1Post Graduate Student (PhD),2Professor of Social and Administrative Pharmacy Discipline, Professor of Clinical Pharmacy Discipline; School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Minden, Pulau Pinang
Received: 14 Jun 2017 Revised and Accepted: 31 Aug 2017
Objective:Aims of this review were to identify actual or potentialextended services performed in community pharmacy settings, perceptions among community pharmacists (CPs), general practitioners (GPs), consumers and policymakersof these extended services and barriers towards its performance.
Methods:A literature review was conducted, using Google Scholar and PubMed as a searching engine.
Results:Identifying eight quality full texts to review which fulfil the inclusion searching criteria, revealing a wide range of actual or potential extended services performed byCPs such as counselling on asthma, cardiovascular disease, breast cancer, diabetes, smoking cessation and self-medication. GPs’ perceptions towards these extended services werevaried,not or in favour of CPs to performsome actual or potential extended services. Customers werein favour of CPs to performthese actual or potential extended services whereas CPsindicateda few barriers towardsthe performance of these actual or potential extended services.
Conclusion:As a conclusion, CPs in Malaysia were in the right position to performthe actual or potential extended services, collaborating with GPs to promote bettermedication use andenhance patients’ quality of life. Some barriers towards these extended services must beintervened in order to enhance the quality of the services.
Keywords:Extended services, Community pharmacist, Perception, Barrier, Malaysia
© 2017 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open-access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
In Malaysia,the community pharmacists (CPs) are in a dilemma as theyare not given the main right to control allmedication distribution. Their role is shared with the general practitioners (GPs) who are alsoallowed to distributemedications to their patients. Even though ahistory in Europe had enactedthe separation role of GPs and CPs back in a few hundred years ago , the separation roleis not much changingin the developing country like Malaysia except for the practice in the hospital settings. Whereas CPs are still working under harsh environment, focusing more on health products or cosmetics or hygiene products to sustainexisting in the market . However, in other parts of the world, the community pharmacy practice is keeping on changing, transforming thepractice towards more patient-oriented, adding value to the age-old role as pharmacist . For example, pharmacists are now becoming a pharmacotherapy expert, advising GPs on drug therapy plan and collaborating with them to monitor the drug therapy outcome . Unfortunately,it isquite hard to see CPs in Malaysia performing patient-oriented basedservices and ifdo, there is lacking information about the services. What isgoing on in the community pharmacy settings? Do CPs perform any extended services instead of selling health products? What are the perceptionsof these extended services? What are the barriers towards these extended services? Therefore, the aims of this review are to observeactual or potential extended services performed by CPsin community pharmacy settings, view perceptions among CPs, GPs,customers and policymakersof these extended services and identify barriers towardsits performance in the context of Malaysia scenario. The rationale of this review is the fact that it can highlight some ideas to CPs, customers, policymakers and other health care professionals about actual or potential extended services performed in community pharmacy settings.
A systematic search of international literature review and studies wasundertaken using Google Scholar and PubMed as an electronic database, searching for abstracts in English from January 2006 till May 2017. The search terms used were: Malaysia; community pharmacist; extended roles; extended services; expansion roles; expansion services; perception; perspective; attitudes; barriers; limitation. The abstracts wereevaluated by a researcher, searching for relevant materials that fitted with the inclusion criteria as depicted in table 1. The abstracts that adhered to the inclusion criteria were assessed for full texts. Then two researchers assessed in detail the contents of eachtext, searching for materials thatfulfil the criteria as depicted in table 1. These full texts werereflected inthe present review.
Table 1: Criteria for inclusion of studies in the review
|Population||Community pharmacy, community pharmacists, customers, policymakers and general practitioners in Malaysia|
|Phenomenon of interest||Actual or potential extended servicesperformed in community pharmacy settings. Perception among the community pharmacists, customers, general practitioners and members of policymakerof these extended services. Identifying barrierstowards its performance|
|Primary outcome measures||
The outcome measures but not restricted to it were:
●To describe actual or potential extended servicesin community pharmacy settings
●To describe perception or attitudes among community pharmacists, customers, general practitioners and members of policymakerof the extended services
●To identify barriers towards its performance
|Types of studies||Quantitative cross sectional survey, qualitative study|
A total of522 titles and abstracts were reviewed and assessed against the inclusion criteria as depicted in table 1, led to 62 titles and abstracts. These shortlisted titles and abstracts were assessed for full texts which led to 52 texts. Two researchers had ratedthese texts to identify inclusion criteria which led to 8 quality texts and thesetexts were included in this review. The flow of the searching process was depicted in fig. 1.
Fig.1: Flow diagram of searching and inclusion criteria
Table 2: Literature review about actual and potential extended services, perceptions and barriers
|Authors||Study objective/ outcome measure||Method of data collection||Principal findings||Conclusion|
Hassali et al
|To identify health promotion activities and barriers towards its performance in community pharmacy settings||A cross-sectional survey design was conducted involving face to face interview and distributing questionnaires to 100 community pharmacists (CPs) in Penang||A total of 80% responded to the study, indicating their highly involved in diabetes counselling (n=26, 32.5%), followed by weight management counselling (n=20, 25.0%), traditional and complimentary medication counselling (n=18, 22.5%) and nutrition/physical activity (n=16, 20.0%). CPs were least involving in immunization (n=5, 6.3%), followed by drug misuse (n=3, 3.8%), special population (n=3, 3.8%) and asthma counselling (n=3, 3.8%). Varieties responded were identified towards uncertain extended role of CPs. Among barriers towards extended roles were lack of time, lack of profitability and absence of standard guideline to follow||CPs are providing a wide range of actual or potential extended services. However some barriers are addressed to be resolved. These extended services reveal that community pharmacy practice in Malaysia is not stagnant. CPs are keeping on transforming their practice towards more patient-oriented practice.|
Hassali et al
|To evaluate general practitioners’ (GPs) perceptions towards professional training and roles of community pharmacists (CPs)||A cross-sectional survey was conducted, involving 160 GPs in District A||80 (50.0%) GPs responded to the study. Majority GPs disagreed if CPs were diagnosing minor illnesses (52.5%) and conducting screening test (52.5%). But GPs agreed if CPs were educating patients about medication safety (52.5%), referring patients to GPs (76.3%) and collaborating with CPs (77.5%). GPs (61.3%) agreed that CPs were more towards patient-oriented than before, advising patients of selecting non-prescription medications (46.3%)||GPs are now more aware about the role of CPs and ready to collaborate with CPs for patients’ benefit. GPs are in favour of CPs to manage some medical issues especially related to medication problems. However, GPs are not in favour of CPs to make diagnosis.|
Beshir & Hanipah
|To identify community pharmacists’ knowledge, perceptions and barriers towards provision breast cancer health promotion services||A face to face interview, using structured questionnaire was conducted in district of Hulu Langat and Sepang, involving 52 CPs||A total of 35 CPs (67.0%) responded to the study. Majority respondents answered correctly about breast cancer incidence. CPs perceived that they can influence patients to conduct earlier screening to detect breast cancer (n=9, 25.7%) and they should involve in breast cancer health promotion (n=9, 25.7%). Distributing info about breast cancer (n=10, 28.6%) was important. Lack of time (n=28, 80.0%), knowledge (n=27, 77.1%) and training (n=22, 62.9%) were among the barriers||Even though none of CPs involve in breast cancer health promotion, the study reveals the potential of CPs to take part in this potential extended role. This extended role can increase the image of CPs as a professional practitioner.|
Azmi et al
|To view general practitioners’ (GPs) perception of community pharmacists’ (CPs) specific patient care activities||A mail-survey was conducted in the state of Penang involving all GPs, using a developed questionnaire||Majority of the respondents were favour of CPs’ roles in providing public health education (58.7%), informing GPs about prescribing and prescription errors (56.0%) and referring patients to GPs who had medication issues (53.0%). However, the respondents were not favour of CPs’ roles in conducting smoking cessation programme (34.8%) and providing drug information to GPs (43.0%)||There are potential roles for CPs to provide specific patient care activities and collaborate with GPs for patients’ benefit. Majority of GPs are favour of CPs to manage some medical issues even though GPs are not favour of CPs to do other issues. However, GPs are actually in favour of working with CPs.|
Rajiah et al
|To view community pharmacists’ (CPs) perception towards patient counselling and continuing pharmacy education program (CPEP) as well as barriers towards its performance||This was a cross-sectional study, using a self-administered questionnaire, involving CPs in Selangor and Kuala Lumpur||A total of 220 CPs responded to the study, indicating lack of time (33.0%), patient’s interest (27.0%) and knowledge (20.5%) as among the barriers. Promoting public education (52.0%), increasing number of pharmacists (20.0%) and attending CPEP were the strategies to overrun the barriers||CPs can take the role to provide patient counselling. They can enhance their knowledge by attending CPEP. This CPEP can help CPs to enhance their confidence when CPs decide to counsel their patients.|
Sarriff et al
|To view the general public’s level of knowledge and awareness of cardiovascular diseases (CVDs) and expectation of community pharmacists’ (CPs) role to prevent and manage CVDs||A prospective, cross-sectional study, using self-administered questionnaire, involving 456 general public, was conducted in the state of Penang||Respondents had poor (46.0%), moderate (43.0%) and good (9.0%) knowledge of CVDs and its warning symptoms, respectively. Public awareness of CVD risk factors was better than their knowledge of CVDs and its warning symptoms; in which had poor (37.0%), moderate (35.0%) and good (28.0%) awareness, respectively. The majority of respondents were favourable responses on the role of community pharmacists in identifying and preventing CVD risk factors in the community||CPs shall take the role to assist the general public about managing CVDs as part of their extra services. This extended service can enhance the value of CPs’ knowledge especially related to CVD medications. CPs can identify, prevent and resolve all kinds of drug related problems, specifically among the CVD patients.|
Saw et al
|to explore the private general practitioners’ (GPs) views in integrating pharmacists into private primary healthcare clinics in Malaysia||To recruit private sector GPs to participate in focus groups and semi-structured interviews. The sessions were audio recorded, transcribed verbatim and thematically analysed using NVivo 10||Thirteen private GPs participated in one focus group and ten semi-structured interviews. Four major themes were identified: (i) poor understanding of pharmacists’ roles; (ii) readiness to accept pharmacists in private primary healthcare clinics; (iii) lack of confidence and trust in pharmacists; and (iv) perceived increased costs with pharmacist integration. The study indicated respondents’ views and acceptance were largely influenced by the amount of exposure and experience they had working alongside pharmacists. Respondents viewed a lack of confidence in pharmacists and increase in costs associated with an employed pharmacist within private primary health care clinics as barriers to integration||CPs must enhance their knowledge and skills in order to enhance their confidence when working with GPs. CPs must also perform their best to gain GPs’ trust and confidence. At the end, it is hoped that CPs will be accepted as member of health care team.|
Saw et al
|To investigate general practitioners’ (GPs) views towards integrating pharmacists into private primarily health care clinic in Malaysia||The study was involving GPs in Selangor and Kuala Lumpur, using focus groups and semi-structured interview for those who could not commit into the focus group||A total of 13 GPs responded to the study, three in focus group, and ten in semi-structured interview. The study revealed GPs had poor understanding about pharmacist’s roles in private primarily health care clinic, lack of confidence and trust in pharmacists and indicated high cost with pharmacist’s participation. However GPs were ready to accept pharmacist’s role in the primarily health care clinic||GPs must be educated about the potential role of pharmacists in the primarily health care clinic. GPs must have stronger confidence and trust with pharmacists so that both profession can work together|
Description of the included text
The characteristic of the individual textswas depicted in table 2. The texts involved a cross-sectional survey with semi-structured interview (n=1), cross-sectional survey (n=4), semi-structured interview (n=1) and focus group discussion (n=2). It is noted that the texts were assessinghealth promotion activitiesin community pharmacy settings andits barriers ,GPs’ perceptionsof CPs’ actual or potential extended services [7,8],CPs’ knowledge and perceptionofactual or potential extended services [9,10],customers’ perceptionsof CPs’ roles to prevent and manage majordisease  and GPs’ perception ofintegrating pharmacists into privateprimary health care clinics [12,13].
A total ofnineteen actual or potential extended serviceswere noted in thereview (see table 3).Medicationcounselling [6-8,10] and conducting smoking cessationprogram [6,8,11] were the most rated extended services. Surprisingly, it was found that CPs were noted theless paying attention to identify, prevent and resolve drug-related problem . It was also noted that CPs were referring their customers to GPs  even though it was previously noted that the practice itself was more towards business-oriented practice. In addition, CPs were also noted to counsel their customers about major diseases such as asthma, diabetes and cardiovascular [6,11], crossing over the age-old role as a medication dispenser.
Perception towards extended services
A total oftwenty perceptions were noted from thereview (see table 4), demonstratinga wide range of perceptions among the customers, CPs and GPs of extended services performed in the community pharmacy settings. It was noted thatGPs’ and CPs’ perceptions were the most rated. It was found that GPs have poor perceptions towards the extended servicesperformed in community pharmacy settings [7,8]. However, GPs were noted to have favour of CPs to manage medication use among their patients and accepting referral customers from CPs [7,8]. This review did not identify about policy maker’s perception of CPs’ extended services.
Barriers to the extended services
A total ofseventeen actual or potential barriers towards the extended services werenoted inthisreview (see table 5). It was noted that lack of time, training, budget, confidence and poor understandingabout CPs’ roles were the most rated as actual or potential barriers[6,8-10,12,13]. Besides that, it was noted that customers’ health promotion activitieswere a unique potential barrier to the extended services , reflecting a trend of self-care treatment among the people.In addition, it was also noted that CPs indicated language barrier was among the barriers , reflecting multi-racial ethnic languages in Malaysia might have the tendency to decrease the verbal interaction between CPs and customers.
Data which reflected policymakers’ views about the barriers to the performance of these extended services, was not noted in this review.
Table 3: Extended services of community pharmacist, CV=Cardiovascular; GPs=General practitioners
Table 4: Perception towards extended services, GPs=General practitioners; CPs=Community pharmacists; PO=Patient-oriented; SC=Smoking cessation
Table 5: Barriers towards extended services
This review revealssome actual or potential extended services performed in the community pharmacy practice and it reflects a tendency among CPs to transform their current practice towards morepatient-oriented services [6-13]. Such patient-oriented services noted were face to facecounselling [6-11],treating minor ailments , health promotion activities [6,8] andscreening for drug-relatedproblems . Thisreview reveals that the community pharmacy practice in Malaysia iskeeping on changing and moving forwardas a response to thedemand of the local population.Such transformation era is alsoconsistently observed in other countries such as Australia, Jordan, China, Canada, South Africa and the United Kingdom respectively [14-19]. For example in Australia, CPs are well known for offering services such as asthma, diabetes, methadone, herbal medicines, hypertension and wound care services as an extra service . In Jordan, CPs havetaken the responsibilities to identify, prevent and resolve drug-related s problems amongthose customers who consume multiple or long-term medications . In China, CPs have taken initiatives to learn in detail aboutthe philosophy of pharmaceutical care so that they can serve the customers with the highest standard of practice. In Canada, CPs decide to involve in conducting smoking cessationprogram and screening their customers for hypertension, diabetes, dyslipidemia and sexual health problem as a part of their extra services . Surprisingly, in future CPs in South Africa would be given with more exclusive right in their practice. They will be given the right toexamine their customers, make a specificdiagnosis, prescribe a specific medication to their customers and monitorthe outcome of the drug therapy plan . However, in adeveloped country like the United Kingdom, CPs were only given the right to prescribe some exclusive medications as a part of their extended services whilecollaborating in work with other GPs for the benefit of their patients .These scenarios reflect CPs are taking the challenge to e improve their practice through extended services. Nevertheless,the actual or potential extended services performed in the community pharmacy settings in Malaysiaare quite lagging from other countries. However, this review reveals that CPs have potential to extend their services towards more patient-oriented[6-13],and enhance their image as a healthcare professional.
This review indicates some perceptions towards the actual or potential extended services performed in the community pharmacy settings. It is noted that GPs are underestimating CPs in variable perspectives such as lack of clinical therapeutic knowledge and skills. Therefore, GPs are not in favour of CPs to provide extra services such as advising them about medication use or else. Other previous studies which are conducted in developed and developing countries are also indicating some variable perceptions towards the extended services. For example,CPs in Jordanare not given the right image as aprofessional practitioner in the health care team . GPs and local people are describing CPs as a businessman rather than a health care provider. As a result, CPs do not have the opportunity to provide extra services to serve the population. Main reason noted is the extended services are not demanded by the local population.In contrast, CPsin the developed countries like Australia and the United Kingdomare in favour of providing a wide range of extended services[14,19]. It is noted that the extended services are a part of the demand coming from their association  and government . In addition, CPs have strong desire to perform their knowledge and skills in order to improve their current practice . Besides that, CPsin South Africa believe that they shouldprovide more extended services and take more responsibilities withdrug therapymanagement . Whereas CPs inHong Kong decide to extend their services as a part of establishing ac working relationship with other health carepractitioners . Believe that the extended services canbenefit their customers in terms of safety and effectiveness of medication use . Interestingly, CPs inNepal believe that the extended services are a part of their strategies toimprove their sales as well asovercome business competition . Nevertheless,CPs in Dubaihas decided to perform extra services in their community pharmacy settings because they believe that the services might have potential tobenefit theircustomers in varieties perspectives . In short, these variable perceptions noted around the world can highlight some ideas to improve the performance of extended services in the community pharmacy settings.
In this review, it is noted a wide range of barriers towards actual or potential extended services performed in the community pharmacy settings. Interestingly, thebarriersare not much different from other barriers notedin other countries. For example, it is also noted that lack of time [14,17,19,21,23-26], budget [17,19], reimbursement [14,16,17,19,23,25,26], training [14,19,20,29], self-confidence [14,18,19], knowledge [14,16,17,20,21,23,27-30], counselling room,[17-19,23] and shortage of pharmacists [14,16,17,27] are among the barriers in the United Kingdom, Australia, Belgium, Nepal, Pakistan, China, South Africa, Netherlands, Singapore, Canada and United Arab Emirates respectively. More interestingly, our review reveals a unique barrier towards extended services which has not been noted in other previous studies. It is the customers’ health promotion activities. This activity is referring to supplement-or vitamin-based products that are accessiblein the market and the products do not need for GPs’ or CPs’ supervision to consume. For example, those people who involve in a multi-level health product scheme are allowed to promote and sell supplements or vitamins to their customers. Most of the time, the people areabsence of clinical therapeutic knowledge and skills. Although they might attend a short course to learn more about medical issues and their health products, they are not in the right position to advise people about the medical problem. However, in this scenario, they are potentially acting as a drug expert and giving inadequate advice to their customers. Unfortunately, it is believed that the customers have given their trust to them to give some advice and products for maintaining their health. As a result, it becomes a barrier towards the performance of extended services in the community pharmacy settings. It is because that CPs have to work hard to gain trust from the people to accept their services rather than seeking for unprofessional advice, In short, it is noted that there are some barriers that require for intervention before the extended services can be performed in the community pharmacy settings. Interestingly, the barriers are consistently noted around the world.
In this review, it is noted that the actual or potential extended services performed in the community pharmacy settings are consistent with the Malaysian National Medicines Policy. This policy which wasendorsed by the Malaysian Cabinetlast October 2006, with a full-term review in October 2012 indicates all healthcare practitioners must make sure themedications that supplied to their patients are safe, appropriate and quality . In addition, the healthcare practitioners must empower their patients in the areas of medication adherence, responsible with self-medication, storage, and self-confidence to interact with other healthcare professionals . The healthcare practitioners should also facilitate continuity of care and they should collaborate with each other and share patient medical and medication profile without compromising patient’s confidentiality . In short, the Malaysian National Medicines Policy indicates all healthcare practitioners including CPs to play more comprehensive roles in their practice,enhance patients’ quality of life andreduce mortality rate due tomedication use. Interestingly, it is noted in this review that CPs are in the right track to perform these duties to serve the people. It is noted that CPs have performed some actual extended services such as counselling their customersabout asthma , cardiovascular [6,11], breast cancer , diabetes , drug misuse , medicine [7,8,10], self-medication , smoking cessation [6,8,11] and weight management . This scenario reflects that CPs are no longer sitting at the back of the counter and trying to avoid of interacting with the people. The fact is that CPs have comeout of their box and start to interact with peoplein order to improve their medicationuse. In short, this review reveals that the actual or potential extended services performed in the community pharmacy settings are consistent with the Ministry of Health’s future plan which is improving the quality of life among the Malaysian population.
The actual or potential extended services performed in the community pharmacy settings requires CPs to enhance their knowledge and skills. It is noted in this review that GPs are underestimating CPs’ clinical therapeutic knowledge . Therefore, GPs might not in favour of CPs to manage some extended services such as smoking cessation program,order for the blood test or else [7,8].As responding to the scenario, GPs must know about the available advanced training for CPs who wantto perform extended servicesFor example, the Malaysian Academy of Pharmacy has been dedicated to advancing the pharmacists’ roles through education, advocacy, research and services towards better pharmacy practice . Thisconstitution offers the pharmacists a wide range of knowledge and skills such as certified smoking cessation service provider, osteoporosis, oral contraceptives, understanding generic medicines, dengue and diabetes medication therapy adherence clinic. A few years back, the constitution has collaborated with the American Pharmacists Association to certify pharmacists as a specialist pharmacist in areas of ambulatory care, oncology, psychiatric, pharmacotherapy and critical pharmacy. Theseknowledge and skills reflect the competent of the certified pharmacists to perform the extended services. Therefore,the certified CPs should no longer be underestimatedif theyhave the chanceto perform the extended services in the community pharmacy settings. Therefore, CPs should take the opportunity to enhance their knowledge and skills, as responding to thedemand of the population in Malaysia. Furthermore, it is noted that in the previous studies conducted in India and Indonesia which reveal the educational interventioncan enhance knowledge, attitudes, and practice among the trainedCPs who performextended servicesin the community pharmacy setting [33,34].
This review reveals that CPs in Malaysia hasthe potential to extend their services to serve the people. Even though there are some barriers towards these extended services, the barriers can be intervenedon condition that there is a will to change among CPs as well as strong political support from the government to enhance the quality of pharmacy practice. Some positive perceptions among thecustomers and GPsof these extended services can encourage CPs to have the self-confidence to perform these actual or potential extended services.
It is noted that some full access texts are not available until the charges to view the contents are being settled. As a result, the scenario might have a tendency to influence the quality of this review since there is lack of article to review. Therefore, it is hoped that in future the researchers will be allocated with an appropriate budget to assist them to pay for the charges to review all the available full access textsin the online internet.
We are grateful to those who help us to finish up this review article.
A#1 conducted, collected andanalyzed data collection. A#2 monitored the quality of data collection. A#3 provided expertise in extra comments.
Authors declare no conflict of interest in the study
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How to cite this article
Nazri Nordin, Mohamed Azmi Ahmad Hassali, Azmi Sarriff. Actual or potential extended services performed by Malaysian community pharmacists, perceptions and barriers towards IT’S performance: a systematic review. Int J Pharm Pharm Sci 2017;9(10):13-20.