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Perception of community pharmacists in pakistan towards patient counseling

Introduction:

The profession of pharmacy has undergone several changes in the past.1 The modern pharmacist considers pharmaceutical care as their focus point. 2 Throughout the era of the pharmacy profession, from the traditional compounding system to the modern era of pharmacy practice, dispensing was a major responsibility of the pharmacists. 3 Community pharmacists live in close contact with patients and the public.4 In developed countries community pharmacists play an important role in advising patients about their medications and lifestyle modifications.5-8 In developing countries, the role of community pharmacists are less felt and this limits their contribution in procurement, supply and selling of medicines.9 Pakistan is a developing country in South Asia where the pharmacy profession is in the phase of transition. 10 Community pharmacists in Pakistan often called as retail pharmacists make a substantial contribution to community health.11 Patient counseling is an important responsibility of the pharmacist that goes beyond providing of information.12 Patient counseling improves patients' understanding about their medications and is known to improve compliance.13,14 Since the involvement of community pharmacists in patient counseling is felt to be less, there is a need to explore their perception towards patient counseling. Studies from developing countries reported a mixed opinion among community pharmacists regarding patient counseling.15-17 Obtaining information regarding the perception of the community pharmacists might help in strategizing interventions to improve the involvement of community pharmacists in patient counseling. Hence the present study was conducted.

Objectives:

The study had the following objectives

  1. To collect the demographic details of the community pharmacists in Karachi city, Pakistan
  2. To explore the community pharmacist perceptions towards patient counseling
  3. To identify problems experienced by the pharmacists in counseling patients and
  4. To know the community pharmacists perception towards continuous pharmacy education(CPE)

Methodology: A semi-structured questionnaire in accordance with the objectives of study was designed by investigators/researchers of the study attached as Appendix 1.

Study setting: Community pharmacies in Karachi City, Pakistan. Karachi is one of the largest cities of Pakistan with a population of around 13 million.

Study type: Cross sectional study involving community pharmacists in which the community pharmacists' perception towards patient counseling was evaluated using a questionnaire.

Study tool:

A questionnaire consisting of 20 questions was used as the study tool.17 This questionnaire was used by researchers in Nepal in the year 2008 and was used in the current study without any change. Prior to using the questionnaire, permission was taken from the authors and the journal.

Method of data collection:

A prospective study was conducted in February 2009 in Karachi, Pakistan. Every three randomly selected pharmacies from different towns of Karachi were included in the study. A self-administered questionnaire was applied to the available community pharmacist/pharmacy attendant.

Method of data analysis:

The filled questionnaires were entered and analyzed in Microsoft Excel-XP spread sheet.

Results:

Characteristics of pharmacies:

The total number of pharmacies who responded to the survey was 57. The details regarding the demography of the respondents are listed in Table 1.

Sources of drug information:

The most common sources of drug information available in the surveyed pharmacies were Red Book (49.1%; n=28), Quick Index of Medical Practitioners (QIMP) (28.0%: n=16), Pharmaguide (43.8%; n=25), and Martindale (3.5%; n=2). 10.52% of (n=6) pharmacies failed to give any response about sources of drug information while 24.5% (n=14) cited more than one book.

Views of the pharmacists about their professional roles and responsibilities:

The opinions expressed by the community pharmacists are given below (Table 2).

There were mixed feelings among community pharmacists and pharmacy attendants towards patient counseling. Majority of pharmacies (70.1%; n=40) cited ‘compliance improvement' as main reason to give advice to patients. ‘Professional satisfaction' (54.3%; n=31), ‘duty' (47.3%; n=27), ‘improvement in sales' (19.2%; n=11) and ‘strategy to overcome competition' (15.7%; n=9) were cited other different reasons for counseling. Some community pharmacists stated more than one purpose to give advice to patients.

Points covered during counseling:

Major points covered by the community pharmacists during counseling were related to dose (91.2%; n=52), side effects (77.1%; n=44), and administration (63.1%; n=36). Storage (31.57%; n=18) and other information pertaining to medicine use (5.2%; n=3) were cited as minor features of counseling.

Frequently asked questions by patients:

Information seeking behavior of patients was mainly about cost (92.9%; n=53), side effects (70.1 %; n=40), dose (59.6%; n=34), administration time (43.85% n=25), and duration of therapy (40.35% n=20). Questions about disease (38.5%; n=52), and storage conditions (22.8%; n=13) were also asked by patients visiting pharmacies. All the surveyed pharmacies cited more than one than question being asked by patients. To be precise patients might have asked more than one question at a time from the pharmacist.

Barriers in counseling:

Lack of time (84.2%; n=48), lack of knowledge about medicines and disease (47.3%; n=27), and lack of interest from patients (19.2%; n=11) were cited as barriers in counseling. Twenty community pharmacists suggested more than one barrier in professional counseling.

Strategies to overcome barriers:

Plans to overcome barriers in patient counseling include increasing pharmacist workforce in pharmacies (64.9%; n=37), participation in CPE (61.4%; n=35), counseling fees (43.8%; n=25), separate counseling area (17.54%; n=10) and procurement of adequate books (8.7%; n=5). All the community pharmacists suggested more than one strategy to overcome barriers in professional counseling.

Topics for continuous pharmacy education (CPE):

Common drugs (87.7%; n=50) and common diseases (52.6%; n=30) were cited as possible topics for CPE while 4 pharmacies failed to cite any topics. Twenty five community pharmacists cited more than topic for CPE.

Discussion:

The Government of Pakistan has set guidelines for issuing a pharmacy license. Apart from proper storage facilities for medicines and maintenance of hygiene in pharmacy premises, medicines should be sold under uninterrupted supervision of pharmacist. The present study showed less number of pharmacists in surveyed pharmacies. A large number of surveyed pharmacies showed interest in counseling the patients. Improved compliance and professional satisfaction were cited as major reasons for professional counseling whereas cost and side effects were major topics in counseling.

Lack of time and lack of knowledge about medicines and diseases were major hindrances in professional counseling whereas measures to remove these obstacles not only include increase in pharmacist workforce and counseling fees but also a separate counseling area. Interestingly, all pharmacies showed interest in attending CPE and many considered CPE as ‘knowledge improvement tool'. This study highlighted sparse availability of professionally qualified pharmacists in pharmacies. In contrast to developed countries, this is not a novel finding in the context of developing countries scenario where the role of community pharmacist is not necessarily performed by professionally qualified pharmacists.9, 18-19

A cross-sectional survey on the quality of pharmacies in Pakistan reported less number of qualified pharmacists in the pharmacies.20 Likewise, a previous study about the dispensing practices of pharmacy attendants in Karachi reported very few pharmacologically trained pharmacy attendants.21 These studies are in concordance with our study regarding the presence of professionally qualified pharmacists in pharmacies. Their underutilization in the community setting may be due to their perceived status as ‘less respectable health professionals' in the eyes of the public thus serving as an obstacle to serve as community pharmacist. Educational training programs for non-qualified pharmacy attendants as recently suggested by Sind Pharmacy Council, Karachi can improve the medicine dispensing practices in the region.22 As outlined by the World Health Organization (WHO),23 besides dispensing, counseling patients is one of the core professional responsibilities of the pharmacist. Majority of the respondents in this study showed their inclination towards counseling. Better compliance practices and professional satisfaction were outlined as main reasons for their counseling behavior. In this study questions about cost and side effects were often asked by patients. Some of the previous studies showed pharmacists caring attitudes for their patients as well as their counseling practices on proper medication uses, 24-25. This seems to correlate with the findings of the present study. As this era seems to be of patient, not only the healthcare practices are directed towards patients but patients themselves require active role in their treatment regimens. Consumer education programs can help in improving awareness about medicines.

This study also highlighted the importance of time and knowledge about medicines and diseases as well as patients' interests in professional counseling of patients. Previous studies gave account of similar factors as barriers in counseling patients.26-27 The current study outlined counseling fee, separate counseling area, and increase in pharmacist workforce as measures to overcome barriers to professional counseling. These are in correlation with previous studies done at Singapore and Nepal where pharmacists were in favor of counseling fee and a separate unit for counseling.28-29 A law mandating professional counseling can be tried to encourage pharmacist counseling.

Educational training programs on a regular basis for both pharmacists and pharmacy attendants are a well-known phenomenon.30 All the surveyed pharmacies in the present study not only showed their interest in CPE but a large majority believed CPE to be an important ‘knowledge improvement tools'. A previous study at Finnish pharmacies showed pharmacy professionals intention and eagerness to attend continuing education programs.31 The present study is in agreement with previous findings. The sustenance of comprehensive role of community pharmacist being from a dispenser to a counselor and advisor needs support from educational training programs time to time. The addition of ‘Researcher' as an eighth category 32 to previously coined ‘seven-star' category by WHO, if adopted by pharmacists, would give substantive professional image to pharmacists; be it a caregiver, communicator or decision-maker.

Limitations:

Although this study showed promising results in relation to perception towards professional counseling and CPE programs but owing to small sample size the findings of this study cannot be generalized to community pharmacists in other regions of Pakistan.

Practice implications:

This study is the first study from Pakistan that explored the perception of the community pharmacists. The information obtained in this study would be useful in strategizing interventions to improve the professional status of pharmacists in Pakistan.

Conclusion:

This present study showed large number of visits to pharmacies in Karachi and documented strong interest in patient counseling by the pharmacists. Owing to their non-professional qualification as well as brushing up the knowledge of qualified professionals, CPE programs can serve as knowledge improvement tools. Future research can be directed to more number of pharmacies throughout the whole country of Pakistan.

Acknowledgements

The authors would like to acknowledge Raheela Noman, PhD fellow, HEJ Research Institute of Chemistry, Karachi, Pakistan & Dr Saima Mahmud, Assistant Professor Pharmacology, Baqai Medical University, Karachi, Pakistan for being the data collector in this study. The authors would also like to acknowledge Dr Ravi Shankar, Dept of Clinical Pharmacology, Kist Medical College, Nepal for reviewing and providing valuable comments to the final version of the manuscript. The authors are also thankful to the Journal of Clinical and Diagnostic Research for the permission to use the questionnaire published in their journal.

Table 1. Characteristics of Pharmacies (n=57)

Characters

Parameters

Number (%)

Number of patients visited daily

10-20

9(15.7)

21-35

13(22.8)

36-50

22(38.5)

more than 50

13(22.8)

Time taken to dispense a prescription

Less than 1 minute

10(17.5)

1- 5 Mins

16(28.0)

5-10 Mins

29(50.8)

More than 10 mins

2(3.5)

Qualification of the owner

D.Pharm

1(1.7)

B.Pharm

47(82.4)

M.Pharm

2(3.5)

Others

7(12.2)

*Total number of pharmacists employed

None

44(77.1)

1

7(12.2)

2- 5

4(7.0)

*Qualification of employees of the pharmacy

D.Pharm

None

B.Pharm

11(19.2)

M.Pharm

None

Others

51(89.4)

Working hour of the pharmacy

Upto 10 hrs

9(15.7)

10-20 hours

46(80.7)

More than 20 hrs

2(3.5)

*Two pharmacies failed to answer the total number of pharmacists employed

*Five pharmacies stated more than one qualification for their employees

Table 2 Views of pharmacist about their role

Statement

Yes

No

Do you think a pharmacist is required in a pharmacy

26

31

Do you think you get professional respect from the public

50

2

Do you give advice to your patients regarding medicines

56

1

Do you think giving advice to the patients is important

54

3

Are the patients interested in knowing about their medicines?

52

2

Are you interested in counseling the patients?

54

3

Do you think continuing education program are helpful in improving your knowledge about medicines

54

3

Are you interested in attending continuing education programs

53

4

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