Introduction: Since last decades despite tremendous advancements in medical technology, the global health status needs to be revamped. The commitment of the majority of World Health Organization (WHO) member countries to the Declaration of Alma-Ata in 1978 advocates the concept of ‘health for all’. Unfortunately the fundamental doctrine of the declaration is failed to be reaffirmed by some of the developing countries.1 The developing nations harbor 80% of the world’s population and it been estimated that 2.7 billion people living in this part of the world thrive on less than US$2 a day.2,3,4
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This, in turn, contributed to lack of access to efficient healthcare services among these populations. Moreover, in most of these developing countries, the deliveries of effective healthcare services are compromised due to incompetent and non-qualified healthcare providers. Apart from the need to understand the pathophysiology of disease and their treatment modalities, healthcare providers necessitate to comprehend the local environment or/and culture in order to achieve the desired therapeutic outcomes. Therefore, the reorientation and reconstruction of healthcare professionals’ education and training to generate socially motivated healthcare providers is the need of time.
Pharmacist role in developing countries: In the beginning of the 6th century BC, humans started a several-centuries-process of compiling pharmacological knowledge that contributed towards public health.5 The scope of pharmacy practice encompasses areas of compounding and dispensing medications, services related to patient care including clinical services, reviewing medications for safety and efficacy, and providing drug information. Generally, the existing medical education system produces professionals which have a tendency towards clinical practice or either specialization. Preference is more towards treatment rather than prophylaxis. Moreover, professional training emphasized on subject-centered curriculum linked with high technology and therefore, trainees come in contact with patients usually at the end of the training. As a result, the role of pharmacists in healthcare system is generally bleak, but perhaps more so in developing and transitional economies.
Still in some places pharmacists are increasingly assuming their role as health care workers. Their services include more patient-oriented, administrative and public health functions. This successful transition in pharmacy practice is the result of the implementation of educational programs aimed at making them responsive to the needs of the majority of the population6.
In the context of developing countries, pharmacy profession only captured the imagination of only a small segment of the population as a vibrant healthcare profession. For instance, although HIV/AIDS is rampantly prevalent in many developing countries in Asia, Africa and South America, still pharmacist in these countries is underutilized as healthcare workforce in prophylactic campaigns. Furthermore, issues of public health dimensions that need collective action via intensive efforts of pharmacists and other healthcare team members are nearly non-existent in developing countries. This might be due to the fact that both public and other healthcare practitioners perceived that pharmacists are not well positioned to take such an active role in public health initiatives that are generally considered to be the domains of doctors and nurses preferably7.
Lately, with the tremendous evolution of pharmacy practice in developed nations such as the UK, Australia and US, it thus becomes evident that pharmacists can contribute more towards ‘Health for All’ agenda. Furthermore, there has been a great move by health policy makers and educators in developing skills and attitudes which are necessary to meet the healthcare needs of the majority of the people. This change has also influenced many developing countries to follow the trend. Therefore, within the last two decades extensive transitions had been observed in pharmacy curricula globally, mainly with the incorporation of social and behavioral sciences at many pharmacy schools
Although a complete discussion linking social sciences with pharmacy is not possible in a single document, we try to provide a brief historical background on social pharmacy’ and ‘pharmacy practice’ as well as the importance of social sciences in health. In the current document the authors discuss few case studies from developed countries which establish the relevant link of social and behavioral sciences to pharmacy curricula and, therefore, the importance of social sciences in pharmacy curriculum can thus be ascertained.
The authors will also enumerate the achievements of the Universiti Sains Malaysia in incorporating social pharmacy subjects in undergraduate pharmacy education.
Recent history of social sciences and pharmacy education: Since the early 1980’s, efforts were undertaken to find out which areas of pharmacy practice can greatly contribute in pharmacy training. Among many recommendations, an independent committee of inquiry established under the aegis of the Nuffield Foundation advocated that ‘social and behavioral science’ should be incorporated into the pharmacy undergraduate curriculum. Defined as the scientific study of human behavior, ‘behavioral science’ is often associated with disciplines which deal with people and society including psychology, sociology and anthropology.
‘Sociology’ studies an individual’s actions as a social phenomenon, whereas ‘behavior’ is explained and shaped by the society in which we evolve; reason for which, sociologists prefer to use the term ‘social action’ in place of ‘behavior’. ‘Behavioral science’ also includes social psychology and interpersonal communication. According to Morrall,8 the discipline of sociology demystifies the nature of health and illness, determines the social causes of disease and death, exposes power-factors and ethical dilemmas in the production of health care, and either directly or indirectly helps to create a discerning practitioner capable of more focused and competent decision making. Such a sociologically informed approach to health care is basically needed by all health workers including pharmacists. Due to this importance, institutions such as the schools of pharmacy and the Royal Pharmaceutical Society of Great Britain suggested that aspects of sociology should be incorporated into the pharmacy undergraduate curriculum for adequately preparing pharmacy students for their future practice. In a related opinion, the Royal Pharmaceutical Society’s Education Committee advocated that all schools of pharmacy in their undergraduate programs should include teaching on the social science aspects of pharmacy.9
Why sociology for pharmacists? : Inadequacies and disparities in health care systems are still a major threat to global public health. In response to this, the last decades had witnessed an increasing number of changes in the activities of pharmacists. In primary care activities compounding and formulation of medicines are not practiced anymore. As technological progresses have made the dispensing of medicines a more routine task, how much time pharmacists spend on this activity is questioned. In addition, the number of highly effective proprietary medicines available for sale from a pharmacy, which were previously only available on prescription, has increased and thus expected to increase still further. As such, it is predicted that in near future pharmacists will be able to prescribe medicines as supplementary prescribers in developing countries. These facts have led pharmacists to re-evaluate their roles, and to promote themselves as health professionals as they must consider themselves as’ experts in medicines’ capable to take the lead of patients’ health status and the outcomes of different therapeutic regimen. In secondary care, clinical and ward pharmacy have become important concepts, with pharmacists increasingly being integrated into the health care teams alongside acquiring specializations i.e. in drug information, oncology, paediatrics and radiopharmacy.
The contribution of social science to pharmacy practice: Pharmacy services in developing countries could make a greater contribution to health care. Steps to ensure that pharmacy education provides students with the knowledge and skills to contribute to public health priorities of their local populations are increasingly seen as an important goal of pharmacy education. Clearly, in developing their professional skills in social and clinical pharmacy, students need to appreciate that patients will have their own beliefs, views, and perspectives about their health and use of medicines which might be important determinants of the success of any health promotion activities. These activities include development effective counseling and communication skills, enhancing medication compliance, improving the understanding of one’s disease, encouraging patients to seek professional care, assisting patients in making informed decision, and enhancing pharmacy professionalism and leadership qualities.
Global Case Studies
In 1975, the study commission on pharmacy identified the need to incorporate the behavioral and social sciences in pharmacy alongside clinical practice. In the same year, the Council on Pharmaceutical Education included pharmacy administration, social and behavioral sciences in their indicative curriculum. As per 2004, the American Association of College of pharmacy10 incorporates many social and behavioral topics as required outcomes of pharmacy programs in the USA.
In UK, the Nuffield Committee of inquiry into pharmacy decided behavioral sciences to be incorporated into undergraduate pharmacy curriculum in 1986. To date, social pharmacy is now taught in all schools of pharmacy and forms part of the Royal Pharmaceutical Society¢s indicative curriculum. A number of Northern and Eastern European countries introduced social pharmacy into their curricula in the mid-1970¢s11. In Sweden, courses were taught since 1957, dealing with ‘social pharmacy and low/regulations in pharmacy’ which in 1970 transformed to ‘social pharmacy’. In Denmark, the first ‘social pharmacy’ course was introduced in 1972-73 and by 1980 the course appeared in the course catalogue as ‘social pharmacy with social science’. In 1992, a chair in ‘social pharmacy ‘was established at Royal Danish School of Pharmacy. In Belgium, the concept of communication skills was introduced into the pharmacy fourth year students. A variety of methods that are used to assess pharmacy practice students, including a 6-month pharmacy internship, in which students are assessed by a preceptor’s report; a week-long workshop on communication and pharmacotherapy; a multiple choice exam on pharmacotherapy; and an ‘open book’ oral exam. In the academic year 2000-01, the strongest correlations were between internship and oral exam performance. This trend continued in 2001-02, in addition to multiple choice exam correlating with both oral and internship performance.
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In the scenario of developing countries the contribution of pharmacy education in Malaysia is worth mentioning. The Universiti Sains Malaysia (USM) is the first public university to offer a Bachelor’s degree in Pharmacy in Malaysia since 1972. To date, it has produced more than 2,000 pharmacy graduates which serve as local pharmacy workforce. The School of Pharmaceutical Sciences has a multi-disciplinary pharmacy curriculum designed to provide holistic training to prepare students for life-long learning, and to equip them with broad scientific knowledge and essential skills. The integrated pharmacy program consists of basic science and pharmaceutical science subjects in the first two years of study, and progresses towards patient care and clinical pharmacy. In the third and fourth years, the students’ professional skills are linked to an advanced clinical and pharmacy practice. Hence the curriculum inculcates a high standard of pharmacy training in practical knowledge and professional skills. The 4-year program covers 6 disciplines of study, namely Pharmaceutical Chemistry, Physiology, Pharmaceutical Technology, Pharmacology, Clinical Pharmacy and Social and Administrative Pharmacy. Social and Administrative Pharmacy subjects were first incorporated in the curriculum in 1992-93 academic sessions and has been designed to prepare students for responsible leadership positions in academia, industry or public service.12 Hence this course equips the students for careers in governmental agencies, pharmaceutical firms, community pharmacies, universities, professional bodies and health insurance companies, all of which have a direct and indirect impact on the social fabric of the country. Students learn to give optimum services to the patients, as well as to make them aware about the prevention and cure of diseases.
The Discipline of Social and Administrative Pharmacy (DSAP) at USM is committed to promote research in drug use problems in developing countries.13 At present more than fifty postgraduate students from more than ten developing countries are being guided by the faculty members in carrying out drug-related research in their countries as well as in Malaysia. The priority areas of research of DSAP are multidisciplinary and include pharmacoeconomics, pharmacoepidemiology/ pharmacovigilance, socio-behavioral aspects of health and pharmacy, pharmaceutical care, outcomes research, quality of life assessment, decision analysis, and pharmaceutical management and marketing. Additional domains of research include pharmaceutical public policy, pharmaceutical education, pharmacoinformatics and pharmaceutical anthropology.
Another striking example is the case of Ghana, where pharmacists are often the most easily accessible health professionals to give consultation on health problems14. The incorporation of a landmark health promotional module in pharmacy course in Kumasi, Ghana comprises of both classroom activity as well as outdoor field work. This field work component enables the student to prepare health promotional materials by visiting and observing their local population and thus identify and explore their local compromised resources. This module thus serves to prepare
Challenges for social pharmacy: A good example of how social pharmacy faces challenges can be gained from the recent review by Puspitasari et al 15 , which focused on counseling given to patients who purchase prescription medicines from community pharmacies. Their data showed that the nature of researchers’ relationships with the profession, measures to improve community pharmacy practices, the importance of learning from other disciplines, and the need to internationalize our discipline challenge social pharmacy research works. In addressing the role of a pharmacy, some authors16, 17 have previously suggested that pharmacists should have an increasing role in patient care and that patient counseling is one of the cornerstones of this new role. The very wide variation in counseling rates found by Puspitasari and the colleagues (8 to 80% of patients received verbal counseling) suggests that this new role is carried out more in some settings than others. Social pharmacy research had played and still continues to play an important role in documenting this practice variation. Based on these reports, one of the major challenges is how to improve the practice of those settings and practitioners who are currently lagging behind.
Clearly, researchers dealing with ‘social pharmacy’ and ‘pharmacy practice’ tread a delicate line. In order to accomplish the research findings of social pharmacy into practice the relationship of the social pharmacist with the practitioners must be close and positive enough that practitioners must listen to and involve themselves in the implementation of findings in the hope of improvements in pharmacy practice. In addition, researchers need to be independent enough so that they can identify the need for improvement, and advocate in the interest of public health. Non-pharmacists social pharmacy researchers face an additional set of challenges and pressures which mainly include their own recognition within social pharmacy.18
As pointed out by Puspitasari et al,15 studies on improvements in community pharmacy practice are urgently needed. Previous studies highlighted that motivated, innovative pharmacists can provide effective secondary services, which are undoubtedly important; 19, 20 however, interventional research studies in order to assess or improve the performance of the ‘present’ pharmacist or pharmacy assistants are the need of time. Substantial information on how to improve present pharmacy practice exists in other professions also, and this can be instrumental in bringing changes in social pharmacy.
For instance, the Cochrane Effective Practice and Organization of Care Review Group have a long-term experience in dealing with practice improvement.21,22 Overall, the major outcome of these works is the passive dissemination of information, i.e. written materials and lectures are not effective in changing practice. However, reminders and interactive educational meetings are effective strategies as they promote discussion and educational outreach. Multifaceted interventions tend to be more effective than single ones. Reviews of evidence on specific issues, such as interventions aimed at improving the use of antimicrobials have produced similar findings.23
Strategies for improving practice are a key concern in most health professions such as pharmacy, medicine, nursing, but are dealt with separately in each profession. Although differences may exist between professions and countries, practice researchers in each discipline can learn considerably by interacting with each other. Social pharmacy research is done in few developed countries: USA, UK, the Netherlands, Finland, Australia, and Canada. According to Ryan et al,11 social pharmacy is taught in seventeen countries those above plus four more Scandinavian countries, more European countries, New Zealand, and very few countries in the developing world. Thus the dissemination of social pharmacy research still remains a major challenge, especially in developing countries where there are documented problems in the purchase, distribution, and use of medicines. To overcome these problems, one possibility would be to establish strategic alliances with countries already working in these areas or with organizations such as the World Health Organization and Management Sciences for Health (www.msh.org) that have expertise, experience, and commitment to improve access to and use of medicines in developing countries.
Conclusion: Social pharmacy program can be approached globally through various course types and formats. These courses make the students expose and explore societal concerns and health inequalities in their respective resource-deficient settings. Practical application of some components makes the student aware of the impact of sociodemographic on health and illness and inculcates sound understanding of the culture as well as social and moral obligations towards society in general and individual in particular.
With regard to Universiti Sains Malaysia, constructive discussion to incorporate social-behavioral concepts and principles into other courses throughout the pharmacy curriculum can make the future prospects bright for social pharmacy. Students should be taught social pharmacy concepts and principles in every subject as pharmacoeconomics, pharmacoepidemiology, socio-behavioral aspects of health and ethical issues could and should be discussed during lectures and prior to clinical rotations. This shift in pharmacy practice from a product- to an information- and patient-based orientation affects patient knowledge, and increases liability and health care costs, which continue to place pharmacists in a position of great responsibility.
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