**4. Barriers and perceptions of extended community pharmacy services**

There is a wide range of barriers to the performance of extended services notified as illustrated in **Table 3**. Such barriers are a serious impediment to the extended service's progress and it is noted that CPs, GPs, and consumers can be the origins of the barriers. For example, CPs in the United Kingdom, Australia, Belgium, Nepal, Netherlands, Singapore, Canada, and the United Arab Emirates specify a lack of time to spend with their customers might be the paramount barrier to the extended services. Additionally, CPs in the United Kingdom and Australia have to reinforce self-confidence to perform such services since there is a potential lack of on-going training for them. Interestingly, it is notified that CPs in Russia and Sudan are incorporating a lack of clinical component in the pharmaceutical education as the obstacle which puts a stop to the extended services. Foremost, it is noted that CPs in the United Kingdom, Singapore, the United Arab Emirates, Canada, Australia, and China might lose their enthusiasm to implement such extended services due to reimbursement affair. Furthermore, CPs in the United Kingdom and Canada intensify the extended services and require financial support. Therefore, it is crucial intentionality to determine such barriers and CPs must have the devotion to rectify the situation with strong feeling and belief of each extended service that can benefit their customers at all.

Most prominent in rank, it is noted that CPs might not have an interest to execute the extended services due to their absence of knowledge and skills as illustrated in **Table 3**. The reasons


**4. Barriers and perceptions of extended community pharmacy** 

There is a wide range of barriers to the performance of extended services notified as illustrated in **Table 3**. Such barriers are a serious impediment to the extended service's progress and it is noted that CPs, GPs, and consumers can be the origins of the barriers. For example, CPs in the United Kingdom, Australia, Belgium, Nepal, Netherlands, Singapore, Canada, and the United Arab Emirates specify a lack of time to spend with their customers might be the paramount barrier to the extended services. Additionally, CPs in the United Kingdom and Australia have to reinforce self-confidence to perform such services since there is a potential lack of on-going training for them. Interestingly, it is notified that CPs in Russia and Sudan are incorporating a lack of clinical component in the pharmaceutical education as the obstacle which puts a stop to the extended services. Foremost, it is noted that CPs in the United Kingdom, Singapore, the United Arab Emirates, Canada, Australia, and China might lose their enthusiasm to implement such extended services due to reimbursement affair. Furthermore, CPs in the United Kingdom and Canada intensify the extended services and require financial support. Therefore, it is crucial intentionality to determine such barriers and CPs must have the devotion to rectify the situation with strong feeling and belief of each extended service that

GPs, general practitioners; UAE, United Arab Emirates; HK, Hong Kong; Mal, Malaysia; Aust, Australia; Sin, Singapore;

Most prominent in rank, it is noted that CPs might not have an interest to execute the extended services due to their absence of knowledge and skills as illustrated in **Table 3**. The reasons

**services**

Pain management service: Aust [13]

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Sexual health counseling: Canada [17] Skin-care management service: Aust [13]

Wound care service: Aust [13], UAE [19] Monitoring medication outcome: Mal [32]

Special population counseling: Mal [30] Breast cancer counseling: Mal [33]

Oral health counseling: Mal [30]

Pharmacist-led patient self-management of chronic disease: HK [27, 29]

Weight management counseling: Aust [13], Canada [17], UAE [19], Mal [30]

Psychiatric pharmacy service: Aust [13], Belgium [24]

Specialized compounding service: Aust [13], UAE [22]

Providing medication information to GPs: Mal [32]

DRP, drug-related problem; SC, smoking cessation; #, number.

**Table 2.** Details of countries which indicate extended pharmacy services.

can benefit their customers at all.

Lack of knowledge and skills: Aust [13, 16], Belgium [24], China [15], Pakistan [38], Nepal [25], HK [27], Canada [17], Russia [10], Sudan [23], UAE [22], Mal [33, 34] Lack of competence to formulate a drug therapy plan: UK [11] Other HPs confuse with recent extended services: UK [11], Aust [13], HK [29], UAE [21], Sudan [23], Mal [32, 36, 37] Lack of on-going training program: UK [11], Japan [28], Aust [13], HK [27], Sudan [23], Mal [30, 33, 34] Lack of profitability: Mal [30, 33] Government/organizational puts a stop to such extended services: UK [11], Pakistan [38], Sin [9], HK [27, 29], UAE [19] Lack of an access to medication record: UK [11], Belgium [24], Sin [9], Aust [13], HK [27], Canada [17], Sudan [23] Other HPs have a negative way of thinking: UK [11], Aust [16], Pakistan [38], HK [27], Canada [17], UAE [21, 22] Lack of a return performance evaluation: UK [11] Such extended services confusticate the customers: UK [11], HK [27, 29], China [15], South Africa [18] Absence of a counseling space: UK [11], Belgium [24], Canada [17], South Africa [18], Mal [34] Absence of a principle model as a merit procedure for CPs: Canada [17], Russia [10], UAE [22], Mal [30] Lack of confidence and trust among GPs: Mal [32, 36, 37] Gender barrier: Mal [33] Health promotion which is carried out by the customers: Mal [30] GPs, general practitioners; CPs, community pharmacists; HK, Hong Kong; UAE, United Arab Emirates; Sin, Singapore; Aust, Australia; UK, United Kingdom; Mal, Malaysia; CPs, community pharmacists; HPs, healthcare providers; #, commencing a wide range of extended services. Therefore, it is notified that some customers in Australia refuse to reimburse CPs for such services. Consequently, it is crucial to take into account of consumers to be members of policymaker so that their official spokesman can give intellectual, moral, and instruction to the society about the benefits of such extended services. Foremost, GPs and consumers must acknowledge the role of CPs as the supreme medication protector in the healthcare system. Their feeling and belief might make the extended services look more attractive or otherwise. Therefore, it is critical to determine their point of views regarding the provision of extended services in community pharmacy settings. As illustrated in **Table 4**, it is notified that CPs in the United Kingdom, Australia, Hong Kong, South Africa, the United Arab Emirates, and Sudan have taken into account of collaborating with GPs to

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**Perception of extended services**: **Country published (Article #)**

Government's rule to execute such extended services: UK [11] A solution to the shortage of general practitioners: UK [11] Reimbursement scheme for such extended service: UK [11]

Advancing personal marketability: UK [11]

A part to enlarge on-going career: UK [11]

Personal satisfaction: UK [11], Nepal [25]

Improving sales: Nepal [25], UAE [20]

Africa [18], UAE [21], Sudan [23], Mal [31, 33, 36, 37]

Benefit the customers: UK [11], Nepal [25], Sudan [23]

Benefit the profession in many aspects: UK [11], South Africa [18]

A strategic plan to eliminate business competition: Nepal [25], UAE [20] GPs are not favor of CPs to conduct the smoking cessation program: Mal [32] GPs are favor of CPs to determine the drug-related problems: Mal [32]

GPs are aware of CPs more toward patient-oriented profession: Mal [31] GPs are not favor of CPs to document customers' profiles: Mal [31]

GPs are not favor of CPs to recorrect written prescriptions themselves: Mal [31]

Determine to experience a new challenge in an on-going practice: UK [11]

Customers rarely adjudge the community pharmacy as a healthcare facility: Jordan [14] Having a tendency to minimize the general practitioners' overburden duties: Aust [13]

Supporting from the pharmacy associations to exercise such extended services: UK [11], Aust [16]

A duty to take more responsibilities with their medication action plan: UK [11], South Africa [18]

Magnifying the superior image of pharmacy practice: UK [11], South Africa [18], Mal [33]

GPs are willing to work side-by-side with CPs to review medication outcome: Mal [31, 32]

Determine to exercise their knowledge and skills: UK [11], Nepal [25], Aust [16], South Africa [18], Sudan [23]

A potential to establish a working relationship with other healthcare providers: UK [11], Aust [16], HK [27], South

number.

**Table 3.** Details of countries which indicate barriers toward performance of extended pharmacy services.

are putting into the frame that it is crucial to initiate a strategy formula in order to eliminate the barrier toward extended services. In absence of the strategy formula, CPs might not have the opportunity to undergo phenomenal experience via extended services. Therefore, in our opinion, it is necessary to give intellectual to CPs who can take the first step to commerce a triage action mode as an earlier extended service in community pharmacy settings. Such action mode is a critical exercise because CPs are always in the right position to act as a 'gate-keeper' to the entire healthcare system. Following the sequence, it is believed that CPs might make a start to acquire knowledge and skills in dissimilar extended services in order to serve the customers. Nonetheless, it is necessary to institute a fundamental procedure for CPs to follow in making an accurate triage action plan. The procedure should be simple and easier to be carried out in the frenetic surrounding.

Nevertheless, the consumers in point of fact are the paramount importance to the provision of extended services in community pharmacy settings. Such extended services turn to be ineffectual if the consumers refuse to admit the true benefits of such services. As a result, the consumers might testify against such extended services via their negative justification. For example, as illustrated in **Table 3**, it is noted that the consumers in Canada possess insufficient time to be in contact with CPs and such extended services are not adjudged to be the recipient to ameliorate their health status. Such feeling and beliefs are obstacles to the normal progress of commencing a wide range of extended services. Therefore, it is notified that some customers in Australia refuse to reimburse CPs for such services. Consequently, it is crucial to take into account of consumers to be members of policymaker so that their official spokesman can give intellectual, moral, and instruction to the society about the benefits of such extended services.

Foremost, GPs and consumers must acknowledge the role of CPs as the supreme medication protector in the healthcare system. Their feeling and belief might make the extended services look more attractive or otherwise. Therefore, it is critical to determine their point of views regarding the provision of extended services in community pharmacy settings. As illustrated in **Table 4**, it is notified that CPs in the United Kingdom, Australia, Hong Kong, South Africa, the United Arab Emirates, and Sudan have taken into account of collaborating with GPs to


are putting into the frame that it is crucial to initiate a strategy formula in order to eliminate the barrier toward extended services. In absence of the strategy formula, CPs might not have the opportunity to undergo phenomenal experience via extended services. Therefore, in our opinion, it is necessary to give intellectual to CPs who can take the first step to commerce a triage action mode as an earlier extended service in community pharmacy settings. Such action mode is a critical exercise because CPs are always in the right position to act as a 'gate-keeper' to the entire healthcare system. Following the sequence, it is believed that CPs might make a start to acquire knowledge and skills in dissimilar extended services in order to serve the customers. Nonetheless, it is necessary to institute a fundamental procedure for CPs to follow in making an accurate triage action plan. The procedure should be simple and easier to be

GPs, general practitioners; CPs, community pharmacists; HK, Hong Kong; UAE, United Arab Emirates; Sin, Singapore; Aust, Australia; UK, United Kingdom; Mal, Malaysia; CPs, community pharmacists; HPs, healthcare providers; #,

Lack of knowledge and skills: Aust [13, 16], Belgium [24], China [15], Pakistan [38], Nepal [25], HK [27], Canada [17],

Other HPs confuse with recent extended services: UK [11], Aust [13], HK [29], UAE [21], Sudan [23], Mal [32, 36, 37]

Government/organizational puts a stop to such extended services: UK [11], Pakistan [38], Sin [9], HK [27, 29], UAE

Lack of an access to medication record: UK [11], Belgium [24], Sin [9], Aust [13], HK [27], Canada [17], Sudan [23] Other HPs have a negative way of thinking: UK [11], Aust [16], Pakistan [38], HK [27], Canada [17], UAE [21, 22]

Lack of on-going training program: UK [11], Japan [28], Aust [13], HK [27], Sudan [23], Mal [30, 33, 34]

Such extended services confusticate the customers: UK [11], HK [27, 29], China [15], South Africa [18]

Absence of a principle model as a merit procedure for CPs: Canada [17], Russia [10], UAE [22], Mal [30]

**Table 3.** Details of countries which indicate barriers toward performance of extended pharmacy services.

Absence of a counseling space: UK [11], Belgium [24], Canada [17], South Africa [18], Mal [34]

Nevertheless, the consumers in point of fact are the paramount importance to the provision of extended services in community pharmacy settings. Such extended services turn to be ineffectual if the consumers refuse to admit the true benefits of such services. As a result, the consumers might testify against such extended services via their negative justification. For example, as illustrated in **Table 3**, it is noted that the consumers in Canada possess insufficient time to be in contact with CPs and such extended services are not adjudged to be the recipient to ameliorate their health status. Such feeling and beliefs are obstacles to the normal progress of

carried out in the frenetic surrounding.

Russia [10], Sudan [23], UAE [22], Mal [33, 34]

Lack of a return performance evaluation: UK [11]

Lack of confidence and trust among GPs: Mal [32, 36, 37]

Health promotion which is carried out by the customers: Mal [30]

Lack of profitability: Mal [30, 33]

Gender barrier: Mal [33]

number.

[19]

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Lack of competence to formulate a drug therapy plan: UK [11]

GPs are favor of CPs to refer customers to them: Mal [31, 32] CPs are not regarded as the best practitioner to advise GPs about the rationale medication use: Mal [31, 32] GPs should listen to CPs about written prescriptions' issues: Mal [31, 32] CPs are not well trained to perform screening tests: Mal [31] GPs are favor of CPs to treat minor ailments: Mal [31, 32] CPs are underestimated by GPs: Mal [31] CPs' knowledge and skills are underutilized: Mal [32] CPs are not well trained in clinical therapeutic knowledge: Mal [31] Customers appreciate extended services: Mal [33, 35] CPs are potential to counsel about health screening: Mal [33, 35] CPs are the best practitioner to educate about medications: Mal [31, 32] CPs should involve in health promotion: Mal [32, 33, 35] GPs, general practitioners; CPs, community pharmacists; Aust, Australia; UK, United Kingdom; UAE, United Arab The following sequence is to help out CPs to make a medication therapy plan. It might involve CPs and customers to sit down and start to determine the ideal medication to alleviate the on-going minor ailments or maintain the current health status. Consequently, this sequence is magnifying the role of CPs as an adviser to the customers. The last sequence in a triage action plan is to help out CPs to assist their customers to experience the other extended pharmacy services which are available in community pharmacy settings as illustrated in **Table 2**. The main intention is to help out the customers to enhance their quality of life via CPs' knowledge and skills. Furthermore, the knowledge and skills might have potential to add on more value to an earlier medical treatment or else. As a consequence, it is critical for CPs to start out this triage action mode as a fundamental extended service in advance. Therefore, STARZ-DRP is picked up as the appropriate fundamental procedure to follow via experience in an earlier study [43]. Foremost, STARZ-DRP is helping out CPs to execute the role as the supreme medication protector via determining the drug-related problem (DRP) which might have potential to be the origin of actual or potential medical problem [50]. As a consequence, it is the opportunity for CPs to interact with GPs to discuss in detail about the DRP which might be

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STARZ-DRP is a simple mnemonic to remember and it is initiated to make it easier for CPs to make an accurate triage action plan and distinguish the origins of DRP [50]. As illustrated in **Table 5**, the mnemonic integrates several words which are entitled to act as an action to

**S Symptom presentation** refers to subjective evidence of health problem perceived by the patient

filtering or screening process to rule out the presence of severe symptoms.

**A Associated symptoms** refer to patient symptoms explored and determined by the pharmacist during the interview. It does not refer to the symptoms presented earlier by the patient. This is done by using the pictorial documentation form as depicted in **Figure 1**. To aid and ease the pharmacist during the interview, the human body is arbitrarily divided into four regions: (i) Front: the part of the body facing the pharmacist (asking for symptoms like bloating, heartburn, nausea, vomiting, breathlessness, etc.), (ii) Back: (asking for symptoms like lower and upper back pain, shoulder pain, and neck pain), (iii) Upper (head) (asking for symptoms like headache, dizziness, problems with sleep, etc.), (iv) Lower (asking for symptoms like numbness in both legs and hands, constipation, and swollen feet). Perhaps, the method is likened to a

**R Recurrence problem** refers to the symptoms have been treated before, specifically when the symptoms recur

**Z Zoom into the patient's medication experience** refers to information collected by the pharmacist related to any medical problems (e.g., hypertension, diabetes, hyperthyroid, etc.), medication utilization (e.g., use of prescription and non-prescription drugs, and herbal supplements), immunization history, allergies, drug sensitivities, drug side effects, adverse reactions, and the consumption of alcohol, caffeine, and tobacco.

This is not a diagnostic tool, rather it is a format with the purpose of organizing a community pharmacist's knowledge in a manner that allows him/her to begin identifying the actual and potential drug-related problems and subsequently

The patient's vital signs will be measured when necessary. At times, the patient's blood pressure, pulse rate, and body temperature are measured to aid the pharmacist in assessing the appropriateness of symptoms for self-medication.

experienced by the customers.

**T Time of onset and duration** of the present symptoms

and persist despite the treatment prescribed.

referring triage patients to the appropriate healthcare professionals.

.

**Table 5.** Definition of letters in STARZ #,\*

**Letter Description**

**#**

\*

**Table 4.** Details of countries which indicate perception of extended pharmacy services.

Emirates; Mal, Malaysia; HK, Hong Kong.

operate such extended services. Such working relationship might bring benefits to consumers at all. For example, it is notified in an earlier study which signifies that such relationship can be a service to superintend hypertension patients [47]. Additionally, it is noted that such relationship in managing more chronic diseases have been reflected in an earlier review article [9]. Nevertheless, such working relationship might have potential to summon misconception in the responsibilities of both parties as notified in an earlier study [48]. Therefore, it is necessary to initiate a constructive strategy to fortify such working relationship in the healthcare system [49]. The strategy formula must have a conceptual framework as a general guiding principle to make it easier for CPs to work side-by-side with GPs. For that reason, an instrument is known as STARZ-DRP put into operation as a course of action to enroll both healthcare providers into a strategy medical team [50].
