The attitudes and beliefs of pharmacists and pharmacy staff investigated in the papers included in this review related to four main topics: perceptions of role, competence/confidence, barriers and training.
Perceptions of Role
The majority of participants in a survey in Scotland agreed (63%) or strongly agreed (16%) that public health is important to their practice and a little over half agreed (48%) or strongly agreed (8%) that they were public health practitioners [
21]. A survey in Nigeria also reported that the majority of participants (94%) thought it was acceptable for pharmacists to be involved in health promotion activities [
71]. Pharmacists and support staff taking part in focus groups in Sweden on the whole welcomed their role as a health promoter [
56]. However, it was noted that not all participants felt this way and preferred to develop activities in areas in which they received their basic training. Consistent with this, a study in Moldova found that participants rated public health activities significantly lower in importance than all other aspects of professional practice assessed (e.g. dispensing activities) [
65]. Furthermore, a survey in Scotland offering participants a choice of hypothetical jobs found that participants would rather provide a minor illness service than health promotion advice and would forgo £2798 of income to do this [
72].
Perceptions regarding the pharmacists' role in smoking cessation counselling were generally favourable. Nearly all pharmacists surveyed in Thailand, Finland and the USA agreed that they should play a role in smoking cessation [
45,
37,
16]. The majority of participants (83%) in another survey in the USA believed that pharmacists should be more active in assisting with smoking cessation [
55]. However, in a survey in Turkey only 57% of participants thought that pharmacists should warn patients about the harmful effects of smoking [
50]. A study in Canada found that pharmacists rated medicine related aspects (e.g. advising on the use of NRT) of their smoking cessation role as more important than other aspects (e.g. assessing patients' dependence on nicotine) [
34]. Another paper based on the same sample found that participants were significantly more likely to carry out smoking cessation interventions with customers if they scored above the median in ratings of importance of various smoking cessation roles [
32].
Perceptions about the pharmacist's role in sexual health services were generally positive. The majority of pharmacists (98%) surveyed in a study in Scotland agreed that they would be willing to offer free Chlamydia postal testing kits [
26]. In a survey in the USA 55% of pharmacists were interested in providing emergency hormonal contraception (EHC) [
68]. Pharmacists interviewed in a study in the UK [
69] were found to hold largely positive views about providing EHC. However, around one quarter of pharmacists in another study in the USA were opposed to providing EHC largely due to religious and moral beliefs [
67]. Pharmacists in the latter two studies also reported concerns that the service may be overused and lead to increases in unprotected sex and sexually transmitted diseases [
67,
69]. The benefits of providing this service that were highlighted by pharmacists in these two studies included increasing access to EHC, confidentiality, reducing unwanted pregnancies and improving status of the pharmacy profession [
67,
69].
Attitudes towards providing services for drug misusers have become more favourable over recent years. Surveys in England and Scotland in 2007 reported that attitudes were significantly more positive since assessed in a similar survey in 1995 [
38,
60]. Similarly, a study in the USA reported an increase in the number of pharmacists who agreed that sterile needles should be made available through community pharmacy [
39].
Despite a shift in attitudes, views towards providing services for drug misusers are still mixed. Pharmacists taking part in focus groups in Estonia and a survey in the USA highlighted a number of concerns about the effect of selling sterile needles on customers and business [
58,
41]. Support staff in a survey in Scotland also reported similar concerns [
30]. Only half of support staff (52.6%) in this study thought that their pharmacy should provide services to drug misusers [
31]. The possibility of providing free injecting equipment to drug misusers was met with strong resistance in the study in Estonia. The majority of pharmacists in a survey in Scotland disagreed or neither agreed or disagreed that HIV/hepatitis prevention is an important role for pharmacists [
73].
However pharmacists supplying sterile needles for purchase in the USA and UK reported few problems providing this service and little detrimental effect on customers or their business [
41,
42]. Pharmacists selling sterile injecting equipment in Vietnam reported that they felt a responsibility to prevent blood borne infection and were willing to provide health education to customers that were drug misusers [
43]. More positive views were also reported in a study in the USA with nearly all pharmacists (98%) reporting that they felt they should play a part in helping prevent the spread of blood borne infections such as HIV and over two thirds supporting the availability of sterile needles for purchase in community pharmacies [
41].
Competence/Confidence
Findings regarding confidence and competence in providing health promotion services were mixed. A survey of pharmacists in Scotland found that around one third of participants did not feel that they were competent in promoting and protecting the populations' health or encouraging behavioural change [
21]. Around two thirds felt they lacked the underpinning knowledge and one third felt they could not apply their knowledge. Pharmacists taking part in a survey in Moldova rated their competence in health promotion activities at between 2.9 and 3.6 (0 = low competence and 5 = high competence) which was lower than competence scores for all other aspects of professional practice [
65]. In contrast, the majority of pharmacists (95%) in a survey in Nigeria felt confident in advising patients on health promotion [
71].
Pharmacists in Australia were reasonably confident in providing a smoking cessation service, with a mean confidence score of 3.7 (1 = not confident and 5 = extremely confident), and did not report confidence as a major barrier to smoking cessation activity [
19]. Nearly all participants (92%) in a study in Canada [
33] agreed that pharmacists can be effective in promoting smoking cessation with most customers. In another study in the USA around two thirds of pharmacists thought that the effectiveness of pharmacist counselling was average or good [
55]. In two of these studies confidence was found to be the greatest predictor of the amount of smoking cessation activity reported and in one perceived effectiveness was also a significant predictor [
19,
55].
Confidence in advising on the prevention HIV/hepatitis was fairly low in pharmacists in a survey in Scotland [
73]. Around half of pharmacists felt confident in advising customers on prevention of HIV and around a third on Hepatitis B/C. Confidence in advising on safer sex was higher with the majority of pharmacists reporting that they would be able to give advice on this to any customer or a drug misuser (78% and 72% respectively). However, only around one third were confident in advising a gay man on safer sex (35%) [
73]. Support staff in a similar survey in Scotland reported lower confidence for advising on safer sex than pharmacists [
74]. Only half of support staff felt able to give accurate advice to any customer (51%) and one third a drug misuser (34%) or a gay man.
Pharmacists' confidence in achieving positive outcomes in weight management counselling was low in one study. Pharmacists in a study in the USA reported mean confidence (1 = not at all confident and 5 = extremely confident) scores of only 3.0 for achieving weight loss in patients as a result of pharmacist counselling and 2.8 for achieving consumption of a calorie controlled diet in patients [
18]. Mean confidence scores for medicine related aspects of obesity counselling (e.g. minimisation of adverse effects of anti-obesity medication) were higher at between 3.3 and 3.4. Self reported frequency of obesity counselling was found to be positively correlated with confidence in achieving positive outcomes. Confidence in providing brief alcohol screening and interventions was also low with over half of pharmacists in a study in New Zealand feeling neutral or disagreeing that they could appropriately advise patients about drinking [
61].
Barriers
A number of common barriers to public health practice were highlighted across the different services. These included availability of a private counselling area, time, customer demand/reaction and reimbursement for public health services.
The findings regarding a lack of private counselling area were mixed. This was identified as a main barrier to providing advice on health promotion in focus groups in Sweden and advice on prevention of HIV/hepatitis in pharmacists and support staff in Scotland [
56,
73,
74]. Nearly two thirds of pharmacists in a survey in Canada felt that having a designated space in pharmacy was very or somewhat important in facilitating smoking cessation practice and nearly half of participants in a study in Thailand (43%) thought the pharmacy setting was barrier to smoking cessation counselling [
35,
45]. Pharmacists' perception of having adequate facilities was found to be a significant predictor of frequency of smoking cessation counselling in one study [
55]. Although a predictor of service provision, the majority of pharmacists (71.7%) in this study did not view the pharmacy setting was an important barrier to smoking cessation counselling. Similarly, pharmacists in Nigeria (93.1%) did not think facilities were a barrier to patient interaction in relation to health promotion generally [
71]. Pharmacists interviewed in England also felt they had adequate facilities to provide a Chlamydia testing and treatment service [
22].
Lack of time was identified as a main barrier to providing advice on prevention of HIV/hepatitis by pharmacists and support staff in Scotland and for health promotion activities by the majority (75%) of pharmacists in a study in Malaysia [
73‐
75]. Between 50 and 70% of participants in two studies in the USA and one in Thailand agreed that time was a barrier to providing smoking cessation counselling and over half in one of the USA studies felt that they were not adequately staffed for providing smoking cessation services [
15,
55,
45]. Similarly, around 70% of participants in a study in New Zealand thought that being too busy was a barrier to carrying out brief alcohol screening [
61]. Time was reported as a barrier to providing EHC by 67% of pharmacists surveyed in a study in the USA [
67]. However, a study on health promotion in Nigeria and another on Chlamydia testing in England reported that time was not an issue in providing these services [
71,
22].
Views on patient demand for public health services in community pharmacy and patient reactions to being offered these services were mixed. Around 60% of pharmacists in a survey in Thailand reported that lack of patient demand was a barrier to providing smoking cessation services [
45]. Focus group participants in Sweden also perceived that patients had low expectations of receiving health promotion advice from pharmacists [
56]. Furthermore, over half of pharmacy assistants in a survey in Scotland felt that client embarrassment was a barrier to offering advice on HIV/hepatitis prevention and a similar proportion of pharmacists in a study in New Zealand felt that patients would resent being asked about their alcohol consumption [
74,
61]. Pharmacists interviewed in the USA reported that they viewed this as a sensitive topic and were hesitant to initiate conversations about smoking as they expected to receive a negative response from customers [
62].
In contrast, the majority of participants in surveys on health promotion and smoking cessation in Nigeria, the USA and Finland did not think that lack of demand was a barrier and thought that patients were motivated to seek health advice from pharmacists, welcomed and valued this advice and were not discouraged from returning to the pharmacy as a result of being offered advice [
71,
33,
55,
37]. Pharmacists in a survey carried out in the USA agreed that customers are becoming more willing to discuss health problems and more accepting of counselling provided by pharmacists, but did not agree as strongly that customers were more accepting of pharmacists managing chronic disease [
76]. Finally, pharmacists involved in offering a Chlamydia testing service reported that client reactions were to being offered the service were mixed but that they were predominantly satisfied as long as discretion was used [
22].
Reimbursement for providing public health services does not seem to be a barrier for most pharmacists. The majority of participants (63.7%) in a study in Malaysia felt neutral or disagreed that a lack of reimbursement was a barrier to their involvement in health promotion and most pharmacists (87.6%) in a survey in Nigeria agreed that it is alright to be involved in health promotion whether there is reimbursement or not [
75,
71]. Studies in the USA, Thailand, and Canada also reported similar findings in relation to smoking cessation [
55,
45,
33,
34].
Training
A need for training was identified in a number of surveys on different public health services. Over half of pharmacists in a study in Scotland reported that attaining additional pharmaceutical public health knowledge was a priority for their practice now and two thirds thought it would be a priority in the future [
21]. Between one third and one half of pharmacists in three studies felt that lack of training or lack of knowledge and skills was a barrier to their smoking cessation practice [
15,
50,
55]. Pharmacists and support staff in Scotland also felt that lack of training was a main difficulty in providing advice on prevention of HIV/hepatitis and over 80% of pharmacists in a study in New Zealand felt it was a barrier to providing alcohol screening and brief interventions [
73,
74,
61]. Over 70% of pharmacists in a survey in Scotland reported that they would like further training on drug misuse [
59]. The majority of pharmacists in Nigeria felt that they had good knowledge on health promotion (86.9%) but also agreed that they would be willing to retrain on health promotion (93.2%) [
71].
Pharmacists taking part in a smoking cessation training needs assessment in Canada reported that training would be helpful on all aspects of smoking cessation practice but rated training on behavioural techniques for quitting smoking and motivating patients as most helpful [
34]. Pharmacists in Scotland taking part in a survey on training needs for working with drug misusers most often cited motivational and counselling skills as areas they would like more training on [
77]. No clear area for future training was identified in a survey in Scotland with the majority of pharmacists agreeing (79.3%) that training should focus on generic knowledge and skills but also with the statement that training should focus on priority health issues such as chronic heart disease (77.2%) [
21]. Training for pharmacy technicians on smoking cessation was found to significantly increase knowledge, confidence and perceptions of the effectiveness of smoking cessation counselling in a study in the USA [
24].