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INTRODUCTION
Background Information
Across the world, every day, millions of people visit community pharmacies for their health care needs Pharmacy
professionals 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. In recent
times, much focus was laid on the new roles of the community pharmacists in developed countries like Australia, United States of
America (USA) 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 availability of and rational use of medicines are critical for a successful therapeutic outcome. Though rapid
developments in science & technology have led to easy understanding of etiology and pathophysiological basis of various diseases and
development of new molecules, many times clinicians fail to achieve the desired therapeutic goals. One of the major reasons for this
can be the patient’s non-compliance towards prescribed treatments.Counselling,one of the most important aspect of pharmaceutical
care, not only enhances compliance but also reduces complications resulting from non-adherence to treatment (2).
Nowadays, the profession of pharmacy revealed the growth of a new development that changed the concept of pharmacy
from a product oriented to a patient focused one, called clinical pharmacy. Now pharmacists are becoming indispensable in
monitoring drug therapy (3).
The clinical pharmacy grow with the concept of pharmaceutical care, the responsible provision of drug therapy for the
purpose of achieving definite outcomes which improves the patients quality of life. Patient counseling is an important means for
achieving pharmaceutical care. It is defined as providing medication related information orally or in written form to the patients or
their representatives on topics like direction for use, advise on side effects, precautions, storage, diet and life style modification (4).
Patient counseling is interactive in nature and involves a one to one interaction between the pharmacist and a patient and/or a
care giver. It should include an assessment of whether or not the information was received as intended and that the patient understands
how to use the information to improve the probability of positive therapeutic outcomes. (5, 17). The ultimate goal of patient
counseling is to provide information directed at encouraging safe and appropriate use of medicines, thereby enhancing the therapeutic
outcomes (6).
The amount and type of information provided to the patient will vary based on the patient need and practice setting. Ideally
the pharmacist should counsel patients on all new and refill prescription. If a pharmacist cannot counsel to this extent, it should be
defined which patient type or which medications pharmacist will routinely counsel the patient. This will vary depending on the
pharmacist client and may include patients receiving more than appropriate number of medication, patients known to have visual,
hearing or literature problem, pediatric and geriatric patients, those with poor understanding of language, those receiving a medication
for the first time, confused customers and careers, etc., patients using new drugs under active surveillance by Drug administration and
control authority(DACA), those drugs with special storage condition, and those with significant side effects, those with complicated
direction, those with additional warning labels and those which are alcohol contra indicated will always receive additional verbal or
written information (7). This study aims to asses’ attitudes and behaviors of practicing pharmacy professionals towards patient
counseling in awi zone, North West Ethiopia.
Statement of the problem
Pharmacists’ communicating with patients is an important way to avoid medication errors and to help patients understand the
intended effects as well as the side effects of their drugs. In fact, an estimated three quarters of pharmacists who attended continuing
education sessions presented by the state board for pharmacy indicated that errors have been prevented as a result of patient
counseling. Studies have shown that the professional expertise provided by a pharmacist during counseling can save money,
unnecessary hospitalization, and in some cases, prevent patient harm/death (8).
Rational drug use requires that patients receive medication appropriate to their medical needs, in doses that meet their own
individual requirements, for an adequate period of time and at the lowest cost to them and their community. Worldwide more than
50% of all medicines are prescribed, dispensed or sold inappropriately, while 50% of patients fail to take them correctly. Inappropriate
use of drugs waste resources often out of pocket payment by patient and result significant patient harm in terms of poor patient
outcomes and adverse drug reactions (9).
Though the diagnosis of a particular disease can be made more easily due to the development in science and technology,
patient counseling, the key factor in improving patient compliance and therapeutic success of drug therapy, needs further focus and
emphasis (10).
In order to improve patient health care and reduce the number of medication related errors, a greater emphasis must be placed
on pharmacists’ patient counseling, while pharmacists are working in situations where manpower cannot satisfy the demands of
increased prescription volume; time still needs to be spent on counseling patient in order to give better patient care (11).
In view of the above facts and in an attempt to improve pharmacists’ patient counseling, this study will assess the attitudes
and behaviors of practicing pharmacy professionals towards patient counseling.
Significance of the study
Dispensing with appropriate counseling is a critical part of drug use process. The way drugs are taken by the patient is often
influenced by the way drugs are dispensed and the type of information given during dispensing. Even if providing patients with
adequate and clear information on drugs is one of the professional responsibilities of pharmacists, it is under viewed by most
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developing countries (12). Hence the knowledge of the status of pharmacists regarding patient counseling will help finding the gaps
and accordingly the solutions.
This study will provide information showing the scope of problem of patient counseling in AWI-zone. This will help local
regulatory authorities to make plan and take interventions according to the result for best benefit of the patients. It will also make
pharmacy professionals to be aware of their professional responsibility of patient counseling and take action to ensure their
indispensability in health care provision. Furthermore, it will serve as base line information for those future researchers conducting a
similar study.
Objectives
General Objective
To assess the attitudes and behaviors of practicing pharmacy professionals towards patient counseling.
Specific Objectives
To determine the pharmacists perception towards patient counseling.
To assess the pharmacists awareness about their professional responsibility.
To identify factors influencing effective patient counseling
To identify the sources of drug information used by the pharmacists.
METHODS AND MATERIALS
Study area and period
The study was conducted in AWI-Zone towns where the center of the zone is located 450kms from Addis Ababa in North
West direction from January 15-25, 2013.
Study design
A cross sectional study was conducted using self administered semi structured questionnaire.
Source population
The source population was all pharmacy professionals working in Awi zone.
Study population
The study population was all pharmacy professionals working in rural drug vendors, drug stores, community pharmacies and
health institution drug dispensaries in AWI-zone.
Study variables
Independent variables
Age
Sex
Educational qualification
Working institution
Dependent variables
Patient counseling practice
Attitudes towards patient counseling
Data collection instruments
A semi structured questionnaire prepared by the investigator was used to collect the information on patient counseling. The
data was collected by the principal investigator.
Data quality control
Pretesting of the data collection format was done before the actual study. Also the data was cleared and checked every day
for completeness and consistency before data processing and analysis.
Data analysis and presentation
The data collected was cleared, summarized, categorized and processed. The processed data was analyzed, compiled and
organized and finally presented using tables and figures/graphs.
Ethical consideration
Formal letter was obtained from student research project, Jimma University and it was given to AWI-Zone health office for
cooperation.
Operational definitions
Patient counseling:-
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Is a one to one interaction between a pharmacist and a patient and/or a care giver and it involves providing medication related
information orally or in written form to the patient or their representatives on topics like direction for use, advise on side effects,
precautions, storage, diet and life style modification.
Drug: -
Any substance or mixtures of substances used in the diagnosis, treatment, mitigation or prevention of a disease/condition in
man or animal.
Dispensing: -
The process of preparing drugs and distributing them to their user with provision of appropriate information.
Drug retail outlets: -
places where drugs are dispensed to patients. It includes rural drug vender, drug store, community pharmacy and health
institution pharmacies.
RESULT
Socio demographic characteristics
A total of 48 respondents were participated in this study. Among them 37(77.08%) were males with work experience of 1 to
20 years and 11(22.92%) were females with work experience of 1 to 10 years. Majority of the respondents (93.75%) were in the age
range of 20 to 40 years. 3(6.25%) were B.pharm holders, 25(52.08%) were Druggists, 16 (33.33%) were Pharmacy technicians,
2(4.17%) each were Nurses and Health assistants. 37(77.08%) of the respondents work in the private sector and the remaining
11(22.92%) work in the government sector. Rural drug vendors were the major 19(39.58%) working institutions followed by drug
stores 18(37.5%) and health institution drug dispensaries 11 (22.92%). None of them have an identified place for patient counseling
(Table 1).
Table 1:- Socio demographic characteristics of pharmacy professionals in Awi Zone, Jan, 2013
Socio demographic characteristics No and percentage
Sex Male 37 (77.08)
Female 11 (22.92)
Age group <30 28 (58.33)
31-40 17 (35.42)
41-50 2 (4.17)
51-60 1 (2.08)
Educational qualification B.pharm 3 (6.25)
Druggist 25 (15.08)
Pharmacy technician 16 (33.33)
Nurse 2 (4.17)
Health assistant 2 (4.17)
Working sector Government 11 (22.92)
Private 37 (77.08)
Identified place for patient counseling Yes 0 (0)
No 48 (100)
Working Institution Drug store 18 (37.5)
Rural drug under 19 (39.58)
Health institution drug dispensaries 11 (22.92)
Pharmacy professionals’ attitude towards patient counseling
About half of the respondents (52.08%) have an attitude of both physicians (prescribes) and pharmacy professionals should
counsel patients about their medication. 39.58% of the respondents believe that patient counseling is pharmacy professionals
responsibility (Fig 1). About 45.83% and 41.67% of the respondents mentioned that they give counseling because of observed
improved patient compliance and personal interest respectively. Lack of knowledge and confidence was the first factor that prohibits
60.42% of the respondents from counseling their patient’s. High patient load, poor response from patients, absence of continuous
professional programs was other barriers assessed. Most of the respondents (70.83%) believe that patient counseling promote
relational use of drugs by patients (Table 3).
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52.80%
39.58%
8.33%
Physicians and
pharmacy professions
Pharmacy professionals
Physicians
Fig. 1:- Response of pharmacy professionals towards the responsible body for patient counseling in Awi zone, Jan, 2013.
Table 2:- Attitude of pharmacy professionals towards the responsible body for patient counseling on their medication based on
their educational qualification age and working institution in Awi zone, Jan 2013.
Factors that affect attitude Responsible body to counsel Total P-value
Pharmacy Physician Both
Educational
qualification
Pharmacist 3 0 0 3
Druggist 9 1 15 25
Pharmacy technician 7 2 7 16
Health assistant 0 1 1 2
Nurse 0 0 2 2
Total 19 4 25 48 0.114
Age-group
30 13 2 11 26
31-40 6 2 11 19
41-50 0 0 2 2
51-60 0 0 1 1
Total 19 4 25 48 0.609
Working institution
Drug store 6 0 2 8
Rural drug vendor 6 3 10 19
Health institution
drug dispensaries
7 1 3 11
Total 19 4 25 48 0.141
Table 3:- Attitude of pharmacy professionals towards patient counseling in Awi zone, Jan 2013.
Attitudes Response No and percentage
Reasons for offering patient
counseling
Give professional satisfaction 20 (41.67)
Observed increased sales 2 (4.17)
Improved patient compliance 22 (45.83)
To overcome competition 5 (10.42)
Professional duty 8 (16.67)
Patients go with satisfaction 15 (31.25)
Reasons for not counseling High patient load 17 (35.42)
Lack of knowledge and confidence 29 (60.42)
Lack of professional fee 4 (8.33)
Poor response from patient 5 (10.42)
Lack of continuous professional development
programs
16 (33.33)
Benefits the patient will get up on
counseling
Improve patient understanding 27 (56.25)
Promote rational use of drugs 34 (70.83)
Sources of information on drugs and attitudes on professional development programs
Leaflets were the major sources of drug information used by most of the respondents 43 (89.58%) followed by formularies
29(60.42%) and books 18(37.58%). All respondents were interested in attending continuing professional development programs and
most of the respondents were interested to learn more on common drugs 40(83.33%) and common diseases 28(58.33%).
Correspondence course is the preferred choice of continuous professional development program by 20(41.67%) of the respondents and
monthly seminars, weekend workshops, evening tutorials and online training were preferred by 15(31.25%), 13(27.08%), 1(2.08%)
and 2(4.17%) respectively (Table 4).
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Table 4:- Sources of drug information and attitudes of pharmacy professionals on professionals on professional development
programs in Awi zone, Jan 2013.
Variable Response No and percentage
Source of information on drugs
Formularies 29 (60.42)
Drug information bulletin 8 (16.67)
Books 18 (37.5)
Leaflets 43 (89.58)
Preferred choice of continuous
professionals development programs
Correspondence course 20 (41.67)
Monthly seminars 15 (31.25)
Weekend work shops 13 (27.08)
Evening tutorials 1 (2.08)
Online training 2 (4.17)
Interested areas to learn more Common diseases 28 (58.33)
Common drugs 40 (83.33)
Life styles 13 (27.08)
Patient medication counseling activities
Majority of the respondents 32(66.67%) do not ask symptoms when they are asked for OTC drugs. 43(89.58%) of the
respondents tell direction for use during OTC drug dispensing. But only 3(6.25%) and 14(29.17%) of the respondents tell common
adverse effects and correct storage conditions. From patient conditions 34(68.75%) of the respondents give special concern to
pregnant women. From disease conditions, special concern was given for hypertension by 41(85.42%) of the respondents and least
concern 8(16.67%) was given for epilepsy. While all of the respondents tell dose of drug and frequency of administration, only
36(75%) and 27(56.25%) of the respondents tell route of administration and proper storage conditions respectively (Table 5).
Table 5:- Patient medication counseling activities provided by pharmacy professionals in Awi zone, Jan 2013.
Counseling Response No and percentage
Information given during OTC dispensing Common adverse effects 3 (6.25)
Correct storage 14 (29.17)
Expected outcomes of therapy 4 (8.33)
Direction for use 43 (89.58)
Patient conditions given special attention Pregnant 34 (68.75)
Child/elder patients 24 (50.0)
Visual/hearing problematic patients 10 (20.83)
Patients taking multiple medicine 22 (45.83)
Disease conditions given special attention Asthma 19 (39.58)
Diabetes mellitus 28 (58.33)
Epilepsy 8 (16.67)
Hypertension 41 (85.42)
Tuberculosis 31 (64.58)
Basic information provided by pharmacy
professionals
Name of drug 6 (12.5)
Route of administration 36 (75.0)
Dose of drug 48 (100)
Frequency of administration 48 (100)
Proper storage condition 27 (56.25)
Special direction and precautions for preparation,
administration and use by the patient 34 (70.83)
Common adverse effects or interactions and therapeutic contraindications that may be
encountered and the 13 (27.08)
action required if they occur
Action to be taken in the event of a missed dose 15(31.25)
DISCUSSION
Counseling at the point of delivery in the pharmacy is an opportunity in which pharmacists can significantly improve
medication safety and patient compliance. Pharmacists can help patients to avoid medication misshapes and latent error at home by
providing them tips on medication safety (7).
Pharmacists must be very clear on what important duties they carry out on behalf of their patient. Many professional
organizations like International Pharmaceutical Society of Australia and Royal Pharmaceutical Society of Great Britain stress that
patient counseling is pharmacists’ responsibility (12). In this study, a significant number of participants (52.08%) respond that patient
counseling is a shared responsibility of both pharmacy professionals and physicians (prescribes). Only 39.58% of the participants
respond that patient medication counseling is pharmacy professionals’ responsibility. In a study conducted in India, respondents from
Karnataka opined that patient counseling is a shared responsibility of both physicians and pharmacists, where as respondents from
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Karalla mention that patient counseling is pharmacists’ responsibility (9). Considering patient counseling as a shared responsibility in
this study may be due to the respondents may not take any course about patient counseling on their professional training since
pharmacy schools in Ethiopia have no course on patient counseling and pharmacists’ communication with other professionals. In the
India, study age and professional education have shown influence on the response. In this study the influence of educational
qualification and age was insignificant (P = 0.14 and 0.609 respectively).
Lack of knowledge and confidence, high patient load, lack of professional fee, patient factors and lack of continuous
professional development programs were barriers to patient counseling in 60.42%, 35.42%, 8.33%, 10.42% and 33.33% of the
respondents respectively. In a study conducted in India, barriers to counseling were also lack of knowledge, non legalization of patient
counseling and doctor dispensing (12). In another study conducted in USA, busyness reduced the odds of any pharmacist talk, oral
information given and assessment of understanding (13). Factors in this study are similar with others except patient factors that
include patients don’t need much talk with the pharmacy professional is different from the study conducted in USA. This may be due
to less development of pharmacy practice in Ethiopia in which the community doesn’t understand the need for drug information and
may also be the community considers pharmacists as traders rather than professionals, as like in India.
The main source of drug information used by the respondents was inserted package leaflets (by 89.58% of the respondents).
But WHO prohibit use of leaflets as source of drug information and promote use of drug information bulletins due to leaflets contain
manipulated information about a particular drug as they are prepared by drug manufacturing companies and thus are subjected to bias
(14). In this study high use of leaflets may be due to lack of up to date drug information.
All participants were interested in the continuing pharmacy education program and they felt that the continuing pharmacy
education would help in improving their knowledge of counseling. A study conducted in Nepal also suggested that CPE was beneficial
to increase knowledge of counseling of community pharmacists who had more direct access to patient and hence counseling (1).
To improve efforts that assist patients in making informed decisions regarding medications, current methods of giving
information such as patient counseling by pharmacists must be examined. In study conducted in England in ten community
pharmacies, while providing patient counseling on new prescriptions, all of the pharmacists discuss side effects and management
strategies (15). In this study only 6.25% of the respondents respond as they tell side effect of drugs. This big difference may be due to
in England pharmacists counsel patients in separate counseling room which creates a better condition to tell more information to
patients. But in this study all pharmacies do not have a separate room for patient counseling and pharmacist-patient communication is
through window or by standing in front which limits degree of communication. In addition to this patient factors and lack of
knowledge and up to date drug information were the possible reasons.
In this study most frequently given drug information were dose, route and frequency of administration (by 100%, 75%, and 100%
of the respondents respectively). In relation to this a research done on outpatient counseling in four referral hospitals of Addis Ababa
showed that, the most frequent type of drug information designed by the patient as well as offered by the pharmacists were frequency
of administration (84% on average) and route of administration (56%) (16).The difference may be due to relatively high patient load
in the four hospitals (on average 67 prescriptions were filled per hour).
CONCLUSION
Most of the respondents believe that patient counseling is a shared responsibility of both pharmacy professionals and
physicians. The respondents give less counseling activities beyond giving drug information on dose, frequency and route of
administration. During OTC-dispensing most of the respondents do not ask symptoms and do not give the required information and
are limited on telling direction for use. Lack of knowledge and confidence, high patient load, lack of professional fee and patient
factors were barriers of patient medication counseling.
Recommendation
Pharmacy schools in the country should include patient medication counseling as one course in their education curriculum.
Updated drug information and training should be frequently given to personnel involved on dispensing.
Further research should be done that include every part of Ethiopia for more significant data.
Acronyms
WHO: World Health organization
DACA: Drug Administration and control Authority
USA: Unites States of America
OTC: Over the Counter
ACKNOWLEDGMENT
We are very grateful to our college staff members for unreserved guidance and constructive suggestions and comments from
the stage of proposal development to this end. We would like to thank Jimma University for supporting the budget which required for
this research.
Finally our deepest gratitude goes to Awi zonal administration office, which helps and allows us in collecting and gathering
data from the hospital.
Funding: Jimma University
Conflict of interest: None declared
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Ethical Approval: The study was approved by the institutional Ethics committee.
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