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The impact of interprofessional collaboration between pharmacists and community health workers on medication adherence: a systematic review

International Journal for Equity in Health volume 24, Article number: 58 (2025) Cite this article

Abstract

Background

There is increasing evidence to support the effectiveness of interventions involving community health workers (CHWs) in improving patient health outcomes, which reinforces their growing integration in healthcare teams. However, little is known about the interprofessional collaboration between pharmacists and CHWs. This systematic review aimed to explore the impact of interprofessional interventions involving pharmacists and CHWs on patient medication adherence.

Methods

The English language scientific literature published in Embase, MEDLINE, Web of Science, CINAHL, Scopus, plus the grey literature were searched in October 2024. Using the software Covidence, two authors screened article titles and abstracts and assessed full-text articles for eligibility. Studies were included if (i) the intervention was delivered by pharmacists and CHWs and (ii) reported on medication adherence outcomes. Data were extracted using a customized template using Excel and synthetized narratively. The Effective Public Health Practice Project quality assessment tool was used to assess the studies’ methodological quality.

Results

Eight studies met the inclusion criteria, including a total of 1577 participants. Seven studies were conducted in the United States, and six were published since 2020. The interventions consisted of medication therapy management, medication reconciliation, and repeated education sessions. The CHW shared clinical and non-clinical patient information and ensured a culturally safe environment while the pharmacist delivered the clinical intervention. In five studies, medication adherence was evaluated solely through patient self-reported measures. One study used an objective measure (i.e., pharmacy refill records) to evaluate medication adherence. Only two studies assessed medication adherence using both self-reported and objective measures (i.e., pill count and proportion of days covered). A significant improvement in medication adherence was observed in three of the eight studies. Half of the studies were of weak quality and half of moderate quality.

Conclusions

There was a small number of studies identified which focused on the impact of interprofessional collaboration between pharmacists and CHWs on medication adherence. The impact of the interprofessional interventions on medication adherence was limited. Further studies of higher quality are needed to better evaluate the impact of such collaboration on patient health outcomes.

Registration

PROSPERO, ID CRD42024526969.

Background

Medication adherence is the extent to which patients take their medication as prescribed by their healthcare providers. It is characterized by three interrelated phases: treatment initiation (i.e., first dose taken), treatment implementation (i.e., the extent to which the patient’s dosing history corresponds to the prescription) and discontinuation (i.e., the patient stops taking the treatment prematurely) [1]. It is estimated that up to one third of patients never fill their first prescription, and of those who fill it, up to half of the patients are considered nonadherent [2, 3]. Within two years of the initial prescription, less than half of these patients are still taking their prescribed medications [3]. Medication nonadherence leads to treatment failure, suboptimal clinical outcomes, premature death, poor quality of life, increased health services use and health care costs [2,3,4,5]. It is thus critical to evaluate and address medication adherence barriers, and optimize patient medication adherence by supporting them in the long term [6].

Having a pivotal role in the primary health care system, pharmacists’ roles are expanding globally, and the evidence of the impact of pharmacist-led interventions (such as medication reviews, medication reconciliation, medication management and medication adherence support) on patient medication adherence and health outcomes, is growing [6,7,8,9,10,11,12]. Community pharmacists are at the front line to identify patient medication nonadherence and support patients’ medication adherence. However, several challenges may arise, such as low awareness for medication adherence in the population, healthcare professionals or policymakers [13], low workforce supply, time pressures [14], or lack of sufficient funding for pharmacists to engage in medication adherence support [13, 15].

The assessment of medication adherence and the identification of its influencing factors in each patient can be challenging. For instance, one of the major determinants of patient medication adherence are the social determinants of health (SDoH) [16, 17], which include the social and cultural background of people, their environment, income, employment status, education, and their age [18]. The SDoH influence many health outcomes and should be addressed as a major component in patient care [19]. However, health professionals often encounter challenges in identifying and managing SDoH in underserved and vulnerable populations (i.e., individuals facing disparities and experiencing barriers to access care [20]) [21, 22].

Collaborating with health workers that have a specific understanding of the patient’s background would be instrumental to delivering effective care and decreasing health disparities. According to the American Public Health Association, community health workers (CHWs) are frontline public health workers who serve as a liaison/link/intermediary between health/social services and the community (often their own community in terms of cultural background and language) to facilitate access to services and improve the quality and cultural competence of service delivery [23]. CHWs can be identified by different terms, e.g., Promotoras de Salud who serve the Latino population [24] or aboriginal health workers who support the Aboriginal and Torres Strait Islanders people in Australia [25]. Socio-demographic characteristics of CHWs, their education and the level of pre-service training vary widely [26]. A review by the World Health Organization (WHO) and the Global Health Workforce Alliance in 2010 established that the minimum level of education to become a CHW should be completion of primary school [26]. The integration of CHWs in health systems and health care teams also varies globally. In the last decade, the implementation of CHW programs in low- and middle-income countries has been growing [26]. During the Coronavirus-2019 pandemic, CHWs were recognized as essential health workers to support communities, which may subsequently improve their integration in health care teams in the long-term [27, 28]. However, the integration of CHWs is limited in European health systems, where they are mostly project-based — CHW are more widely integrated into the United Kingdom health system [29]. CHWs have been involved in improving patients’ navigation of the health system, providing health prevention services, supporting healthy behaviours, monitoring patient health and delivering specific care [30]. The evidence of the effectiveness of CHWs is growing in improving cancer screening [31], improving the management of diabetes [32], hypertension [33] or infectious diseases [30, 34], delivering HIV services [35], preventing undernutrition [36, 37] and improving maternal and child health [30, 38]. CHWs work in diverse settings, including community-based organisations, hospitals or public health departments [39]. The total number of CHWs working in communities and healthcare settings are hard to establish owing to their diverse definition and roles. The United States Bureau of Labor Statistics estimated that 58,550 CHWs were employed across the United States of America (USA) in May 2023 [40], and that the number of CHWs is expected to grow by 13% from 2023 to 2033 (i.e., around 7,500 new CHW positions are projected each year), which is faster than the average growth rate for all occupations [39]. The integration of CHWs within healthcare teams is needed and is growing [30, 41, 42].

Working collaboratively with other healthcare professionals has become a key component of effective care, improving medication adherence and positively affecting patient health outcomes [6, 12, 43,44,45]. Pharmacists, especially community pharmacists and CHWs can work synergistically to modify the way in which the SDoH may act as a barrier to medication adherence in underserved populations. Current research evidence focuses on interprofessional collaboration between CHWs and physicians, nurses, dietitians and social workers in delivering interventions, programs or services that have demonstrated a positive effect on patient health outcomes and in improving patient navigation of the healthcare system [30, 46, 47]. However, little is known about the collaboration between CHWs and pharmacists [48].

Gathering the knowledge and evidence on this topic could help implement interprofessional interventions and foster the connection between pharmacists and CHWs to improve patient health outcomes. Therefore, this systematic review aims to explore the impact of interprofessional interventions involving pharmacists and CHWs on patient medication adherence.

Methods

Design and guidelines

This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [49]. The primary outcomes evaluated were components of medication adherence, i.e., medication initiation, implementation, discontinuation or persistence to treatment, assessed by objective or subjective measures.

The systematic review protocol was registered in PROSPERO (CRD42024526969).

Study eligibility criteria

Studies were included if (i) it was a primary research article published in English (i.e., reviews, protocols, commentaries, letters to editors and conference abstracts were excluded), (ii) the study design was an intervention, a service or a program (i.e., qualitative, observational or cross-sectional studies were excluded), (iii) the intervention involved pharmacists and CHWs, (iv) the intervention involved people taking any kind of medications for a chronic or acute condition or for preventive care or contraceptive purposes and (v) the intervention aimed to improve medication adherence and one of the outcomes of the intervention delivered was a component of medication adherence (i.e., initiation, implementation, discontinuation).

Information sources and search strategy

English language literature was searched in October 2024 in Embase, MEDLINE, Web of Science, CINAHL and Scopus. Additionally, a grey literature search was conducted using similar search terms in Google Scholar and Google search engine.

The research strategy was built with a university librarian using three concepts: (i) pharmacists, (ii) community health workers and (iii) medication adherence (Additional file 1). No restriction on the publication date was applied, i.e., the search was conducted from the inception of the databases until October 2024.

Data collection process

The output references were imported into Covidence (Veritas Health Innovation, Melbourne, Australia), a web-based collaboration software platform that streamlines the production of systematic and other literature reviews [50]. Most of the duplicates were removed by the software, and the remainder was removed manually. First, two authors (CB and RN) independently excluded irrelevant articles based on the screening of their titles. Second, the remaining articles were screened based on their abstracts. Of note, while review articles were not eligible, the reference list of the review articles was also searched for any potential literature. Third, the selected articles were assessed for eligibility by CB and RN after a full-text reading. The discrepancies were discussed and resolved at each stage. To reduce any potential selection bias, any further discrepancies were discussed by another two authors (PA and SKM), until all agreed.

The data from the selected articles were extracted using a customized template for data extraction using Excel version 16 (Microsoft) developed by the authors. The variables extracted where possible as per the terminology used in the study were: intervention, setting, sample size, participant population, study design, medication adherence measure and results.

The authors of the included articles were contacted in case additional information was needed. The results were synthesized narratively.

Study quality assessment

The methodological quality of the included studies was assessed independently by two authors (CB and RN) using the Effective Public Health Practice Project quality assessment tool [51]. Six domains were evaluated: (i) selection bias, (ii) study design, (iii) confounders, (iv) blinding, (v) data collection methods, and (vi) withdrawals and drop-outs. For every domain, a score was determined: 1 for strong, 2 for moderate, and 3 for weak quality. The scores were then used to assess the quality of the study as a whole: the study was considered of strong quality if no weak rating was assigned, of moderate quality if one weak rating was identified, and of weak quality if two or more weak ratings were assessed [52]. Discrepancies were resolved by discussion between the authors (CB and RN).

Results

The PRISMA flow diagram (Fig. 1) presents the article selection process. After duplicates were removed, 1495 articles were screened, of which 1289 were excluded based on their titles. Of the 206 articles assessed for eligibility, 147 were excluded based on their abstracts screening and 51 after a full-text reading. Finally, 8 articles met the inclusion criteria.

Fig. 1
figure 1

Flow diagram of the article selection process. Note. CHWs: community health workers

Full size image

Study characteristics

In total, eight studies were included [53,54,55,56,57,58,59,60]. Seven studies were conducted in the USA [54,55,56,57,58,59,60] and six of the eight studies were published since 2020 [54, 56,57,58,59,60]. Three studies had a pre-post design [55, 57, 60], three were observational [53, 56, 59] and two were randomized controlled trials [54, 58]. Three studies involved interventions lasting less than 6 months [56, 57, 59], while five studies had interventions that lasted 6 months or longer [53,54,55, 58, 60].

Participants included

The most common group of patients included in the studies were patients with hypertension and/or diabetes [54, 55, 60]. The other studies involved patients with human immunodeficiency virus (HIV) initiating antiretroviral therapy [53], community dwelling older adults [57], patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) [59], patients treated with oral anticancer medications [56] and Cambodian Americans with depression and at risk of diabetes [58]. In total, the studies involved 1577 participants, ranging from 33 [60] to 517 participants [55].

Settings of the interventions

Most of the interventions (7/8) were conducted in the community (i.e., patient’s home) [53,54,55, 57,58,59,60] and only one study was conducted in a hospital [56]. Clinical, hospital or specialty pharmacists were mostly involved (6/8) [53, 54, 56,57,58,59]; 2 studies involved academic pharmacists (i.e., pharmacist researcher affiliated with a university or an academic institution) [55, 60]. Community pharmacists were not directly involved in the intervention of any included studies.

Most of the studies defined CHWs by the same title, although CHWs were referred to as “health coaches” in one study [54], and “medication navigator” in another study [56]. In one study, “promotora” was used to refer to CHWs [55].

Data of included articles are presented in Table 1.

Table 1 Included study data
Full size table

Interventions involving pharmacists and CHWs

Five studies reported on interventions where the pharmacist reviewed the current medication list, identified drug-related problems, developed a medication action plan or sent recommendations to healthcare providers (i.e., in most of the studies, the patients’ primary care physicians) [54, 55, 57,58,59]. In three of these five studies, CHWs were actively involved during the intervention delivered by the pharmacist to ensure a culturally safe environment and patient understanding (i.e., translated the information in the patient’s language, facilitated telehealth and introduction with pharmacists, assisted the patient during medication reconciliation) [54, 55, 58].

Two studies described how CHWs were actively involved in collecting patient information and medication records or assisted pharmacists with addressing medication adherence barriers [57, 60]. It is interesting to note that in one study, the CHW was described to be the only healthcare professional to be in direct contact with the patient during the intervention [60].

In three studies, the pharmacist delivered education sessions in addition to providing repeated medication management interventions [53, 54, 56]. These were all facilitated by the CHW who organized support group meetings [53], visited the patient at home to provide self-management education and collect clinical data (i.e., blood glucose and blood pressure levels) [54], and reinforced patient understanding regarding the medication [56]. CHWs addressed barriers to medication use, collected information regarding the medications and shared relevant information with pharmacists [54, 56,57,58, 60].

The training and supervision of CHWs and pharmacists was not always comprehensively described in the included studies. While in the study from Gerber et al., health coaches (term used for CHWs) received extensive study-specific training [54], in the study from Lin et al., the oncology team and the oncology specialty pharmacist provided formal training to medication navigators on medication education and triaging of medication-related problems (i.e., formal training) [56]. In the study by Meyer et al., pharmacists were required to have a geriatrics specialty designation and the staff received extensive orientation to the intervention, and frequent training in geriatrics and aging [57]. In the study from Polomoff et al., the pharmacist investigator and study coordinator trained CHWs in medication therapy management, CHWs shadowed experts who completed the medication review form and performed role play [58]. Prior to conducting the intervention independently, CHWs were supervised for some of the medication review sessions they conducted with participants [58]. In the study by Wheat et al., pharmacists and student pharmacists provided training to CHWs in medication therapy management (including health disparities, cultural competency, motivational interviewing, communication skills, ways to identify adherence barriers and how to collaborate with a pharmacist) [60].

Methods to measure medication adherence

In five studies, medication adherence was evaluated subjectively solely through patient self-reported measures [54,55,56, 58, 60], of which four [54, 56, 58, 60] used at least one validated questionnaire (such as the BMQ [65] or the Drug Adherence Workup Tool [67]) or questions adapted from previously validated questionnaires (such as from a 3-item medication adherence measure, previously validated for patients with HIV [63]). Two studies measured adherence through self-reported measures based on the frequency of missed doses or self-reported barriers to taking medications and did not report on the validity of the questionnaire used to assess medication adherence [55, 58].

One study solely used an objective measure (i.e., pharmacy refill records) to evaluate medication adherence [53]. Only two studies assessed medication adherence using both self-reported and objective measures [57, 59]. In one study, participants completed the MedAdhIR tool and adherence was also evaluated using pill counts [57]. In another study, medication adherence was assessed through the modified Drug Adherence Work-up Tool and the proportion of days covered [59].

Study quality assessment

Using the Effective Public Health Practice Project quality assessment tool [51], none of the studies were considered to be of a strong (or high) quality. Half of the studies (4/8) were considered to be of weak methodological quality [53, 55, 57, 60] and half of moderate quality [54, 56, 58, 59]. The studies were determined to be of weak or moderate quality due to the study design (i.e., the studies were mostly observational with a pre/post design, only two studies were randomized and controlled trials), presence of confounders, lacking of blinding, and lacking of reliability in the data collection methods.

Impact of the intervention on medication adherence outcome

Table 1 summarizes medication adherence measures and results in the included studies.

Three of the eight studies showed a significant improvement in medication adherence [53, 57, 58]– the quality assessment was of weak quality in two [53, 57] and moderate in the third [58]. In these studies, adherence was evaluated with pharmacy refill records [53], the validated self-report MedAdhIR tool and pill-count [57], and the validated BMQ questionnaire and non-validated self-report measures [58]. The interventions, which showed a positive outcome, were repeated education sessions [53], medication reviews and medication therapy management [57, 58].

Three studies did not demonstrate statistically significant improvements in medication adherence [54, 55, 59], including a study which evaluated adherence with the proportion of days covered [59], one study using a validated questionnaire [54], and another study using a non-validated questionnaire [55]. The quality assessment of these studies was respectively of moderate [54], weak [55] and moderate quality [59].

Two studies using validated questionnaires to assess medication adherence were descriptive and did not conduct statistical analyses on medication adherence outcomes [56, 60]– these studies were considered as moderate quality [56] and weak quality [60].

Discussion

This is the first systematic review to evaluate the impact of interprofessional interventions involving pharmacists and CHWs on patient medication adherence. The evidence of the impact of the interventions on medication adherence is limited. While only a small number of studies were eligible for inclusion in this systematic review, there was a large degree of heterogeneity among the included studies, which used various methods to measure medication adherence. Most of these methods were subjective, relying on patient self-reported measures through different kinds of questionnaires, which were not always validated. Studies of higher quality are needed in this field of research.

A majority of the included studies relied solely on self-reported adherence measures. The use of subjective measures to evaluate medication adherence allows obtaining the patient’s perspective on their medication adherence, is low cost and can be easily implemented in adherence studies [68, 69]. However, they are prone to desirability bias (i.e., patients may respond according to their perspective of a favourable answer) and memory bias, leading to an overestimation of medication adherence compared to objective measures, that provide an accurate record of medication adherence [68, 69]. Of note, when researchers modify a validated questionnaire, they should validate the instrument and its scoring [70], which has not been clearly reported in the included studies.

The variety of questionnaires in terms of question phrasing, intervals of recalls, scale formats, type of nonadherence (i.e., intentional versus non-intentional), and adherence phase (i.e., initiation, implementation and discontinuation), prevents the comparison of results between the studies [68, 71]. Based on such variations in questionnaires, the literature recommends to concomitantly use objective measures to corroborate self-reported measures [2, 69], which was reported in only two selected studies [57, 59]. In addition to quantitative data, qualitative data should also be collected in adherence studies to better understand the factors influencing medication adherence that are addressed by the intervention [72,73,74].

Even if medication adherence is considered a surrogate outcome to assess the impact of the intervention on patient clinical outcomes, only one of the studies that significantly improved medication adherence reported the direct impact of the improvement of medication adherence on a clinical outcome (i.e., viral load with the number of copies of HIV-1 RNA per mL, which defined treatment failure) [53]. Considering the variety of adherence outcome measures reported in the included studies and the fact that no clinical outcomes were collected during the interventions, it is difficult to draw clear conclusions on the impact of the adherence interventions on patient clinical outcomes.

Future studies should explore the collaborative practice between CHWs and pharmacists using at least one objective method to measure medication adherence and should explore the impact of the medication adherence intervention on clinical outcomes.

While there is extended evidence of the effectiveness of pharmacist-led interventions to improve medication adherence [6, 12, 75,76,77,78,79], the literature reporting effective CHWs-led interventions to improve adherence is growing [80,81,82,83]. The systematic review findings demonstrate that through a collaborative approach with pharmacists, CHW-led interventions may benefit from the pharmacist’s clinical expertise in medication reviews and medication management to optimize the intervention, in the same way as pharmacist-led interventions would benefit from the cultural and social expertise of the CHWs to collect relevant adherence data and provide culturally sensitive adherence interventions. Indeed, in the three studies that demonstrated significant improvements in adherence [53, 57, 58], CHWs’ roles were instrumental in collecting information regarding the medication history-taking, the prescriptions and assessing patient medication adherence. The trust built between the patient and the CHW, as well as their shared cultural background may have helped the patient to explain their medication management with accuracy. The information collected by the CHW allowed pharmacists to deliver the intervention (i.e., reviewing medications, identifying drug-related problems, addressing medication barriers and providing an individual care plan), which eventually tailored the intervention to the patient’s needs. In addition to collecting relevant information, the CHWs also organized support group meetings for patients, they contributed to the medication therapy management process by providing education and behaviour modification.

Segal et al. proposed a collaborative CHW-pharmacist practice model, where CHWs collect the patient medication list, uncover patient medication self-management and evaluate medication adherence barriers [16]. The CHW share the information collected with the pharmacist, and they then both collaborate on the implementation of an action plan to optimize medication adherence [16]. The CHW implements the plan with the patient and ensure follow-up [16]. The findings of this systematic review corroborate that the evaluation of patient medication adherence by the CHW provides a robust assessment of medication adherence, and the interprofessional collaboration with pharmacists to optimize medication adherence can improve the effectiveness of the interventions. CHWs and pharmacists could then synergistically work together on evaluating, maintaining and improving patient medication adherence in the long run, which may ultimately improve patient health outcomes.

Of note, the interventions included in this systematic review were delivered by clinical, hospital, specialty or academic pharmacists, and community pharmacists were not directly involved in the included interventions. This shows that the integration of community pharmacists in the interprofessional healthcare teams is still limited. Future studies should explore the integration of community pharmacists in interprofessional collaborative practices, as it could improve the recognition of their roles and expand their responsibilities, including in supporting patient medication adherence [84].

This systematic review has several strengths. The strong methodological rigour was guided by the PROSPERO protocol and PRISMA guidelines. The search strategy was comprehensive, completed in consultation with a librarian. The screening and quality assessment of the studies were conducted by two independent authors, and other authors were involved in discussions in case of discrepancies.

Some limitations are to be considered. First, the definitions and roles of the CHWs were not clearly separated out from other health professions and were rarely comprehensively described in the literature. The quality of the collaboration between pharmacists and CHWs was also not described (e.g., regarding communication, the trusted and respectful relationship); there should be more research into this topic. A contact with the study authors was often needed to confirm the study eligibility. Second, due to the heterogeneity of the methods to measure medication adherence and the different study designs in the included studies, a meta-analysis was considered unsuitable.

Conclusions

There was a small number of studies that focused on the impact of the interprofessional collaboration between pharmacists and CHWs on medication adherence. Most of the methods used to evaluate medication adherence were subjective, relying on patient self-report. Clinical, hospital, specialty or academic pharmacists led the interventions — community pharmacists were not directly involved. The evidence of the impact of the interprofessional interventions on medication adherence was limited. Future high-quality studies are needed to better evaluate the impact of such collaboration on medication adherence and patient health outcomes.

Data availability

The datasets supporting the conclusions of this article are included within the article and its additional file.

Abbreviations

BMQ:

Beliefs about medicines questionnaire

CHF:

Congestive heart failure

CHWs:

Community health workers

CI:

Confidence Interval

COPD:

Chronic obstructive pulmonary disease

EWS:

Eat, Walk, Sleep

HIV:

Human immunodeficiency virus

mHealth:

mobile health

MedAdhIR:

Medication adherence individual review

MOATT:

Multinational Association of Supportive Care in Cancer (MASCC) Oral Agent Teaching Tool

MTM:

Medication therapy management

OAM:

Oral anticancer medication

PDC:

Proportion of days covered

SD:

Standard deviation

USA:

United Stated of America

WHO:

World Health Organization

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Acknowledgements

The authors thank Ms Kanchana Ekanayake, librarian at the University of Sydney, for her help in building the research strategies.

Funding

CB is supported by the Swiss National Science Foundation (Postdoc.Mobility Grant P500PM_217609). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. School of Pharmacy, The University of Sydney, Sydney, Australia

    Carole Bandiera, Ricki Ng & Parisa Aslani

  2. School of Population Health, University of New South Wales, Sydney, Australia

    Sabuj Kanti Mistry

  3. International Centre for Future Health Systems, University of New South Wales, Sydney, Australia

    Elizabeth Harris & Mark F. Harris

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  1. Carole Bandiera
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Contributions

CB, RN, SKM, EH, MH and PA built the research protocol. The research strategies were developed by CB, with the help of a university librarian. CB and RN screened and selected articles, involving SKM and PA in the discussion. CB and RN assessed the methodological quality of the studies. Analysis was performed by CB, reviewed and revised by RN and PA, and reviewed by SKM, EH and MH. CB wrote the original draft, reviewed and revised by RN and PA, and SKM, EH and MH reviewed the manuscript.

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Correspondence to Carole Bandiera.

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Bandiera, C., Ng, R., Mistry, S.K. et al. The impact of interprofessional collaboration between pharmacists and community health workers on medication adherence: a systematic review. Int J Equity Health 24, 58 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12939-025-02415-4

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International Journal for Equity in Health

ISSN: 1475-9276

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