Perception Of Nepalese Community Pharmacists Towards Patient Counseling And Continuing Pharmacy Education Program: A Multicentric Study
Correspondence Address :
Arjun Poudel (B.Pharma), Hospital and Clinical Pharmacist Drug Information and Pharmacovigilance Center, Dept. of Hospital and Clinical Pharmacy Manipal Teaching Hospital, Pokhara, Nepal.E.mail:email@example.com,P:+977 61 526420,Mobile:+977 98460 33006
Objective: To study the perception of community pharmacists towards patient counseling and continuing pharmacy education programs.
Methods: A semi structured questionnaire was developed by the researchers. The research was carried out in six major cities in Nepal, namely Kathmandu, Pokhara, Biratanagar, Birgunj, Nepalgunj and Bhairahawa. The filled questionnaires were analyzed as per the study objectives.
Results: Altogether, 60 community pharmacists were included. Among them, 88.33% (n=53) were male. More than 50 patients visit most of the community pharmacies [36.67% (n=22)] daily. Most of the dispensers [56.67% (n=34)] took 1-5 minutes for dispensing a prescription. In most of the pharmacies [56.67% (n=34)], there were 2-5 dispensers and the qualification of a majority of dispensers were orientation training. Most of them [56.67% (n=340] believed that counseling was necessary as it was their own duty, but however, 48.33% (n=29) said that it was necessary to increase patient compliance. Our finding suggests that 83.33% (n=50) of retailers were facing some problems during patient counseling. All participants were interested in the continuing pharmacy education program.
Conclusion: On the whole, the community pharmacists had a positive response towards patient counseling. Our findings suggest the need for continuing pharmacy education programs in Nepal to strengthen the concept of patient counseling.
Community pharmacy,Community pharmacist,Patient counseling,Continuing pharmacy education,Nepal
Across the world, every day, millions of people visit community pharmacies for their health care needs(1). Pharmacists are placed at the first point of contact in the health care system due to their free accessibility and friendly approach. In contrary to this scenario, many general practitioners do not regard pharmacists as potential members of the health care team(1). In recent times, much focus was laid on the new roles of the community pharmacists in developed countries like Australia, United States of America and the United Kingdom. The role of the pharmacist, especially as a health adviser, is highly esteemed and acknowledged by general practitioners in these countries(1).
The need and potential for counseling the patients regarding their drug therapy has been an important part of the pharmacy practice and pharmaceutical care. It has been the responsibility of the pharmacist to counsel the patients before dispensing the medication(2). Counseling not only enhances compliance, but also reduces complications due to non-compliance to treatment(3). Pharmacists are trying to move away from a drug-focused approach to a patient oriented approach according to the patientâ€™s needs, with the aim of achieving better outcomes from drug therapies(4). This requires close co-operation between pharmacists and other health care professionals, especially physicians, and requires knowledge and skills extending beyond the product knowledge about medicines(5).
Despite the beneficial role of community pharmacists, not much research focusing on their roles and responsibilities have been conducted in developing countries like Nepal. According to a study conducted in Nepal, self medication and non-doctor prescription were the common drug use problems there (6). In the same scenario, people without academic qualifications in field of pharmacy were allowed to run pharmacies and dispense medicines in Nepal (7). A study conducted in the capital city of Nepal demonstrated that unauthorized dispensing is clearly problematic, although the legislation in Nepal approves a medical prescription for the purchase of antibiotics(8). Drug retailers do not have adequate understanding about the disease process in question, in order to justify their sale of those antibiotics. More exhaustive efforts to educate drug retailers on their role in dispensing, along with increased enforcement of existing regulations, must be followed in Nepal (8). Therefore, there is a greater need to advocate and conduct research concerning long term health promotion and public education through the profession of pharmacy (9). In order to improve the professional roles of pharmacists in Nepal, there is a need for training the community pharmacists towards patient counseling. Evaluating the current perception of the community pharmacists can be useful to initiate appropriate interventions. Hence, the present study was undertaken with the following objectives.
The objectives of the study were
1. To study the demographic details of the community pharmacists
2. To study the sources of drug information used by the community pharmacists
3. To explore the community pharmacistâ€™s perceptions towards patient counseling and to identify the major barriers for effective counseling
4. To evaluate the community pharmacistâ€™s perception towards continuing pharmacy education programs.
A semi-structured questionnaire was formulated by the researchers (Appendix-1) (Table/Fig 1) as per the study objectives.
A prospective study was conducted between 15th January 2008 to 15th March 2008 (two months) in six major cities of Nepal (Biratanagar from the eastern region, Birgunj and Kathmandu from the central region, Bhairahawa and Pokhara from the western region and Nepalgunj from the mid-western region of Nepal). 10 randomly selected community pharmacies from each city were included in the study. Community pharmacists from the randomly selected pharmacies were interviewed with the formulated questionnaire.
The filled questionnaires were analyzed as per the study objectives using Microsoft Excel version 2003. The SPSS version 9.0 was used to carry out the descriptive statistics.
Altogether, 60 community pharmacists were included in this study. Among them, 88.33% (n=53) were males and 11.66% (n=7) were females.
Number of patients visiting community pharmacies (n=60)
Everyday, more than 50 patients visited 36.6% (n=22) of the community pharmacies, followed by 35-50 patients [26.6% (n=16)], 20-25 patients [20% (n=12)] and 10 -20 patients [16.6% (n=10)] to fill their prescriptions.
Dispensing time in community pharmacies (n=60)
More than half [56.6% (n=34)] of the dispensers took 1-5 minutes for dispensing a prescription, followed by 5-10 minutes [31.6% (n=19)]. Ten percentage (n=6) of them took more than 10 minutes, and 1% of them took less than 1 minute. In most of the pharmacies [56.67% (n=32)], there were 2-5 dispensers, followed by a single pharmacist in 33.33% (n=20) of pharmacies and only 13.33% (n=8) of pharmacies had more than 5 dispensers.
Qualification of the owners of community pharmacies (n=60)
The qualifications of the owners of the pharmacy were orientation training [83.33% (n=50)], followed by D. Pharm [8.33% (n=5)], B.Pharm [3.33% (n=2)] and other qualifications [5% (n=3)].
Problem faced during patient counseling (n=77)
Fifty four percent (n=41) of community pharmacists felt that lack of time was the major problem or barrier faced during patient counseling, followed by lack of knowledge 28% (n=21), and lack of patient interest 8% (n=6). Eight percentage (n=6) of them felt that they do not face any problems during patient counseling. Four percentage (n=3) had other problems.
Strategies suggested by dispensers to overcome the barriers (n=90)
The various strategies suggested by the dispenser to overcome the experienced barriers, are given in (Table/Fig 3).
Qualification of dispensers of community pharmacies (n=118)
As like the qualification of owners of the pharmacies, the qualifications of a majority of dispensers were orientation training [61% (n=72)] followed by other qualifications [30% (n=35)]. Six percentage (n=7) of the dispensers were D. Pharm holders and only 3% (n=4) had a B. Pharm degree.
Common sources of drug information available in the community pharmacies (n=108)
The commonest sources of drug information were, the Current Index of Medical Specialties (CIMS), a commonly used drug index from the neighboring country India [52% (n=56)], followed by Indian Drug Review [(IDR) 8.33% (n=9)] and Monthly Index of Medical Specialties (MIMS) [6.48% (n=7)].
The purpose of giving medication counseling (n=110)
There are different feelings among the dispensers regarding the counseling. Nearly one third [31% (n=34)] of them considered counseling as their duty. The views expressed by them regarding the purpose of counseling are given in (Table/Fig 2).
Frequently asked questions by the patients (n=210)
Patients asked several questions to the pharmacists while counseling. The details on frequently asked questions are given in (Table/Fig 4).
The dispenserâ€™s interest in the CPE program (n=116)
All the participants (community pharmacists or respondents) were interested in the Continuing pharmacy education (CPE) program and all of them felt that Continuing pharmacy education program would help in improving their knowledge. Furthermore, more number of dispensers were interested in the CPE program on common drugs [46% (n=53), followed by the CPE program on diseases [35% (n=41)], the CPE program on lifestyle [13% (n=15)] and others [6% (n=7)].
Surveys have found that community pharmacies are very often the first and only source of health care outside the home. In Nepal, the Department of Drug Administration (DDA), the national drug controlling authority under the Ministry of Health and Population in the year 1981, established a 45-hr course for drug retailers, which emphasized practical training as well as formal teaching on pharmacology, ethics, storage of drugs, and legal issues(10). For running a community pharmacy, the DDA has allowed pharmacists, assistant pharmacists or persons who had taken a 45- hr course or training, as capable for running a pharmacy (11). In our study, the qualifications of the majority [61% (n=72)] of dispensers and pharmacy owners were found to be orientation training,. The reason might be the less number of pharmacists and assistant pharmacists available in the country(12). Several studies have suggested that private drug sellers generally have little formal education or professional training (13), (14).
Our study found that on an average 50 patients visit most of the community pharmacies per day. Most of the dispensers took 1-5 minutes for dispensing a prescription. The drug utilization study in Nepal has suggested that the average dispensing time in the public sector is 86.1 seconds (15).
The major source of drug information available at community pharmacies was the Current Index of Medical Specialties (CIMS) [52% (n=56)]. Use of the British National Formulary (BNF) and the American Hospital Formulary Service (AHFS), were also found in some of the pharmacies. Most of dispensers in this study feel that providing counseling to the patient is the duty of the pharmacist. Many professional organizations like the Society of Hospital Pharmacists Australia (SHPA) and The American Society of Health-System Pharmacists (ASHP), have also mentioned that patient counseling is the responsibility of pharmacists (16),(17) The concept of patient counseling by pharmacists is new in Nepal. However, the Manipal Teaching Hospital (MTH) in Western Nepal had established a counseling center during the beginning of March 2004. The preliminary evaluation of the services provided by the center concluded that the medication counseling center can play a definite role in enhancing the patientâ€™s understanding about medications and the disease pattern, which in turn may improve patient compliance (18). Moreover, the newly drafted National Good Pharmacy Practice Guidelines also suggest that the pharmacist should provide counseling (19).
Lack of time was the major problem faced by the most of the dispensers, which was mainly due to the lack of manpower. However, a study conducted by Mishra et al. found language to be the major barrier for better counseling (18). As lack of time was the major problem faced by a majority of dispensers the solution suggested by them to overcome the barriers, was to increase the number of pharmacists. According to the dispensers, frequently asked questions by the patients were related to costs, doses and duration of the medication. The query related to cost was the most expected one, as the per capita income of the Nepalese population is very less. Similarly, the query related to dose and duration of the medication was also common, because it was always confusing when more than one drug was prescribed.
All participants were interested in the Continuing pharmacy education (CPE) program and felt that the Continuing pharmacy education program would help in improving their knowledge. One of the studies on the effect of a continuous community pharmacy practice also suggested that the program was beneficial for all students and participating pharmacists (20). Community pharmacists participated in patient counseling more frequently than institutional pharmacists, while institutional pharmacists participated in drug monitoring more frequently than community pharmacists. Community pharmacists had more direct access to patients and so the counseling was effective (21).
Our study found that community pharmacists in Nepal meet a larger number of patients and are interested in patient counseling. Their education level is low and thus, there is a need for CPE programs for them in order to upgrade their knowledge. They are at present, equipped with a limited number of drug information sources needed to provide patient counseling. There is a need for research in this area, involving more number of community pharmacists, so as to extrapolate our findings.
Though the study was successful in evaluating the perception of the Nepalese community pharmacists on patient counseling and CPE programs, it had a few limitations. The total numbers of pharmacists studied were low and hence, our findings may not reflect the perception of the entire community of pharmacists in Nepal.
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