What do community pharmacists think about undertaking screening and brief interventions with problem drinkers? Results of a qualitative study in New Zealand and England

Alienation and/or anomie in pharmacists: A systematic review and narrative synthesis of the international literature

BACKGROUND

Flourishing and belonging are key concepts for the wellbeing of staff and the success of a profession. Alienation and anomie are distinct types of psycho-social ills which inhibit flourishing and belonging. A better understanding of these may offer hope in preventing many negative work endpoints, including burnout and intention to leave.

OBJECTIVES

To systematically review and narratively synthesise alienation and/or anomie in pharmacists across the globe, reviewing all types of methodological designs, published in peer-reviewed journals.

METHODS

We identified published peer-reviewed research through searching eight electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science - Core Collection, Scopus, and Google Scholar) and extensive hand/citation searching. Two independent reviewers identified and critiqued eligible studies, extracted data, and synthesised the findings. The synthesis evaluated the focuses, causes, associated factors, and/or consequences of alienation and/or anomie and aligned these to six deductive themes from alienation theory: care; values; meaning; recognition; autonomy; and shared responsibility.

RESULTS

Searches identified 886 papers, with 47 included in the final results. From the synthesis, ten key causes of alienation and/or anomie were identified; 1) Changing Professional Identity, 2) Reimbursement Models & Corporatisation, 3) Focus on Medicines Rather than People, 4) Misunderstanding & Deprofessionalisation, 5) Environments & Culture, 6) Suboptimal Societal Mandate, 7) Roles Misaligned with Aspirations, 8) Systematic Underutilisation, 9) Lack of Professional Agency, and 10) Value Conflict. From the evidence, there was high confidence that inhibitions of care, values, recognition, and/or autonomy (four of the six deductive themes) were associated with alienation and/or anomie.

CONCLUSION

Alienation and/or anomie are present across many countries and regions. This paper helps us understand the aetiology of this complex psycho-social syndrome, a necessary first step in creating an inclusive profession where all pharmacists can flourish. Future research needs to trial new interventions targeted at correcting this professional malady.

Positioning of community pharmacists in interactions with general practitioners and patients regarding prescribing and using antibiotics

Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is important for ensuring antibiotics are used correctly and combating antibiotic resistance. The study's main objective was to investigate how CPs, GPs and patients, respectively, position CPs in their interactions with patients on antibiotic-related matters in Norwegian pharmacies. Seven focus-group interviews were performed. Data were analyzed using systematic text condensation. Positioning theory was used to identify positions assigned to CPs by themselves, by GPs and by patients. CPs position themselves as helpful, accessible drug specialists responsible for advising on antibiotic use, but also consider themselves dependent on GP-supplied information to do so. GPs position CPs as helpful, responsible businesspeople who, however, lack clinical experience and are overzealous gatekeepers. Patients position CPs as helpful people who supply information in "everyday language" and as the GP's extended arm. Patients utter they are best served when GPs and CPs collaborate. This discrepancy is a barrier to optimal service to patients in general, and to proper antibiotic use in particular.

Development and validation of patient-community pharmacist encounter toolkit regarding substance misuse: Delphi procedure

BACKGROUND

Pharmacists' roles and services for patients with substance use are not well defined and inconsistent from site to site. Several barriers have been identified that hinder pharmacists' care for people who use substances, such as a lack of training and resources. Clinical practice tools can aid in transferring evidence-based approaches to the practice sphere.

OBJECTIVES

The aim of the study was to develop a substance misuse management toolkit for community pharmacists to help them manage their encounters with people who use substances.

METHODS

A focused literature review was conducted and 2 needs assessment studies, one for community pharmacists and one for patients informed the development of the toolkit. The toolkit is an adaption of the screening, brief intervention, and referral to treatment (SBIRT) approach, which is one of the most well-defined and effective strategies for substance use management. However, SBIRT is a novel care model in community pharmacy settings. Therefore, a substance misuse management toolkit with 20 items was created for community pharmacists incorporating evidence-based strategies and clinical algorithms. Delphi procedure was used to validate the toolkit.

RESULTS

Two rounds of questions were sent to experts in the field of substance misuse, some of whom were pharmacists. In both rounds, these experts were asked to rate the appropriateness and clarity of items in the toolkit and provide comments and suggestions. Items with a median rating of 7 or more out of 10 were included in the toolkit. In the second round, the experts were asked to rerate the revised version and provide additional feedback. After the second round, agreement was reached for almost all items of the toolkit.

CONCLUSION

A Delphi procedure was successfully used to provide evidence of the validity of the new guiding toolkit for community pharmacists. The toolkit will be implemented and evaluated to provide additional evidence of validity in practice.

Effect of patient-led cooperative follow-up by general practitioners and community pharmacists on osteoporosis treatment persistence

AIM

Osteoporosis is a major risk factor for fractures. Poor persistence with osteoporosis medication hampers outcomes. This study assessed whether encouraging the formation of patient-led follow-up cooperatives between general practitioners (GPs) and community pharmacists improved medication persistence.

METHODS

All consecutive patients who attended an osteoporosis patient education program were invited to participate. They were given a logbook containing questionnaires they would bring to 6-monthly visits to their GP and pharmacist. The effect of this 3-year cooperative follow-up on persistence with medication and lifestyle changes was assessed.

RESULTS

In total, 121 patients (average age, 67 years; 93% female) participated. Poor cooperation between GPs and pharmacists was noted. Nevertheless, medication persistence ranged from 83% to 91% over the 6 visits. However, since patient drop-out rates were high and questionnaire return rates were low, a post-study medical chart review was performed. This confirmed that persistence was high (74%-83%) at 3 years post-enrollment, even for oral bisphosphonate-treated patients (73%-76%). However, adoption of anti-osteoporosis lifestyle changes was poor throughout the study: one- to two-thirds of the patients did not alter their diet, physical activity, or surroundings to prevent falls.

CONCLUSION

One study goal, namely, to encourage GPs and pharmacists to cooperate in patient follow-up, was not achieved. However, high medication persistence was observed. This may reflect the education program, patient empowerment, personalized attention from study personnel, and being in a study. Patient-centered approaches can thus significantly increase medication persistence in osteoporosis. Ongoing education may be needed to improve patient adoption of and persistence with lifestyle changes.

The relationship between knowledge, attitudes, and practices of community pharmacists regarding persons with substance use disorders

Background: Community pharmacists can play a meaningful role in identification and treatment of substance use disorders (SUD). However, inadequate disease knowledge and negative attitudes are known barriers. The relationship between knowledge, attitudes, and practice of pharmacists regarding persons with SUD has not been evaluated comprehensively in the United States. The objective of the study was to assess knowledge of community pharmacists regarding medications for SUD and evaluate their attitudes, levels of stigma, and clinical practices in SUD. Methods: A questionnaire was developed to assess practices, knowledge, screening services, and attitudes toward harm reduction strategies and treatment. A standardized measure of stigma was included along with demographics. A cross-sectional electronic survey was conducted in Pennsylvania, Ohio, and West Virginia among a non-probability sample of community pharmacists working for a retail pharmacy chain (n = 910) and a local alumni network (n = 50). Scores were calculated for each factor and descriptive analyses, mean differences (t-tests and ANOVA), correlations with demographics and practice characteristics were performed. Linear and ordinal regressions were utilized to predict knowledge, practice, screening, and stigma scores. Results: A total of 134 responses (response rate 13.9%) were collected. On average, the pharmacists were 38 years old, had worked for 15 years, primarily full-time with practice locations in suburban settings. Only 53% reported they received SUD education in pharmacy school. Pharmacists received a mean score of 5.5 and 3.5 out of eight and seven on knowledge and practice scales, respectively. Pharmacists overall had slightly stigmatizing and negative attitudes, with higher stigma significantly related to performing lesser services and considering screenings as important. Number of years worked significantly predicted knowledge and screening. Conclusion: Relationships between knowledge, attitudes, and practices indicate a need for experiential education that includes psychosocial aspects of care with increased opportunities for practice.

Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK

There has been a strong policy emphasis over the past decade on optimising patient-centred care and reducing general practitioners' (GPs') workload by extending community pharmacy services and collaboration between pharmacists and GPs. Our aim was to review current evidence of pharmacists' and GPs' views of extended community pharmacy services and pharmacists' roles in the United Kingdom (UK). A systematic review was undertaken looking at UK studies investigating pharmacists' and/or GPs' views of community pharmacy services or roles from 2005 to 2017. A range of databases were searched including EMBASE, PubMed, Scopus, Web of Science, International Pharmaceutical Abstracts (IPA), PsycINFO, Science Direct and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). In addition, reference lists of included studies were screened and grey literature was searched. Following the application of inclusion/exclusion criteria, the quality of papers was critically analysed, findings were extracted into a grid and subjected to narrative synthesis following thematic analysis. The search strategy yielded a total of 4,066 unique papers from which 60 were included. Forty-seven papers covered pharmacists' views, nine combined both pharmacists' and GPs' views and four covered GPs' views. Study designs included interviews (n = 31, 52%), questionnaire surveys (n = 17, 28%) and focus groups (n = 7, 12%). Three main themes emerged from the data: "attitudes towards services/roles", "community pharmacy organisations" and "external influences". Pharmacists and GPs perceived a number of barriers to successful implementation and integration of pharmacy services. Moreover, collaboration between pharmacists and GPs remains poor despite the introduction of extended services. Overall, extending community pharmacy services require quality-driven incentives and joint working between community pharmacists and GPs to achieve better integration within the patient's primary care pathway.

Perspectives on privacy in the pharmacy: The views of opioid substitution treatment clients

BACKGROUND

Many pharmacists practise in settings in which protecting privacy can be difficult. To address this, some community pharmacies are rearranging their retail space to provide private areas for clinical consultations. Such facilities are deemed particularly important when dealing with clients who have sensitive medical conditions, such as opioid dependence.

OBJECTIVE

To explore Opioid Substitution Treatment (OST) patients' perceptions of privacy in a community pharmacy setting, with a particular focus on the layout of the community pharmacy.

METHODS

We conducted semi-structured interviews with OST clients. Recruitment and the interviews were conducted at state government drug and alcohol clinic. The interviews were audio recorded and transcribed verbatim. The data were analysed in NVivo using the framework approach.

RESULTS

We interviewed fourteen OST clients. Most participants were concerned about privacy and considered that the pharmacy layout could enhance or hinder privacy. However, they disagreed about exactly which pharmacy layout was most privacy-protecting. In addition, a small group of clients interviewed who had a very positive relationship with pharmacists believed that the relationship contributed to their confidence that their privacy was protected.

CONCLUSIONS

There is little consensus amongst consumers about how to protect privacy in the community pharmacy. The range of views expressed by clients in this study may reflect the lack of consensus about the nature of privacy in health ethics. Attention to the meaning of and rationales for privacy protections may be helpful when designing pharmacy layouts to meet the needs of a broad range of consumers. An enclosed or screened private area which can be used as a consultation area for all private pharmacy discussions, including for OST dosing, could be a solution to addressing these varying views on privacy in the pharmacy. Further attention to enhancing the pharmacist and client relationship may assist in reducing sensitivity about privacy.

Extending alcohol brief advice into non-clinical community settings: a qualitative study of experiences and perceptions of delivery staff

Background

At a population level, the majority of alcohol-related harm is attributable to drinkers whose consumption exceeds recommended drinking levels, rather than those with severe alcohol dependency. Identification and Brief Advice (IBA) interventions offer a cost-effective approach for reducing this harm. Traditionally, IBA interventions have been delivered in healthcare settings and therefore contextual influences on their use in non-clinical settings are not well understood.

Methods

Qualitative face-to-face and telephone interviews with staff responsible for delivering a pilot IBA intervention across community settings in the UK. Interviews were recorded and transcribed verbatim. Inductive thematic analysis was used to identify key issues and the constant comparison method was employed to compare barriers and facilitators to implementation across and within settings.

Results

A number of facilitators and barriers to delivery and implementation was identified across settings. These included familiarity with the customer base, working within public spaces, and assimilation of the intervention within existing role boundaries. Despite underlying concerns relating to the sensitive nature of the topic, most delivery staff felt their respective settings were appropriate for the delivery of the intervention and had proactively engaged members of the public with varying levels of risky drinking and readiness for behaviour change. Perceptions of actual or potential intervention success were conceptualised in relation to existing day-to-day role boundaries and responsibilities and the contexts in which they took place.

Conclusions

Findings support the potential value of multi-setting community approaches to facilitate more inclusive engagement with IBA. By comparing experiences and views from staff responsible for delivering the intervention across different community settings, our findings provide insight into how intervention acceptability and success are framed across settings, and how the intervention is assimilated within everyday practice and role boundaries. This study also highlights key areas to be addressed when implementing IBAs in non-clinical community settings by staff with diverse levels of health-related knowledge, skills and support needs. Although essential, the need for adaptable training and delivery approaches across different setting types is likely to result in methodological challenges that need to be addressed when evaluating future interventions and setting-specific influences on behaviour change and health outcomes.

Pharmacy-based alcohol-misuse services: current perspectives

Context

Globally, the use of alcohol is a leading cause of mortality and morbidity. Opportunistic screening and brief interventions (SBIs) have been shown to be effective in reducing alcohol consumption in certain primary care settings and provide a means of reaching some of those who do not seek treatment for alcohol-related problems. Further, community pharmacies have the potential to reach consumers at an early stage of their alcohol use and incorporate intervention and advice into their role in providing medications.

Aim

The purpose of this review was to inform pharmacists and stakeholders of the evidence base for SBI in community pharmacy settings. To date, there has been limited research on the effectiveness of alcohol SBI in community pharmacies, with a systemic review only identifying two randomized trials.

Methods

This narrative review reports on the period 2007–2017, covering feasibility studies, pilot programs, and surveys of consumers and pharmacy staff attitudes relating to alcohol SBI in this setting. Studies were identified via MEDLINE, CINAHL, Google Scholar, and reference lists of relevant publications.

Findings

The findings indicated that the provision of community pharmacy alcohol SBI requires training in communication and intervention skills and in some cases increasing confidence and alcohol-related knowledge. Consumers were generally receptive to the SBI approach but requested private areas for delivery of such.

Conclusion

The high prevalence of “at risk” alcohol use in many countries and the low level of treatment seeking by this group means that novel approaches to engage opportunistically with these people is imperative in reducing alcohol-related harms. However, before committing routine health funding, these novel approaches need rigorous evaluation.

Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

'Making the invisible visible' through alcohol screening and brief intervention in community pharmacies: an Australian feasibility study

BACKGROUND

Screening and brief interventions (SBI) for alcohol related problems have been shown to be effective in health settings such as general practice or emergency departments. Recent data from the United Kingdom and New Zealand suggest that SBI can be delivered through community pharmacies, but this approach has not been tested in Australia. This study assesses the feasibility of delivering alcohol SBI via community pharmacists.

METHOD

We recruited five pharmacies and developed an SBI training package to be delivered by pharmacy staff, who screened consumers and delivered the brief intervention where appropriate. Consumers also completed a questionnaire on the process. At three months consumers were telephoned to enable 'retention' to be quantified. After completing recruitment, a semi-structured interview was conducted with pharmacists on the process of delivering the intervention, potential improvements and sustainability.

RESULTS

Fifty consumer participants were screened, ten from each pharmacy. There were 28 (57 %) men and 21 (43 %) women with one not responding. Most (67 %) were aged 25-55 years. Their AUDIT scores had a range of 0 to 39 (mean 10.9, SD 9.8) with 11 categorised as 'hazardous (8-15)', four as 'harmful (16-19)' and eight as 'probably dependent (20+)' consumers of alcohol. Reactions to the process of SBI were generally favourable: for example 75 % agreed that it was either appropriate or very appropriate being asked about their alcohol consumption. With respect to follow-up interviews, 23 (46 %) agreed that they could be contacted, including five from the highest AUDIT category. Subsequently 11 (48 %) were contactable at three months. Three of the five non-low risk drinkers had reduced their level of risk over the three months. Ten pharmacists participated in semi-structured telephone interviews. Overall these pharmacists were positive about the intervention and five main themes emerged from the interviews: 1) flexibility applied in recruitment of participants, 2) easiness in use of AUDIT score to facilitate discussions, 3) perceived positive intervention impact, 4) enhanced role of community pharmacists and 5) facilitators and challenges experienced.

CONCLUSIONS

Pharmacy-based SBI appears to be acceptable to consumers and feasible for pharmacy staff to deliver. Challenges remain in translating this potential into actual services.

Community pharmacists require additional support to develop capacity in delivering alcohol-related health information to older adults

OBJECTIVES

This qualitative study explored the barriers and enablers influencing Western Australian (WA) community pharmacists' knowledge, confidence, willingness and practice in engaging older clients (>60 years) in alcohol-related health discussions.

METHODS

Two focus groups were conducted with a total of 14 community pharmacists who had previously completed a formative quantitative survey (n = 63), and indicated willingness to participate in a follow-up focus group. Focus group questions, informed by the survey results, explored participants' perceptions about barriers and enablers to delivering health information and advice about alcohol to older clients (60+ years). Shaw and colleagues' theoretical framework was used to understand barriers and enablers in relation to role legitimacy, role adequacy and role support.

KEY FINDINGS

Participants acknowledged that providing health information about alcohol to older clients is a legitimate part of a community pharmacist's role, and most were confident performing this role in situations perceived as core to their professional practice, such as while dispensing medicines. However, many participants identified limited knowledge, skills and confidence in assisting older clients who may have alcohol issues, beyond advising them on medication and alcohol use. Structural barriers such as time and financial barriers were also identified.

CONCLUSION

Routine professional practice including dispensing medicine and home medicine reviews may provide valuable opportunities to engage older clients in alcohol-related discussions. However, limited knowledge concerning appropriate strategies to assist older clients reduce their alcohol consumption, coupled with limited skills and confidence among community pharmacists in raising sensitive alcohol-related issues with clients, suggest the need for specific alcohol-related training and support.

Prescribing or dispensing medication represents the best opportunity for GPs and pharmacists to engage older people in alcohol-related clinical conversations

OBJECTIVES

This research aimed to identify older Australian drinkers' knowledge about Australian Alcohol Guidelines and their beliefs about the risks and benefits of alcohol; their recall of alcohol-related issues being raised with them by their community pharmacist and General Practitioner (GP); and their receptiveness to alcohol-related information being provided by either health professional.

METHODS

This research was conducted in Perth, Western Australia. Flyers calling for participants were placed in local health and service centres, and advertisements were placed in local media. Participants who met eligibility requirements were posted a survey pack (n = 190) including an information letter, consent form, quantitative survey, and return addressed, postage paid envelope. 188 people aged over 60 years returned completed questionnaires.

KEY FINDINGS

Women were more familiar with national alcohol guidelines, and were more conservative about the potential health benefits of alcohol. While 90% of participants were receptive to their GP asking about their alcohol use, only 30% of men and 20% of women recalled their GP raising this issue with them in the prior 12 months. Of these, high-risk drinkers were six times more likely than low-risk drinkers to have been asked by their GP. Likewise, 50% of men and 65% of women were receptive to having alcohol-related health conversations with their community pharmacist, but less than 4% recalled their pharmacist raising this issue. Participants were most receptive to receiving information about alcohol-medication interactions.

CONCLUSIONS

This research highlights that prescribing and dispensing medication represents the ideal opportunity for health professionals to deliver alcohol-related information to older people.

A qualitative study of English community pharmacists' experiences of providing lifestyle advice to patients with cardiovascular disease

BACKGROUND

Cardiovascular disease (CVD) progression is modifiable through lifestyle behaviors. Community pharmacists are ideally placed to facilitate self-management of cardiovascular health however research shows varied pharmacist engagement in providing lifestyle advice.

OBJECTIVE

This study explored community pharmacists' experiences and perceptions of providing lifestyle advice to patients with CVD.

METHODS

Semi-structured interviews were conducted with fifteen pharmacists (1 supermarket; 7 multiple; 7 independent) recruited through multiple methods from community pharmacies across the Midlands, England. A thematic analysis was conducted using a Framework approach.

RESULTS

Pharmacists categorized patients according to their perceptions of the patients' ability to benefit from advice. Many barriers to providing lifestyle advice were identified. Confidence to provide lifestyle advice varied, with pharmacists most comfortable providing lifestyle advice in conjunction with conversations about medicines. Some pharmacists felt lifestyle advice was an integral part of their role whilst others questioned whether pharmacists should give lifestyle advice at all, particularly when receiving no remuneration for doing so.

CONCLUSION

Pharmacists viewed providing lifestyle advice as important but identified many barriers to doing so. Lifestyle advice provision was influenced by pharmacists' perceptions of patients. Professional identity and associated role conflict appeared to underpin many of the barriers to pharmacists providing lifestyle advice. Pharmacists may benefit from enhanced training to: increase their confidence to provide lifestyle advice; integrate lifestyle advice with regular pharmaceutical practice and challenge their perceptions of some patients' receptiveness to lifestyle advice and behavior change. Changes to the way UK pharmacists are remunerated may increase the provision of lifestyle advice.

Alcohol and prescription drug safety in older adults

Background

The objectives of this study were to investigate older adults’ knowledge of prescription drug safety and interactions with alcohol, and to identify pharmacists’ willingness to disseminate prescription drug safety information to older adults.

Methods

The convenience sample consisted of 48 older adults aged 54–89 years who were recruited from a local pharmacy and who completed surveys addressing their alcohol consumption, understanding of alcohol and prescription drug interactions, and willingness to change habits regarding alcohol consumption and prescription drugs. To address pharmacist willingness, 90 pharmacists from local pharmacies volunteered and answered questions regarding their willingness to convey prescription drug safety information to older adults.

Results

Older adults reported low knowledge of alcohol and prescription drug safety, with women tending to be slightly more knowledgeable. More importantly, those who drank in the previous few months were less willing to talk to family and friends about how alcohol can have harmful interactions with prescription drugs, or to be an advocate for safe alcohol and prescription drug use than those who had not had a drink recently. Pharmacists reported that they were willing to convey prescription drug safety information to older adults via a variety of formats, including displaying or distributing a flyer, and directly administering a brief intervention.

Conclusion

In this study, older adults were found to have inadequate knowledge of prescription drug safety and interactions with alcohol, but pharmacists who regularly come in contact with older adults indicated that they were ready and willing to talk to older adults about prescription drug safety. Future research should focus on interventions whereby pharmacists disseminate prescription drug safety information to older adults in order to improve healthy prescription drug and alcohol behavior and reduce medical and health costs associated with interactions between alcohol and prescription drugs.

Review of services provided by pharmacies that promote healthy living

BACKGROUND

The recognition that community pharmacies have the potential to make a greater contribution to promoting public health has led to a new concept, called the Healthy Living Pharmacy (HLP). These are designed to meet public health needs through a tiered commissioning framework delivering health and well being services through community pharmacy, tailored to local requirements for tackling health inequalities.

AIM

To search the literature for quality evidence to support the inclusion of services in the HLP portfolio and suggest areas where more evidence is required.

METHOD

A systematic review of the research literature covering the period January 1990-August 2011 inclusive, using MEDLINE, EMBASE, Pharmline, NHS Evidence and the Cochrane databases. On-line searching of the grey literature (e.g. conference proceedings) was also carried out. Standard methods of assessing quality were employed.

RESULTS

A total of 377 papers were included. Over time, there was a marked increase in frequency of publications reflecting a growing pharmacy interest in the public healthcare agenda; over a third (35 %) of papers appeared in the last three-year study period. The body of research had a wide geographical basis; contributions were as follows: UK (51.5 %), US (20.4 %), Australia/New Zealand (9.8 %), Europe (7.7 %) and Canada (7.2 %). The topics of contraception, cardiovascular disease prevention, diabetes and smoking cessation accounted for 40 % of included papers. The literature supports the introduction of specific community pharmacy services, targeted at customer groups, both with and without pre-existing diseases. Good evidence exists for smoking cessation, cardiovascular disease prevention, hypertension and diabetes. Some good evidence exists for interventions on asthma and heart failure. The evidence supporting weight management, sexual health, osteoporosis detection, substance abuse and chronic obstructive pulmonary disease is weak and needs development.

CONCLUSION

There is strong evidence for the role of community pharmacy in a range of services, not only aimed at improving general health, but also maintaining the health of those with existing disease. In other areas, the evidence is less strong and further research is required to justify their inclusion in a HLP portfolio.