
==== Front
Explor Res Clin Soc Pharm
Explor Res Clin Soc Pharm
Exploratory Research in Clinical and Social Pharmacy
2667-2766
Elsevier

S2667-2766(24)00087-8
10.1016/j.rcsop.2024.100490
100490
Article
Comparing South Dakota Pharmacist Perspectives of Pharmacy Services in Rural versus Urban settings
Miller Erin E. Erin.Miller@sdstate.edu
abce⁎
Hunt Aaron fg
Middendorf Alex abde
Van Gilder Deidra abde
Blanchette Abigayle fh
Sirek Abigail fi
Pinto Sharrel fj
a South Dakota State University, Brookings, SD, United States of America
b SDSU College of Pharmacy and Allied Health Professions, Brookings, SD, United States of America
c SDSU Department of Allied and Population Health, Brookings, SD, United States of America
d SDSU Department of Pharmacy Practice, Brookings, SD, United States of America
e Community Practice Innovation Center, Brookings, SD, United States of America
f Work Was Completed When This Individual Was In A Role at South Dakota State University, Department of Allied and Population Health, and the Community Practice Innovation Center, USA
g Utah State University, Logan, UT, United States of America
h Pharmacist, Lewis Drug, Sioux Falls, SD, United States of America
i Pharmacist, Ely-Bloomenson Community Hospital, Ely, MN, United States of America
j Belmont University, Nashville, TN, United States of America
⁎ Corresponding author at: 2400 S Minnesota Ave, Sioux Falls, SD 57105, USA. Erin.Miller@sdstate.edu
08 8 2024
9 2024
08 8 2024
15 10049022 9 2023
6 8 2024
6 8 2024
© 2024 The Authors. Published by Elsevier Inc.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Access to healthcare services is a major barrier to residents of the rural state of South Dakota. As a highly accessible member of the healthcare team, outpatient pharmacists can play a key role in a patient's healthcare journey. There is a need to identify the unique barriers and facilitators pharmacists in both rural and urban areas face to maximize the impact of their role.

Objective

The objective of this work was to compare perceptions of rural and urban pharmacists regarding the facilitators and barriers to providing patient care in South Dakota.

Methods

This qualitative project highlights results from interviews and focus group sessions with a convenience sample of South Dakota pharmacists. Participants were recruited using a referral word-of-mouth system, contracts with healthcare market research agencies, newspaper advertisements, and posters displayed in public locations in South Dakota. Practice location was characterized as rural or urban based on United States Department of Agriculture definitions. Findings from interviews and focus group sessions were coded and analyzed using content analysis by two student researchers.

Results

Participants included 12 rural-practicing and 21 urban-practicing pharmacists in South Dakota. In both rural and urban areas, key barriers included communication with providers (50% rural; 50% urban), lack of electronic health record access (25% rural; 14% urban), not enough staff (22% rural; 20% urban), and patient misunderstanding the scope of pharmacy (22% rural; 40% urban). Barriers specific to rural areas included time to provide services (22%), having smaller facilities (27%) and provider hesitation regarding collaborative practice agreements (29%). There were no urban-specific barriers. Facilitators specific to urban areas included frequent communication with patients (6.1%) and good quality support staff (9.1%). There were no rural-specific facilitators.

Conclusions

Next steps include increasing awareness of pharmacy-based patient care services, researching further to identify the extent to which facilitators and barriers influence the ability to initiate and sustain pharmacy services in rural and urban areas, and providing support to pharmacies to overcome barriers and leverage facilitators.

Keywords

Facilitators
Barriers
Rural health
Urban health
Pharmacy
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pmc1 Introduction

Access to healthcare services is a major barrier for residents of South Dakota. South Dakota is a primarily rural state in the Midwest, United States. The state's 66 counties are defined as 45% rural (fewer than 36 people per square mile) and 52% frontier (fewer than 6 people per square mile).1 Largely due to its rural nature, 75% of South Dakota is designated as a Medically Underserved Area/Population (MUAP). For example, there are 49 hospitals in the state, 38 (78%) of which are classified as Critical Access Hospitals, meaning they have 25 or fewer acute care inpatient beds and are at least 35 miles from the next nearest hospital.2, 3., 4. Patients in rural areas of the state might travel up to 50 miles for an appointment with their primary care physician.3 Access, quality, and disparity concerns can be present, particularly when it comes to preventative care.5 However, the environment also offers opportunity for improvement.6 One possible improvement would be to leverage tools and personnel that are currently being underutilized.7

In rural areas, pharmacists provide a unique and important role in the care of patients, including provision of preventative care. Preventative care services include health screenings, counseling on health topics such as smoking cessation or healthy eating, and routine vaccinations.8 Pharmacists can provide many of the preventative services to their patients depending on their scope of practice, such as point of care blood pressure measurement, lipid testing, blood glucose testing, immunizations, disease state management counseling, and Medication Therapy Management (MTM). MTM takes many forms but generally involves the pharmacist meeting with a patient, reviewing their medications for appropriateness, efficacy, safety, and adherence issues, and providing education or other interventions independently of or alongside other members of the healthcare team. MTM sessions have been shown to be effective in improving medication adherence and optimizing key health markers such as blood pressure, cholesterol, and A1C.9., 10, 11.

Furthermore, pharmacists have been shown to be more accessible than other members of the healthcare team for rural patients.12 While rural patients may need to travel long distances for an appointment with their primary care physician, they could be only five minutes away from the nearest community pharmacy.3 Pharmacists can also work with other providers/prescribers through collaborative practice agreements (CPAs), a formal agreement between two providers/prescribers on some aspect of patient care, which are defined differently across different states and locales and may also be referred to as protocols. For the purposes of this discussion, CPAs would be between a provider/prescriber with broad prescribing/ordering authority and a pharmacist whereby a pharmacist is authorized to provide some element of patient care by having the other provider's/prescriber's authority delegated to them.13 CPAs allow pharmacists to expand their scope of practice to provide additional patient care services, as well as the ability to better manage patients with chronic conditions through interventions such as therapeutic interchange and in ordering laboratory tests.14 This can decrease the time other providers/prescribers spend on simple but time-consuming tasks and communication with pharmacists, quickly improve patient healthcare outcomes, and increase efficiency of care.14 There is a need to understand best practices on how pharmacists can be integrated into care provision through collaborative arrangement like CPAs.

Pharmacists in rural and urban settings may have differing views on healthcare facilitators and barriers. To our knowledge, while previous research comparing rural and urban healthcare have largely focused on physician work conditions, services provided, or access to care, pharmacists have not been a focus. Past studies have examined common barriers to pharmacy services based on population environment, though most have looked primarily at rural pharmacies and have not compared how barriers and facilitators for rural pharmacists compare to those identified by urban pharmacists. Common barriers that have been previously identified for pharmacists include the importance of the role of the pharmacist in rural areas, patients' awareness and not understanding the scope of pharmacy, staffing-related issues, and not having enough time to provide services.15, 16, 17, 18., 19., 20. The purpose of this work was to gather the perceptions of rural and urban pharmacists to determine major facilitators and barriers to patient care.

This project is part of a five-year effort to better address the impact of common chronic disease states in South Dakota by preventing and managing health conditions such as diabetes, heart disease, and stroke. In the first year of the project, a landscape analysis was conducted via interviews and focus group sessions with patients, practitioners, and third-party payers. The information collected, including pharmacist perceptions on the facilitators and barriers to patient care in rural and urban South Dakota, was used to inform project activities developed, implemented, and evaluated in the final four years of the project.

2 Methods

2.1 Recruitment

A convenience sample of 33 pharmacists were recruited using a referral word-of-mouth system, contracts with healthcare market research agencies, newspaper advertisements, and posters displayed in the community. Inclusion criteria included all pharmacists practicing in rural or urban locations in South Dakota. For the purposes of this project, pharmacy locations were defined as rural or urban according to USDA definitions, with any location containing a population of fewer than 50,000 people classified as rural.13 All participants completed a written, informed consent before participating. This project received approval from the South Dakota State University Institutional Review Board.

2.2 Interview Methods

Based on participant preference, participants completed either a 1.5-h individual interview or a 3-h focus group session, with pharmacists or mixed groups of pharmacists and other healthcare professionals. For mixed-groups, participants' responses were coded by profession to facilitate identification of pharmacist vs. non-pharmacist responses during analysis. The interviews and focus groups followed a semi-structured format with questions about current services offered, facilitators and barriers to providing these services, and other questions pertinent to obtaining individual perceptions of patient care at their facility (see question guides in Appendix 1 and 2). Interviews and focus groups were held in person or virtually and were led by two project team members trained in conducting individual interviews and focus groups. All interviews and focus groups were audio recorded.

2.3 Data Analysis

The interviews and focus group recordings were deidentified and transcribed verbatim by an outside contractor. The transcripts were open coded using an inductive process by two researchers using content analysis. Each transcript was coded independently by one researcher to generate initial codes and identify key quotations. They then identified, reviewed, and defined themes to create a database identifying the key services offered, as well as key facilitators and key barriers to providing services that were identified by each participant from the guided interview questions. All coding and content analysis activities were done under the guidance and oversight of two co-investigators. Member checking was not performed; instead, data validation was ensured through intercoder reliability. Descriptive statistics including counts and percentages were calculated for each identified facilitator and barrier. Respondents who chose to skip a question were excluded from the calculation of percentages for that question. Percentages were compared between rural and urban pharmacists to identify key similarities and differences. Descriptive statistics were calculated and compared using the International Business Machine Corporation's Statistical Packages for Social Sciences (SPSS) software, version 26.

3 Results

Overall, three self-identified hospital-based pharmacists and 30 community-based pharmacists participated. Of those participants, 12 practiced in rural areas and 21 practiced in urban areas.

3.1 Services Offered

Several services were offered by both rural and urban pharmacists (see Table 1). Notably, if specifically asked about MTM services, 75% of rural site participants and 67% of urban site participants reported offering MTM services. When asked about medication adherence, 75% of rural participants and 38% of urban participants reported offering medication adherence services.Table 1 Most Prevalent Services Offered by Rural and Urban Pharmacies.

Table 1Services Offered	Rural	Urban	
Medication Therapy Management⁎	75%	67%	
Adherence monitoring services⁎	75%	38%	
Immunizations	53%	48%	
Medication synchronization	42%	57%	
Medication adherence packaging	33%	52%	
Automatic refills	25%	52%	
Blood pressure screening	33%	19%	
Medication reconciliation	25%	10%	
⁎ Specifically asked if this service was offered.

3.2 Barriers and Facilitators to Effective Pharmacy Services

One barrier equally reported in rural and urban settings (see Table 2) was poor provider/prescriber communication (rural 50% vs urban 50%). Several pharmacists interviewed mentioned poor communication with providers/prescribers and limited access to patient records as barriers. One urban participant stated this regarding communication with providers/prescribers: “[We're] kept on hold for hours trying to get an answer for a simple question [and] jump through hoops to do our job; let us know so we don't have to guess.” Provider/prescriber busyness, provider/prescriber misunderstanding of the pharmacist's role, and providers/prescribers ignoring recommendations were listed as contributing factors to poor communication with providers/prescribers.Table 2 Barriers and Facilitators to Pharmacy Services at Rural and Urban Pharmacies.

Table 2Barriers to Pharmacy Services	Rural	Urban	
Ability to contact/ communicate with providers/prescribers	50%	50%	
Lack of EHR access to share information between professionals	25%	14%	
Provider/prescriber hesitation regarding CPAs	29%	0%	
Smaller Facilities	27%	0%	
Patient misunderstanding of the scope of pharmacy	22%	40%	
Not enough staff	22%	20%	
Time to provide services	22%	0%	


	
Facilitators to Pharmacy Services	Rural	Urban	
Frequent communication with patients	0%	6.1%	
Good quality support staff	0%	9.1%	

Both settings also reported a lack of access to electronic health records (EHR) as a key barrier to providing clinical services to patients (rural 25% vs urban 14%). Suggestions to improve communication with providers/prescribers included a standardized process for connecting with providers/prescribers, a direct phone line for pharmacists to contact providers/prescribers or their nurse, and access to patient health records via EHR access. One rural participant elaborated on the benefits of using information sharing tools like EHRs:Sometimes I think there is not a lot of good communication between the doctors and the pharmacists, and the pharmacists and the diabetic educator. It would be really nice to see if we have more of an electronic file for the patient for their medical care. Maybe the pharmacist can go in and see when their last A1C is. If there is a concern maybe they can document that and the other healthcare providers can kind of follow up and reinforce it and help communication.

When asked about barriers to initiating new pharmacy services, rural pharmacists were alone in reporting smaller facilities (27% rural vs. 0% urban) and provider/prescriber hesitation regarding CPAs (29% rural vs. 0% urban). When asked about provider/prescriber hesitation regarding CPAs and what sentiments they would like passed to other healthcare professionals, one rural participant stated, “Our goal is the same–we are trying to give the patient the best care possible.”

Another barrier to implementing effective pharmacy services that was reported by both rural and urban pharmacists but more prevalent in urban settings was patient misunderstanding of the scope of pharmacy (rural 22% vs urban 40%). When asked about this, a rural participant stated, “We need [patients] to understand we are a part of the healthcare team, not just prescription fillers.”

Staffing was also reported nearly equally as a barrier in both rural and urban settings (22% rural vs. 20% urban). When talking about staff, one urban pharmacist noted that the barrier of time often goes hand-in-hand with the amount of staff available at the pharmacy: “you get so many hours that you can schedule, and that's how much you're allowed. And it doesn't matter if you do 300 prescriptions that day or 600 prescriptions that day. You get the same amount of staff and so, obviously, your time is determined by how busy you are doing other things, and so we don't get all the time we want with each patient that we have.”

When asked to name barriers to providing services, only rural pharmacists stated time to provide services was a barrier (22% rural vs. 0% urban). Interestingly, this barrier was reported at a higher rate by both rural and urban pharmacists when asked specifically about barriers to providing services to patients with CVD/diabetes (40% rural vs. 11% urban). One participant, a rural community pharmacist, spoke specifically about MTM in patients with CVD/diabetes: “They are very time consuming, so you'd have to have at least two pharmacists working that day in order to perform it. . . you can't dedicate the time you need…with the patient.” Many other pharmacists expressed the same sentiment. Their desire and drive to perform MTM services exists, but lack of time and low staffing are hindering their capacity to provide such services.

In this sample, only urban pharmacists reported facilitators across themes. Themes included frequent communication with patients (rural 0% vs. urban 6.1%) and good quality support staff (rural 0% vs. urban 9.1%). When commenting on good quality support staff, one urban pharmacist stated: “I think some of our strength is our staff, you know, and what we've enabled them to do as far as the bigger picture thing with overall healthcare.”

4 Discussion

Few studies have been completed to evaluate the perceived facilitators and barriers to pharmacist-provided patient care services in rural and urban locations in the Midwest. Past studies have shown that rural pharmacists frequently face barriers related to staffing or not having enough pharmacists working at the same time, while facilitators include that the role of the pharmacist is more important in rural communities.15 From our findings, we identified three key areas for barriers and facilitators to address, and how they differ in rural and urban settings. These included Provider-Pharmacist Communications, Initiating Services, and Providing Care to Patients. It is important to evaluate these similarities and differences in rural vs. urban barriers and facilitators to determine where the patient-care process can be enhanced in each respective area.

4.1 Barriers to Provider-Pharmacist Communication

Both rural and urban pharmacists reported communication with providers/prescribers as a major barrier. Pharmacists sometimes require providers/prescribers to provide clarification on prescriptions, discuss medication strength, switch brands and generics, complete prior authorizations, and/or share a patient's response to therapy. In the absence of communication, the pharmacist is unable to enact important changes to a patient's medications.21 Factors contributing to communication barriers mentioned by pharmacists in the project included provider/prescriber busyness delaying or preventing response to recommendations, provider/prescriber misunderstanding of the pharmacist's role, and providers/prescribers ignoring pharmacist-provided recommendations. In past studies, providers/prescribers likewise have reported communication barriers with pharmacists, indicating the issue is well acknowledged.22 Suggestions from the pharmacists involved in our project on how to improve communication with providers/prescribers included a standardized process for connecting with providers/prescribers and a direct phone line for pharmacists to contact providers/prescribers or their nurse.22

Both rural and urban pharmacists reported lack of access to the EHR as a barrier to communication. This finding aligns with other studies as pharmacy access to EHR data has been historically limited.23 Allowing community pharmacists access to EHR data could improve efficiency of communication. If a pharmacist has EHR information available before contacting the provider/prescriber, it could potentially reduce the need to ask the provider/prescriber for clarification, and potentially increase the quality of the communication since the pharmacist is not depending on the provider/prescriber for EHR information.23., 24. Organizations like South Dakota Health Link and others across the nation are actively working to address this barrier by increasing the availability of health information exchange platforms.25

For rural pharmacists, another contributing factor to the provider/prescriber communication barrier may be provider/prescriber hesitation regarding CPAs. While establishing CPAs may or may not inherently improve communication between pharmacists and providers/prescribers, it may limit the need for some routine communication to occur on a daily basis. This change could benefit providers/prescribers as well as pharmacists. Time which had previously been utilized communicating with pharmacists on routinely approved medication changes, managing medication changes, and processing therapy request changes can be better used to help patients.20 Additionally, overcoming provider/prescriber hesitation and implementing CPAs could result in better utilization of pharmacist-provided services and alleviate some of the strain healthcare providers/prescribers experience in rural areas.26,27 Provider/prescriber hesitation may come from several sources and such resistance may be attributed to a lack of understanding of the true scope of a pharmacist's abilities alongside rural-setting primary care providers/prescribers. There have been updates to pharmacist training focusing on patient care delivery as opposed to only product distribution, and this shift is important to recognize. This resistance could also be attributed to providers/prescribers being unsure of the results that initiating a CPA will bring them. Overcoming this hesitation may allow for increased efficiency of the healthcare system and further improve patient outcomes in rural areas.

4.2 Barriers and Facilitators to Initiating Services

Pharmacists were asked questions related to their ability to initiate new services, such as enhanced pharmacy services like MTM. To these questions, rural pharmacists reported barriers and urban pharmacists reported facilitators, indicating that initiation of services may be easier for urban pharmacies than for rural pharmacies. Specifically, rural pharmacists reported smaller facilities impacting their ability to initiate patient care services, such as not having or only having a small room for providing services. Although literature is mixed on lack of a private counseling area as a barrier, rural pharmacists in our project listed this as a barrier while urban pharmacists did not.18

Conversely, facilitators to initiating pharmacy services in urban pharmacies included frequent communication with patients and good quality support staff. For pharmacists, effective communication is a key component of providing patient services.28 We are unsure on the relationship between frequent communication and how it facilitates initiation of pharmacy services but we speculate it could be related to developed patient relationships and understanding the needs of the patients. In our study, a small percentage of urban pharmacists reported having good-quality support staff, which may indicate staffing to be an issue in rural settings. Many rural pharmacies operate with a smaller staff, with only one pharmacist working at times, which reduces options for delegating certain duties to create time for patient-care services.15 Such problems are further exacerbated by frequent staff turnover in rural pharmacies.15 Having good quality support staff can enable pharmacies to operate more efficiently, offer better patient services, and allow the pharmacist to delegate tasks to better manage time.29,30

4.3 Barriers to Providing Care to Patients

In our findings, provision of care services is where barriers were most prevalently reported across both rural and urban pharmacists. Barriers included patients misunderstanding the scope of pharmacy, staffing issues, and not having enough time to provide services. Each of these barriers have been previously reported in the literature.16, 17, 18., 19., 20.

While both rural and urban pharmacists reported patient misunderstandings of the scope of pharmacy, urban pharmacists mentioned this barrier at nearly twice the rate. This difference may be attributed to the urban patient population having multiple healthcare providers/prescribers available. Having a high number of different providers/prescribers may contribute to patient misunderstanding of the scope of pharmacy, as well as serve a barrier to patients forming a relationship with their pharmacist. Close, trusting relationships between pharmacists and patients increases the likelihood that a patient will seek healthcare advice from the pharmacist, and thus may also lead to patients having a better understanding of the services their pharmacist can offer.15,31, 32, 33 Patients in rural settings may have more trust in their pharmacists due to knowing them outside of their professional role, which may allow for the pharmacist to appear more reliable and approachable and for patients to better understand the scope of their services.15,34

Additionally, both rural and urban pharmacists mentioned a variety of staffing-related issues as a contributing factor across several of the questions, but staffing-related issues were most pronounced when discussing barriers to providing services. Concerns such as low staffing, having only one pharmacist on duty, and high turn-over of staff were reported. These findings align with themes that frequently appear in the literature, particularly with the rise of dependency on pharmacy services that occurred during and since the start of the COVID-19 pandemic.18., 19., 20.

Interestingly, even though staffing-related concerns were raised across rural and urban sites, a related barrier, time to provide services, was reported from only rural pharmacists. Time as a barrier to providing services in pharmacies has been reported in several studies across the globe, with staffing issues being a major factor impacting time-related barriers.18,35 Not having enough time to complete services can impact patient communication, initiation of patient services, and the offering of MTM services, making this barrier a major limiter in a pharmacist's ability to do their job.36 Interestingly, in our findings both rural and urban pharmacists listed time as a barrier at a higher rate when asked specifically about providing services to patients with CVD or diabetes. This is likely because more time is typically required to provide certain services, like MTM, which are more often needed for patients with complex chronic conditions. The consequences of time-related barriers impact patients directly: an inability to provide or initiate important patient services can cause increased medication errors and patient misunderstandings.36 To address time-related barriers, past studies have proposed strategies such as prioritization of tasks in the pharmacist's workload.37 While such approaches may be helpful, the ability to implement them may be difficult for pharmacies with staffing-related barriers, limiting the applicability of such an approach.

4.4 Limitations

Several factors limited the results of the project. One of the main factors was the low number of hospital pharmacists interviewed. This is partially due to the investigatory nature of the project and the process of targeting community-based pharmacists in the selection process. Higher levels of formality in requesting interviews could have increased the number of pharmacists interviewed, and more algorithmic lines of interview dialogue could have allowed for more specific data to be gathered. Further development of interview questions could also allow for more detailed responses and useful data. Changing the data collection process to a survey as opposed to interviews may also yield higher participation and more measurable data with readily comparable results.

5 Conclusions

This was an introductory project paving the way for more rigorous investigative work in the future. With general barriers and facilitators specific to rural and urban pharmacists in South Dakota determined, future research on this topic in the state will have a more tailored direction. Next steps to expand on facilitators and overcome barriers should include increasing awareness of pharmacist-provided patient care services already accessible to the public. Further, training quality support staff and increasing numbers of quality support staff would seek to address the time barrier in rural settings. Facilitating CPA usage alongside awareness will also allow for an additional increase of pharmacist provided services to become available to the public. This would improve patient knowledge of pharmacist-provider care services, improve patient health through increased use of those services, and increase provider/prescriber efficacy through delegating authority to pharmacists to offer appropriate services that patients may not otherwise have access to. By maximizing the potential of underutilized tools and personnel while targeting barriers, the field of pharmacy and the patient care process can be greatly improved.

Funding

This project was completed in collaboration with the South Dakota 10.13039/501100003921 Department of Health , supported by the 10.13039/100000030 Centers for Disease Control and Prevention of the 10.13039/100000016 U.S. Department of Health and Human Services under grant # 1 NU58DP006526–01-11 . The contents are those of the author(s) and do not necessarily represent the views of CDC or the U.S. Government.

Institutional review board statement

This project was reviewed and approved by the South Dakota State University IRB, approval number IRB-1901020-EXM.

Informed consent statement

All participants interviewed consented to participation prior to participation in this project.

CRediT authorship contribution statement

Erin E. Miller: Writing – review & editing, Writing – original draft, Supervision, Project administration, Investigation, Funding acquisition, Data curation. Aaron Hunt: Writing – review & editing, Writing – original draft, Project administration, Methodology, Funding acquisition, Formal analysis, Data curation, Conceptualization. Alex Middendorf: Writing – review & editing, Writing – original draft, Investigation, Funding acquisition, Data curation, Conceptualization. Deidra Van Gilder: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Abigayle Blanchette: Writing – review & editing, Writing – original draft, Data curation. Abigail Sirek: Writing – review & editing, Writing – original draft, Data curation. Sharrel Pinto: Writing – review & editing, Writing – original draft, Supervision, Project administration, Funding acquisition, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

Pharmacist Interview Facilitation Guide

Image 1

Pharmacist Focus Group Facilitation Guide

Image 2

Acknowledgements

The authors would like to acknowledge Dr. Chamika Hawkins-Taylor for key help in developing individual interview and focus group questions, Madeiline Osborn for key help writing and editing, Jacob Ford, Scientific Writer, for editorial assistance on this manuscript, and Stephanie Hanson for her guidance on qualitative analysis.
==== Refs
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