.
Pharmacists’ attitudes about pharmacy sale of
needles/syringes and needle exchange programmes
in a city without needle/syringe prescription laws.
B3 US
Study design and participants Cross-sectional
survey. Telephone interviews with 75 randomly
selected community pharmacists in Baltimore, USA.
Outcome measures Willingness to sell
Study/authors Scott J, Kennedy EJ, Winfield A &
Bond CM. Pharm J (1998) 261: R24.
Investigation into the training needs of an
information pharmacist at a drug counselling and
needle exchange agency. C1 UK
Study design and participants Qualitative
study. Analysis of 70 queries received by a
pharmacist during sessions at a drug counselling
and needle exchange service.
mailings. In 1995, 50.1% were dispensing
controlled drugs for drug misusers, increased from
23.0% in 1988. Injecting equipment was being sold
by 34.5% (28.0% in 1988). A needle exchange
service was being provided by 18.9% compared
with 3.0% previously.
needles/syringes and any procedures/requirements
for such sales. Awareness of and attitudes to, the
Baltimore NEP.
Results Overall 87% of pharmacists reported
selling needles and syringes at their discretion, and
61% (46) pharmacists described having one or
more procedures for the sale of needles and
syringes. Of those pharmacists reporting such
procedures 54% asked for picture identification,
34% required a prescription and 34% a diabetic
identification.
Outcome measures Training needs of
pharmacists working with drug users.
Results Categories of query were: drug
information; adverse drug reactions; health problem
(drug-related); health problem (non drug-related);
identification of pharmaceuticals; harm reduction
techniques; drug testing; ‘other’. Being able to
respond to drug users using familiar terms was
also identified as a key need.
Study/authors Matheson C, Bond CM & Mollison J.
Addiction (1999) 94: 1349 –59.
Attitudinal factors associated with
community pharmacists’ involvement in services
for drug misusers. B3 UK
Study design and participants Cross-sectional
national survey. Questionnaire survey of
‘pharmacists in charge’ of community pharmacies
in Scotland.
Outcome measures Descriptive data collected
on demography, drug misuse service provided,
training. Attitude statements were used and these
were incorporated into a scale which was
correlated with behavioural data on whether or
how services were provided.
Results Response rate was 79%. Pharmacists that
provided services had significantly more positive
attitudes to drug misusers. Attitudes were also
associated with health board (more positive if
more services), sex (male more positive) and years
on register (less time more positive). Attitude was
an independent predictor of whether
needles/syringes were sold, methadone was
dispensed and methadone consumption supervised.
Study/authors Matheson C, Bond CM & Hickey F.
Fam Pract (1999) 16: 375–9.
Prescribing and dispensing for drug misusers in
primary care: current practice in Scotland. B3 UK
Study description and participants Objectives
were to obtain baseline data on current
prescribing practice by medical practitioners and
drug agencies; dispensing practice by community
pharmacists across Scotland for the management
of drug misuse, and variations in practice between
local health boards. A structured postal
questionnaire was sent to all community
pharmacists in Scotland (n= 1142) in 1995.
Outcome measures Percentages of pharmacies
dispensing drugs for the management of drug
misuse; percentage of methadone prescriptions
Study/authors Matheson C & Bond CM. Int J
Pharm Pract (1999) 7: 256 –63.
Motivations for and barriers to community
pharmacy services for drug misusers. B3 UK
Study description and participants The
objective was to investigate what motivated
pharmacists to provide services for drug misusers
and to identify barriers preventing service
provision. Telephone interviews were conducted
with a purposive sample of 45 community
pharmacists who had responded to a national
questionnaire survey.
Outcome measures Factors that motivated
pharmacists to provide drug misuse services or
Study/authors Hayes M, Hutchings J & Hayes P.
Matern Child Health J (2000) 4: 203–8.
Reducing unintended pregnancy by increasing
access to emergency contraception pills. B3 US
Study design and participants A before and
after study of pharmacy supply of emergency
hormonal contraception. Pilot project in
Washington state involving 140 pharmacies. 1000
pharmacists received training.
Interventions Pharmacists were enabled to
prescribe ECP through CDTAs with physicians. A
requiring supervised administration; percentage of
pharmacies providing this service.
Results The response rate was 79%. Sixty-one per
cent of pharmacists were currently dispensing
drugs for the management of drug misuse. Sixty-
five per cent of methadone prescriptions were
dispensed daily on the request of the prescriber. Of
the 3387 people receiving a methadone
prescription, 32.9% had to consume their daily
dose on the pharmacy premises under a
pharmacist’s supervision. Nineteen per cent of
pharmacies provided a service to supervise the
consumption of methadone and a further 14%
were prepared to but said they had no demand for
the service. The proportion of prescriptions
requesting supervision of methadone consumptions
varied considerably between health boards.
were cited as reasons not to participate in service
provision.
Results Pharmacists were found to be motivated
to provide services by an awareness of the needs
of the community, a desire to reduce the spread of
blood-borne diseases, and a desire to expand their
professional services. Barriers to service provision
were concerns for the effect of service provision on
other customers, safety, workload and poor
remuneration. The authors concluded that the
active encouragement of local health boards,
further education and remuneration might
encourage pharmacists’ participation in drug
misuse services.
public awareness campaign was conducted, with
an ECP hotline.
Outcome measures Numbers of participating
pharmacies; numbers of CDTAs established;
numbers of ECP prescriptions provided.
Results 140 pharmacists participated and 145
CDTAs were created. In 16 months of pharmacy
provision 11,969 ECP prescriptions were provided,
preventing an estimated 700 unintended
pregnancies. Calls to the ECP hotline increased
from 116 to 1160 per month.
66
EMERGENCY HORMONAL CONTRACEPTION
67
Study/authors Sommers SD, Chaiyakunapruk N,
Gardner JS & Winkler J. J Am Pharm Assoc (2001)
41: 60–6.
The emergency contraception collaborative
prescribing experience in Washington state. C1 US
Study design and participants Questionnaire
survey of service providers and users. Provider
questionnaires were distributed 6 months after the
programme started. User questionnaires were
distributed at the point of service and returned by
mail.
Interventions An ECP programme for supply
through community pharmacies was established in
Washington state. The scheme encouraged
pharmacists and prescribers to establish
Study/authors Bissell P, Savage S, Anderson C &
Goodyer L. Proceedings of 7th Health Services
Research and Pharmacy Practice Conference,
Nottingham, (2001).
Regulating sex: a potent new role for pharmacists?
Attitudes to the supply of emergency hormonal
contraception. B3 UK
Study design and participants Qualitative
study. In depth interviews were carried out with 20
community pharmacists supplying emergency
hormonal contraception in the Lambeth,
Southwark and Lewisham area of London and with
24 pharmacists in the Manchester, Salford and
Trafford area.
Interventions In late 1999 and early 2000,
community pharmacists in Manchester, Salford and
Trafford, and Lambeth Southwark and Lewisham
Health Action Zones began supplying EHC under
PGD. On completion of a training program,
pharmacists could supply EHC to women free,
Study/authors Sharma S, Anderson C. Health Ed J
(1998) 57: 42–50.
The impact of pharmacy using window space for
health promotion about emergency contraception.
B3 UK
Study design and participants A ‘before and
after’ study of the effect of pharmacy window
displays on enquiries about emergency
contraception. 20 pharmacies participated in
Ealing, Hammersmith and Hounslow Health
collaborative prescribing arrangements, whereby
pharmacists were authorised to prescribe ECP.
Outcome measures User satisfaction with
interaction with the pharmacist and specific
information. Provider attitudes towards, and
experiences of the programme.
Results Response rates were 51% (159) for
pharmacists, 27 (49%) for prescribers and 470
(6.5%) for users. Most (92%) of pharmacists and
prescribers were ‘satisfied’ or ‘very satisfied’ with
their prescribing agreements. Pharmacists were
highly rated by users for their interactions with
patients and quality of information about ECP use.
Ratings were lower for information about side
effects, recognition and follow-up of ECP failure,
and regular contraceptive methods.
following a confidential consultation. Pharmacists
were paid a fee per consultation.
Outcome measures Pharmacists’ perception of
the scheme.
Results Pharmacists were extremely positive
about supplying EHC under PGD. However, some
were concerned that the supply of EHC through
pharmacies might encourage ‘abuse’ or repeated
use. Pharmacists were against deregulating EHC on
the grounds that it might promote abuse of a
potentially ‘potent’ product. The cost of EHC was
thought likely to be a disincentive to use amongst
poor women. Accounts about safety and
appropriate use of EHC were seemingly
intertwined with social attitudes and values. In
addition, pharmacists’ support for the PGD supply
route appeared to stem from the desire for
enhanced professional status as much as providing
an important public service.
Authority, in conjunction with West London Health
Promotion Agency. Pharmacists attended an
evening seminar to introduce the scheme.
Pharmacies were paid £250 for participating.
Outcome measures Number of enquiries about
ECP, number of leaflets, ECP dispensed, pregnancy
tests sold, 2 weeks before, during, and 2 weeks
following campaign. Customer questionnaire to
determine response to the display and how they
would use pharmacies.
Study design and participants Qualitative
study. In depth interviews with 14 pharmacists,
14 medicines counter assistants, and a number of
stakeholders to ascertain their views about a test
service package to promote the use of folic acid in
pregnancy. The findings were intended to inform
the production of a final version of the package.
Study/authors Rajyaguru R & Anderson C.
Proceedings of the 5th Health Services Research
and Pharmacy Practice Conference, Aston (1999).
Evaluation of a community pharmacy service
package to promote the use of folic acid in
planned pregnancy. B3 UK
Study/authors Anderson C. Patient Educ Couns
(2000) 39: 285 –91.
Health promotion in the community pharmacy: the
UK situation. C1 UK
Study design and participants Literature
review.
Results Most studies were small scale. Use of
pharmacy window displays increased uptake of
leaflets and numbers of prescriptions for
Study/authors Anderson C, Bissell P, Sharma S &
Sharma R. Int J Pharm Pract (2001) 9(Suppl): R56.
Supplying emergency contraception in the
pharmacy: the perspectives of service users. B3 UK
Study design and participants Quantitative
survey and qualitative interviews with service
users. 53 pharmacies participating in a scheme to
supply emergency hormonal contraception were
asked to distribute a questionnaire to each
service user. Qualitative research was conducted
with a sample of service users.
Outcome measures Service users’ level of
emergency contraception. Health promotion
innovations introduced by individual pharmacists,
pharmacy multiples and NHS health
authorities/boards were described. Remuneration
and commercial opportunity costs (e.g. from
reallocation of sales space) remain unresolved.
Training on health promotion may lead to a more
holistic view of health among pharmacists. The
specific components of training that might
contribute to this effect are unknown.
comfort in discussing emergency contraception
with the pharmacist; whether privacy was
perceived as sufficient; satisfaction with how their
request was dealt with.
Results 91% felt ‘very comfortable’ or ‘comfortable’
about discussing emergency contracption with the
pharmacist. Privacy was felt to be sufficient by
86% of respondents. 99% were ‘satisified’ or ‘very
satisfied’ with the way their request for emergency
contraception had been dealt with. Confidentiality
was an issue for 16%, who said they were
‘concerned’ or ‘very concerned’ that their request
would not be kept confidential.
68
FOLIC ACID AND PREGNANCY
Results 20 pharmacies collected data. Enquiries
increased between two- and fourfold. 13 collected
leaflet data – there was an increase in leaflet
uptake by between three- and 43-fold. There was
a fourfold increase in number of pregnancy tests
sold and three times more prescriptions for ECP
were dispensed. 160 women mainly aged from
12–25 years responded to the survey. The majority
considered the display to be ‘good or very good’,
and only 6% had not noticed it. 60% said they
would use their pharmacist in the future for advice
about ECP.
Study/authors Stergachis A. Sexually Transmitted
Dis (1999) 26: S44–7.
Roles for pharmacists in the prevention and
control of sexually transmitted diseases. D US
Study design and participants Discussion paper.
Results Community pharmacies in deprived areas
could provide key access points for prevention and
treatment of sexually transmitted diseases.
Discusses the Washington state protocols for
pharmacist supply of oral contraceptive pills.
69
Study/authors De Jong-Van den Berg LTW, Van
der Zee AH, Schaafsma E, De Smit D, Anderson C &
Cornel MC. Int J Pharm Pract (1999) 7: 138–42.
Counselling women about periconceptional use of
folic acid: the role of the community pharmacist
can be improved. B3 Netherlands
Study design and participants Cross-sectional
survey. Postal questionnaire to random sample of
community pharmacists in the Netherlands.
Interventions Pharmacists were encouraged to
use an additional label when dispensing oral
contraceptives to encourage women, if and when
they decided to have a child, to take folic acid.
Outcome measures Knowledge, behaviour, and
attitudes about the use of folic acid by women of
childbearing age.
Results Response rate 72%. An additional label
about folic acid for use on oral contraceptives was
being used by 30% of respondents. However 63%
of respondents who did not use the labels
expressed concerns about ‘imposing’ information
on women who might not want it. Pharmacists’
perceptions about local GPs’ attitudes also
appeared to influence their willingness to promote
folic acid use. Compared with a similar survey 2
years earlier, more pharmacists appeared to be
promoting folic acid.
ASTHMA
Interventions Pharmacists and assistants had
attended one evening training session as part of
the project. They received promotional materials
including leaflets, posters, and window display
materials.
Outcome measures To explore experiences on
staging and managing the project. Constraints,
motivating factors, use of the promotional
materials ease of implementation, participants
understanding of their role as health promoters,
and to provide feedback on training.
Results Most pharmacists and assistants felt
comfortable when advising regular customers.
Leaflets, poster, and window displays were more
likely to target passing trade. Most of the
pharmacists and asistants from ethnic minority
groups felt they had an important role in
communicating about folic acid with customers
from those groups. A number of constraints and
future training needs were identified. The need to
have a project facilitator was also identified.
Study/authors Bell HM, McElnay JC, Hughes
CM, Gleadhill I. J Asthma (2000) 37: 545–55.
Primary schoolteachers’ knowledge of asthma:
the impact of pharmacist intervention. B2 UK
Study design and participants Controlled
trial of education intervention on asthma for
primary school teachers. Effects assessed by
postal self-completion questionnaire
distributed to 73 schools in Northern Ireland
(150 were invited to take part).
Interventions After completion of the
baseline questionnaire by intervention and
control schools, the five intervention schools
were visited by a pharmacist. The pharmacist
led a 30-minute educational session based on
the package produced by the National Asthma
and Respiratory Training Centre. Intervention
schools were revisited at 4 weeks and the
questionnaire was repeated. Intervention schools
received a training session from a pharmacist.
Topics covered included asthma symptoms, trigger
factors, asthma medications, use of inhalers and
actions to take if a child had an attack.
Outcome measures Teachers’ knowledge about
asthma.
Results 344 questionnaires were returned.
81.4% of teachers reported having at least one
child with asthma in their class. 19.4% had
received previous training about asthma. One in
10 teachers had asthma and 39.4% had a family
member with asthma. The mean knowledge score
was 20.71, which the authors classify as
‘acceptable’. Pre- and post-study scores for 36
interventions were 18.41 and 21.22, and for 45
control teachers were 19.78 and 19.98, a
statistically significant difference (P=0.002).
Study/authors Dixon N, Hall J, Knowles D &
Sanders E. Pharm J (2000) 265: R21.
Can a community pharmacy influence the control
of disease in people with diabetes through the use
of a local quality control scheme? B2 UK
Study design and participants Controlled trial
of a pharmacy led programme. 130 patients with
diabetes participated. Patients were recruited from
the PMRs of one community pharmacy and
allocated to ‘quality control’ (QC) or ‘no quality
control’ (NQC) groups.
Interventions ‘Quality control’ involved
additional information for patients and validation
of their blood glucose measurements by
comparison with pharmacist-conducted and
laboratory conducted tests with feedback.
Patients were interviewed at baseline then three-
monthly during the 1 year study. The patients were
asked to test their blood glucose as they would at
home. The pharmacist also measured blood glucose
and a third sample was sent to the local pathology
laboratory for HbA1c testing. A score card was
completed by the pharmacist for proficiency in
blood glucose testing technique and knowledge of
diabetes. All patients were given an information
leaflet about diabetes, a new set of instructions for
their meter and a diary to record their results.
Outcome measures HBA1c levels in QC and NQC
patients. Scores for blood glucose testing technique.
Results 58 QC and 72 NQC patients completed the
study. All QC subgroups showed smaller increases in
HBA1c than non-QC patients. Average scores for
technique improved in both groups, with no
difference between groups.
70
Study/authors Sarkadi A & Rosenqvist U. Patient
Education Couns (1999) 37: 89–96.
Study circles at the pharmacy – a new model for
diabetes education in groups. B3 Sweden
Study design and participants A ‘before and
after’ study to test the feasibility of a 1-year group
education model for patients with NIDDM at
Swedish pharmacies. The evaluation took place
from 1997 to 1999 and included 39 patients from
eight study groups who had participated for more
than 5 months. Pharmacists and nurses
participated in a 3-day training course. Continuous
training and support were available throughout
the study.
Interventions The groups promoted learning
through peer group help and gave emotional
support to participants.
Outcome measures (1) HBA1c level (2) Utility of
study group.
Results Metabolic control as indicated by HBA1c
improved significantly after 6 months but reverted
to baseline at 12 months. Participants were more
likely to be in the acceptable range for HBA1c
than the population at baseline, indicating a more
motivated group. Participants appreciated the
form and content of the groups. Many said they
would recommend it to someone else with NIDDM.
More than half said that their perception of their
disease and its treatment had changed as a result
of participating.
DIABETES
Study/authors Timmer JW, de Smet PAGM,
Schuling J, Tromp TFJ & de Jong-van den Berg LTW.
Pharm World Sci (1999) 21:200–204.
Patient education to users of oral hypoglycaemic
agents the perspective of Dutch community
pharmacists. B3 Netherlands
Study design and participants Qualitative
interviews with seven pharmacists and seven
technicians with considerable experience of giving
advice in NIDDM. Nominal group technique was
also used.
Outcome measures To determine which activities
were considered desirable and to identify which
other health care providers should be involved.
Results According to the focus group participants,
patient education activities should be directed
primarily at stimulating adherence to dosage
regimen, increasing awareness of side effects and
improving the correct technical use of glucose
meters. Activities directed at lifestyle advice
seemed less desirable. Structural co-operation with
other health care staff was desirable.
71
Study/authors Weitzel KW & Goode JVR. J Am
Pharm Assoc (2000) 40: 252–6.
Implementation of a pharmacy-based immunisation
programme in a supermarket chain. B3 US
Study design and participants Observational
study of pharmacy based immunisation provision.
19 supermarket pharmacies in Virginia, USA took
part. Pharmacies used private consultation rooms
where available, or the most private section of the
patient waitng area. Pharmacists also administered
vaccines at off-site locations. Pharmacists completed
the American Pharmaceutical Association’s
Pharmacy-based Immunisation Delivery Certificate
programme. Follow-up injection technique review
and practice sessions were included. All pharmacists
were required to be certified in cardio-pulmonary
resuscitation and the use of injectable epinephrine
and diphenhydramine in anaphylactic reactions.
Study/authors Grabenstein JD, Guess HA &
Hartzema AG. J Am Pharm Assoc (2001) 41: 46–52.
People vaccinated by pharmacists: descriptive
epidemiology. C1 US
Study design and participants Questionnaire
survey distributed by pharmacists to people
vaccinated to determine user views.
Outcome measures Demographic data on people
Interventions Influenza and pneumococcal
vaccination offered on a walk-in basis or at four-
hour clinics held on at least three days a week.
Vaccination protocol developed jointly with
physicians. Additional pharmacist cover was obtained
to cover clinic sessions.Walk-in immunisations were
dealt with by treating each request as a
‘prescription’ with pre-preparation done by
technician staff. The patient’s doctor was informed
by letter that the immunisation had been given.
Outcome measures Numbers of influenza and
pneumococcal vaccines administered in a 4-month
period in 1998–9 and 1999–2000.
Results 5137 influenza and 613 pneumococcal
vaccinations were administered by pharmacists
during the study period in 1998–9. Over the same
period on 1999–2000 the figures were 18,000 and
1200 respectively.
vaccinated; opinions about different vaccine providers.
Results Mean age was 54 years; 25% were 65 or
older. Almost 50% were taking prescribed medicines
long-term and 84% of people came to the pharmacy
intending to be vaccinated. Many respondents
preferred the pharmacy to other vaccine providers,
based on access, convenience, trust and/or cost.
IMMUNISATION
Study/authors Ernst ME, Bergus GR & Sorofman
BA. J Am Pharm Assoc (2001) 41: 53–9.
Patients’ acceptance of traditional and
non-traditional immunisation providers. C1 US
Study design and participants Postal
questionnaire distributed to patients via a stratified
sample of private family physician clinics, family
medicine residency training programmes, and
provider / non-provider community pharmacists.
Outcome measures Sources of past
immunisations, access to immunisations,
importance of immunisation products and future
use of different health care providers and settings
for immunisations.
Results Response rate was 67% (420).
Respondents frequently received immunisations at
sites other than doctors’ offices. Younger patients
and those living in small towns were more likely to
report receiving an immunisation from a
non-physician. Patients recruited in immunising
pharmacies were more likely to report previous
immunisation from a pharmacist, most often for
influenza. There was greater support for
non-physician immunisation for adult than for
paediatric immunisations.
Study/authors Adie B & Anderson C. Pharm J
(1998) 261: R19.
Investigation into the role of community pharmacists
in the management of head lice infections. B3 UK
Study design and participants Telephone
interviews using structured questionnaire with
stratified random sample of community pharmacists.
Outcome measures Pharmacists’ self-reports of
advice given in response to requests about head
lice and advice offered with sale of treatments.
Results 34 pharmacists agreed to be
interviewed. Half said they had checked hair in
the pharmacy, mostly when asked to do so. A
further 12 said they would be willing to check
72
HEAD LICE
Study/authors Madhavan SS, Rosenbluth SA,
Amonkar M, Borker RD & Richards T. J Am Pharm
Assoc (2001) 41: 32– 45.
Pharmacists and immunisations: a national survey.
B3 US
Study design and participants
Questionnaire survey of 5342 pharmacists from
chain, independent, mass merchandiser/grocery,
primary care clinic and HMO settings.
Outcome measures Current involvement in
immunisation, willingness to become involved,
perceived barriers, participation in educational
events on immunisation, perceptions of patients’
interest in this service.
Results Response rate was 25.3% after three
mailings. Only 53.1% of respondents knew
correctly whether their state allowed pharmacists
to administer immunisations. 2.2% and 0.9% of
respondents reported involvement in
administration of adult and paediatric
immunisations, respectively. Pharmacists who had
attended educational sessions about immunisation
were more willing to provide such services and
perceived fewer barriers to involvement.
Study/authors Davidse W & Perenboom RJ. Ned
Tijdschr Geneeskd (1995) 139: 2149–52.
Increase of degree of vaccination against influenza
in at-risk patients by directed primary care
invitation. B3 Netherlands
Study design and participants Case-finding
study with intervention to increase patient
attendance for influenza vaccination.
Intervention study involving 27 community
pharmacies and 42 general practitioner offices in
the Netherlands covering 133,000 patients.
Interventions Medication data from community
pharmacists’ records were used to identify ‘at risk’
patients. GPs then selected patients to be invited
to attend for ‘flu vaccination.
Outcome measures Percentage of ‘at risk’
patients vaccinated against ‘flu in 1993, compared
with 1992.
Results 15,000 patients were selected by the GPs
and invited to attend for vaccination in 1993. Final
coverage was 75.5%, a 56% increase from 1992. In
comparison, the increase was 8% for the
Netherlands as a whole and 18% for a group of
comparable but non-participating GPs.
Study/authors Grabenstein JD. Vaccine (1998)
16: 1705–10.
Pharmacists as vaccine advocates: roles in
community pharmacies, nursing homes and
hospitals. D1 US
Study design and participants Review paper.
Interventions Pharmacists are authorised to
administer vaccines in 25 states. More than 1000
pharmacists were trained to administer vaccines in
1997.
Results Between 50 and 94% of people who
receive a pharmacist’s recommendation to be
immunised accept the recommendation. Over five
million doses of influenza vaccine per year are
administered in pharmacies. Consultant
pharmacists can recommend vaccines in nursing
homes during monthly medication reviews.
73
Study/authors McVeigh N & Kinirons MJ. Int J
Paed Dent (1999) 9: 31–5.
Pharmacists’ knowledge and attitudes concerning
sugar free medicines. B3 UK
Study design and participants Quantitative
questionnaire survey of pharmacists practising in
Greater Belfast, Northern Ireland.
Outcome measures Attitudes towards sugar in
medicines and sugar-free preparations. Knowledge
about sugar-free preparations.
Study/authors Gilbert L. SADJ (1998) 53: 439– 43.
The role of the community pharmacist as an oral
health adviser – an exploratory study in South
Africa. B3 South Africa
Study design and participants Survey of a
random sample of community pharmacists in
Johannesburg, South Africa.
Outcome measures Incidence and nature of
Results Response rate 74% (52). Overall 25%
reported receiving formal education about the
effects of sugar in medicines on oral health. 46%
said that sugar in medication was ‘definitely’ an
important cause of dental caries in children and
44% that it was a possible factor. Major factors
cited to influence the provision of sugar-free
medicines were parental requests, health
promotion literature and media advertising.
dental enquiries; knowledge of preventive
measures; willingness to engage in promotion of
oral health.
Results Community pharmacists receive and
handle substantial numbers and range of inquiries
and were positive about this role. There was little
evidence of networking with dentists or other
health professionals. The pharmacists had received
little education on oral health.
ORAL HEALTH
Study/authors Maguire A, Evans DJ, Rugg-Gunn
AJ & Butler TJ. Community Den Health (1999) 16:
138–44.
Evaluation of a sugar-free medicines campaign in
north-east England: quantitative analysis of
medicines use. B2 UK
Study design and participants A ‘before and
after’ study of the effect of providing information
on recommendations for sugar-free medicines.
GPs and community pharmacies in two test and
two control districts in England.
Interventions 12-month campaign using
information packs designed to increase the
proportion of sugar-free medicines dispensed for
paediatric use.
Outcome measures Numbers of prescriptions
and OTC medicines sales of specified medicines.
Results There was a significant increase in the
prescribing and dispensing of sugar-free medicines.
There was a small increase in sales of sugar-free
OTC medicines.
hair if asked. Most pharmacists reported that
treatment sales were mainly to third parties, with
only five saying that the patient was usually
present. 24 pharmacists usually recommended the
same product and in 16 cases this was the health
authority’s treatment of choice. Locum pharmacists
were less likely to be aware of the health authority
recommendation. 11 pharmacists said they
reinforced the product advice to leave on the hair
for 12 hours. None of the pharmacists
recommended a routine repeat application after
seven days. Only three said they would
recommend ‘wet combing’ as treatment.
74
Study/authors Ghalamkari HH, Rees JE, Saltrese-
Taylor A & Ramsden M. Pharm J (1997) 258: 27–32.
Evaluation of a pilot health promotion project in
pharmacies: (1) Quantifying the pharmacist’s
health promotion role. B2 UK
Study design and participants 14 CPs (from an
invited cohort) were randomly allocated into test
and control groups. A further control group who
had not been invited was also included. The test
group took part in three days training.
Interventions Each pharmacist was required to
log their health promotion activity over 8 months
in smoking cessation, pregnancy, sun and skin
protection, blood pressure monitoring, peak flow
measurement and infestations.
Study/authors Coggans N, McKellar S, Bryson S,
Parr RM & Grant E. Pharm J (2001) 266: 514–8.
Evaluation of health promotion development in
Greater Glasgow Health Board (GGHB) community
pharmacists. C1 UK
Study design and participants Quantitative
survey of pharmacy customers. A structured
questionnaire was distributed to customers of 32
community pharmacies participating in the GGHB
health promotion scheme. 410 respondents before,
and 410 of these after pharmacists’ training,
recruited through the pharmacies.
Interventions Five pharmacy health promotion
facilitators worked with GGHB Health Promotion
department to develop a training programme, a
health promotion resource manual and to provide
support for specific campaigns. Pharmacists
participated in a 2-day course covering health
promotion topics relating to national priorities
plus communication skills.
Outcome measures Percentage of customers
reporting learning from pharmacist, assistant and
health education leaflets. Percentage reporting
that the pharmacist asked general health
questions when prescription was dispensed or OTC
medicines were purchased.
Results Compared with baseline data there was
an increase in cutomers reporting they learned
something useful from pharmacists, assistants and
leaflets. More customers reported greater
discussion by pharmacists of general health when
collecting prescription medicines and purchasing
OTC medicines. Fewer customers said at follow-up
that the pharmacist understood the difficulties of
making lifestyle changes. Post-study, pharmacists
self-reported increased skills and knowledge of
health promotion and significantly more contacts
with health promotion facilitators and the local
health promotion department. More pharmacists
gave valid responses to a health promotion
scenario.
MULTI-TOPIC HEALTH PROMOTION PROGRAMMES
Study/authors Blenkinsopp A, Tann J, Allen J &
Platts A. Health Ed J (2002) 61: 52–69.
Evaluation of a community pharmacy health
promotion scheme: User and provider
perspectives. B3 UK
Study design and participants Observational
study. Client questionnaires (recording advice
requested and received and demographic
information); structured telephone interviews
with 10 pharmacists who were participating in a
health promotion scheme. Members of the
project Board were interviewed.
Interventions Ten community pharmacies in
one locality in England took part in a health
promotion scheme. The pharmacists provided
advice in the form of brief (level 1) and extended
(level 2, 20 minute) interventions.
Outcome measures Client uptake by health
topic; client acceptability of the service; pharmacist
and stakeholder views.
Results The number of level 1 and 2
interventions were lower than the project board
expected, except for smoking cessation.
Pharmacists had generally not used their PMRs to
target people for advice. The ‘stage of change’
model was well received but was not perceived to
be applicable for all topics. The feasibility of
offering level 2 type interventions in the pharmacy
was questioned.
FACTORS AFFECTING THE EFFECTIVENESS OF COMMUNITY PHARMACY-BASED
ACTIVITIES TO IMPROVE HEALTH
Facilitators – see ‘Multi-topic Health Promotion Programmes’
Training
75
Outcome measures To establish pharmacy
health promotion activity in trained and untrained
pharmacists.
Conclusions 2103 consultations were recorded.
The test group had more although not a
Study/authors Anderson C. J Soc Admin Pharm
(1995) 12: 115–124.
A controlled study of the efficacy of a health
promotion training scheme on pharmacists’ advice
about smoking cessation. B2 UK
Study design and participants RCT to test the
effect of training on smoking cessation advice in
intervention pharmacies with ‘usual care’. Covert
visits were made to a random sample of 20 out of 42
statistically significantly greater number. The test
group held the highest number of consultations
lasting 6 minutes or more and the lowest lasting
1 minute or less.
pharmacies participating in the Barnet High Street
Health Scheme and 20 randomly sampled control
pharmacies from a neighbouring health authority.
Interventions A 21-year-old mystery shopper,
who was unaware that there were two groups of
pharmacies, posed as a customer with diabetes
who wished to give up smoking. The shopper
asked for nicotine patches. The Barnet pharmacists
had received training in communication skills,
Study/authors Thompson G, Robinson A &
Walker R. Pharm J (1995 )(Supp) R17
Evaluation of the involvement of the community
pharmacist in health promotion. B3 UK
Study description and participants The
objective was to determine the frequency and
nature of community pharmacy involvement in
health promotion in general and smoking
cessation in particular. All 96 pharmacies in one
locality were invited to take part in a six month
project from September 1994 to March 1995.
Selection criteria were then applied to the
pharmacy premises including presence of a
counselling area and evidence of a positive health
promotion environment. Geographical spread was
also taken into account.
Interventions Pharmacists attended a study day
and were paid a monthly fee to participate. For
‘No Smoking’ day participating pharmacies were
randomly assigned to receive locum support or no
support and the availability of the smoking
cessation service was advertised in the local press.
Pharmacists recorded the health promotion
interventions that they made.
Outcome measures Numbers of recording forms
submitted by each pharmacy with self-reporting of
activity and health promotion topics discussed with
pharmacy users. Each form recorded one health
promotion intervention, classified into one of
thirteen health promotion topics.
Results Twenty pharmacies were selected to
participate from 31 that applied. The mean
number of forms submitted per pharmacy was 126
(range 46-328). The submission of forms varied by
month, with the lowest in November-December
and the highest in February-March. The most
commonly-reported interventions were smoking
cessation (23%), healthy eating (7%), pregnancy
testing (7%) and oral health (6%). Three quarters
of interventions took five minutes or less. A
product sale was involved in 20%, with the
remaining 203 calculated to provide 163 hours of
advice. In the week of ‘No smoking’ day advice on
smoking cessation was provided on more than
twice as many occasions by those pharmacies with
locum cover (65) than those who did not (30).
76
health promotion skills, the use of leaflets and
smoking cessation.
Outcome measures Outcome of the consultation.
(Referral was the desirable outcome as the client
was diabetic.) Duration of interview; questions
asked by the pharmacist (checked against a
Pharmaceutical Journal checklist); availability of
NRT and information, busyness of pharmacy,
willingness of pharmacist to help and the
shopper’s overall satisfaction with the consultation.
Results A statistically significantly greater number
of Barnet pharmacists referred the shopper to the
doctor. The Barnet pharmacists spent a
significantly longer time with the shopper (mean
Barnet time 5.3 min, SD 4.7: control 2.45, SD 1.3:
Mann–Whitney U-test P<0.02). Barnet pharmacists
were significantly more likely to ask about the first
cigarette smoked each day, and whether there
were concurrent diseases. In conparison the
control pharmacists allowed little time for client
questions. The Barnet pharmacists appeared to use
leaflets more appropriately. The shopper was given
more than one leaflet by over 75% of the control
pharmacists, which was reported as confusing. The
shopper was more satisfied with the Barnet
pharmacists’ consultations.
Conclusions Training in communication skills,
health promotion skills, the use of leaflets and
smoking cessation improved the quality of health
promotion consultations.
Study/authors Anderson C & Alexander A. Int J
Pharm Pract (1997) 5: 185–91.
Wiltshire pharmacy health promotion training
initiative: a telephone survey. B3 UK
Study design and participants A ‘before and
after’ study of the effect of training in health
promotion. Semi-structured telephone interviews
were conducted with 40 pharmacists before, and at
least 6 months after, attendance on a health
promotion course in Wiltshire Health Authority
Interventions Seven days and 2-evening sessions
were spent on a training course giving an
introduction to health promotion, communication
skills, and specialist health topics.
Outcome measures Self-reported changes in
pharmacists’ knowledge, practice, and attitude.
Results The value of increased knowledge was
recognised by participants, in particular when
talking to patients and other health professionals.
There was a change in attitude towards a more
holistic view of health. Changes in practice were
evident despite recognised constraints.
Study/authors Ghalamkari H, Rees J & Saltrese-
Taylor A. Pharm J (1997) 258: 909–12.
Evaluation of a pilot health promotion project in
pharmacies: (3) Clients’ further opinions and
actions taken after receiving health promotion
advice. B3 UK
Study design and participants Quantitative
survey of users views. 145 clients were surveyed 4
weeks after having received advice from a test
group of pharmacies.
Interventions This research forms part of the
evaluation of the Somerset pharmacy health
promotion scheme.
Outcome measures Whether clients had acted
on the pharmacist’s advice.
Results 105 clients responded (72% response
rate). Over 90% agreed that the pharmacist had
communicated the advice clearly, intelligibly and in
a manner that allowed the client to talk and ask
questions. Nearly 70% had followed the advice.
Only 4% did not follow the advice in any way.
STAKEHOLDER VIEWS
Pharmacy users
77
Study/authors Bell HM, McElnay JC & Hughes
CM. J Soc Admin Pharm (2000) 17: 119–128.
Societal perspectives on the role of the community
pharmacist and community-based pharmaceutical
services. B3 UK
Study design and participants Cross-sectional
survey of public attitudes towards pharmacy.
Structured interviews with 1000 members of the
general public.
Outcome measures To examine public
perceptions of current activities and future roles of
community pharmacists, including views on health
promotion and health screening.
Results Participants were most supportive of
health promotion both within the pharmacy
(91.2%) and within the community (72.3%).
Support for these activities was more common in
younger users; 76.1% of <60 years supported the
provision of health screening. The majority of
them were unwilling to pay for these services but
56.8% and 55.8% were willing to pay for
cholesterol testing and blood pressure monitoring
respectively. Older respondents were more willing
to pay for these services than younger ones.
Almost 40% of those interviewed were willing to
make an appointment with their pharmacist.
Study/authors Anderson C. Int J Pharm Pract
(1998) 6: 2–12.
Health promotion by community pharmacists:
consumers’ views. C1 UK
Study design and participants Quantitative
survey of pharmacy users. Interviews using
structured questionnaire with consumers in six
pharmacies. Conducted as part of the evaluation
of the Barnet High Street Health Scheme.
Outcome measures Respondents’ preferred
source of advice on ‘staying healthy’. Percentage
of respondents agreeing it was the pharmacist’s
Study/authors Dominguez A, Reigidor E &
Gallardo C. Aten Farm (2000) 2: 138–143.
Health information requests in pharmacy. (Spanish
paper, English abstract.) C1 Spain
‘usual job’ to give such advice. Extent to which
leaflets had been noticed, taken away and read.
Results 592 interviews were conducted, spread
equally across the six pharmacies. The GP was the
preferred source of advice on staying healthy for
77% of respondents, the pharmacist 8%. 40%
agreed it was the pharmacist’s usual job to give
general health advice, 19% did not and 41% did
not know. Prescription customers were more likely
to agree it was the pharmacist’s job to give health
advice. While 92% had noticed leaflets, 30% had
taken one or more away to read, most of whom