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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Sudanese community pharmacy practice and its readiness for change to patient care Sumia S.E. Mohameda,c, Adil A. Mahmoudb and Abdulazim A. Alic a Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, bDepartment of Pharmaceutics, Faculty of Pharmacy, National University, Khartoum, Sudan and cDepartment of Pharmaceutics, College of Pharmacy and Health Sciences, Ajman University of Science and Technology
Network, Ajman, UAE
Keywords community pharmacy; medicines management; patient safety; pharmaceutical care; professional practice Correspondence Dr Sumia S.E. Mohamed, College of Pharmacy and Health Sciences, Ajman University of Science and Technology Network, Fujairah Campus, Fujairah, P.O. Box 2202, UAE. E-mail: [email protected] Received June 1, 2013 Accepted September 9, 2013 doi: 10.1111/ijpp.12156
Abstract Objectives This study aims to describe the current state of Sudanese community pharmacy practice and explore the capacity of existing community pharmacies to foster the change to pharmaceutical care (PC) and to assess attitude and knowledge of community pharmacists regarding PC and identify barriers. Methods A structured, self-administered, piloted questionnaire was distributed to the pharmacists in charge of 274, randomly selected, community pharmacies in Khartoum state. The questionnaire included six domains: demographic characteristics, organizational structure of community pharmacies, current activities of community pharmacists, their attitudes and knowledge regarding PC, and potential barriers. Attitude responses were measured by a 5-point Likert scale. Key findings Response rate was 67%. Community pharmacies are short on some tools that are deemed necessary for PC implementation, e.g. consultation areas. Community pharmacists provide mainly product-focused services with no or little PC activities. However, there is a highly positive attitude among the majority of respondents towards practice change to include PC (mean positive score ± standard deviation = 4.39 ± 0.73, frequency (%) = 89%). Many barriers to implementation of PC were identified, e.g. pharmacists’ clinical knowledge and lack of understanding of pharmacist’s new role. Conclusion Sudanese community pharmacists favour practice change to include PC. Successful implementation of PC requires substantial organizational and structural changes in community pharmacies, including provision of clinical knowledge, strengthening of clinical training and new practice standards. This change in practice could benefit from involvement of academia, governmental bodies and professional organizations working together for the pharmacy profession.
Introduction The roles and responsibilities of pharmacists have expanded significantly over the years to include more patient-centered roles.[1,2] The concept of pharmaceutical care (PC) has been developed to encompass this shift.[3] These roles are well recognized and implemented in several countries.[4–18] In many other countries, pharmacists’ responsibilities are generally confined to drug dispensing and limited medication advice, despite favourable views towards PC.[19–27] Generally, the provision of cognitive services in community pharmacies © 2014 Royal Pharmaceutical Society
assumes an existing capacity to integrate such services and pharmacists who are ready for contribution to patient care.[28,29] A number of studies have explored application of different principles for change in community pharmacy practice in an effort to encourage proper implementation of PC.[30–33] In Sudan, the government health system is a three-tiered network: Federal, State and Local. Primary health care was adopted as a main strategy for healthcare provision in 1976 International Journal of Pharmacy Practice 2014, ••, pp. ••–••
2
and re-emphasized in the National Comprehensive Strategy for Health in 1992 and in the 25-Year Strategic Health Plan, 2003–2027.[34] Tertiary level care is provided in teaching, specialized, and general hospitals, which are located in State capitals. Health services provision was free prior to the 1990s, but this is no longer the case. The majority of the population goes first to community pharmacists for medical advice and treatment. This puts great responsibility on the pharmacists. Sudanese community pharmacists can sometimes be the sole healthcare providers for many patients due to several reasons, e.g. their economical status, location of pharmacy and rural and conflict areas. Therefore, they can have a positive role on prevention and early detection of many diseases as well as solving drug-related problems. During the last five decades, the number of pharmacists has expanded, e.g. pre-registered pharmacists (graduates who have taken the pre-registration training course) increased by 305% between the year 2002 and 2009. The majority of pharmacists (70%) work in the community sector, and about half of these are in the capital Khartoum. The Federal Ministry of Health in Sudan is interested in promoting PC and expanding community pharmacists’ services.[35] This together with the increasing public demand for services is encouraging patientfocused practice.[36] Few studies have been conducted in Sudan that describe community pharmacist’s current roles in relation to PC practice.[37–39] The aim of this study was to describe the current state of Sudanese community pharmacy practice and assess the readiness of community pharmacists to provide PC.
Methods The study was approved by the Faculty of Pharmacy, University of Khartoum Ethical Research Committee.
Study design A cross-sectional survey was conducted from September to December 2009 in community pharmacies located in Khartoum state, the capital of Sudan, which is divided administratively into seven localities, with an area of 20 140 km2 and population of 6 182 401.
Study population and sampling procedure A sample-frame was the list of 874 community pharmacies (1700 community pharmacists) in Khartoum obtained from the Directorate of Pharmacy, Ministry of Health, Khartoum. The list was stratified by location, and a random sample of 274 community pharmacies selected for the study.Sample size was determined with 95% confidence interval, 5% precision and 0.5 anticipated proportions and adjusted by Cochran’s correc© 2014 Royal Pharmaceutical Society
Sudanese community pharmacy practice change
tion formula.[40] Randomization was achieved using Naing sample size calculator for prevalence studies.[41] The number of pharmacies chosen,in the seven localities was as follows: Khartoum: 94; Eastern Nile: 32; Bahari: 51; Omdurman: 60; Um bada: 13; Karari: 12; Jabal Awlia: 12.
Data collection A six-section questionnaire was drafted. Each section of the questionnaire was preceded by briefing of what is meant by the heading where that was relevant. Demographic data of community pharmacies and pharmacists was collected. The availability of 13 items, related to pharmacy facilities, e.g. computers, Internet, registers and consultation rooms, was investigated. Eighteen statements were used in a 5-point Likert-type scale to measure frequency of activities performed by community pharmacists when dispensing prescriptions. Attitude of community pharmacists towards pharmaceutical care was assessed by asking respondents to indicate their degree of agreement with 11 statements in a 5-point Likert-type scale. Negatively worded items were reversed for analysis. Community pharmacists continuing professional development (CPD) was assessed by asking the respondents to indicate the time they spend each month for updating their professional knowledge (5-points ranging from ‘nil’ to >10 h) and to choose, from eight choices, the most frequent source of information they use. In the last section of the questionnaire, the respondents were asked to indicate the degree of importance of 21 potential barriers to the implementation of PC in community pharmacies using a 5-point Likert-type scale. At the end of the questionnaire, pharmacists were invited to express comments regarding development of community pharmacy practice. Content and face validity of the questionnaire were established by comparison of the statements with the literature and the input received from a panel of five community pharmacists and academics of professional experience in the field. Wording, relevance and interpretation of the statements were discussed and clarity was assured. A pilot study was then conducted on 20 community pharmacists to revise and finalize the questionnaire. Internal consistency was used to assess reliability of the questionnaire as the statements were measured on an interval/ratio scale. Data collected from the pilot study were analysed using SPSS (SPSS Inc, Chicago, Illinois, USA), and a reliability coefficient (alpha) was determined. Participants from the pilot study were not included in the final sample. The researcher trained four pharmacists to collect data. They all distributed the questionnaires in person due to the unreliable postal system in Sudan. In the first visit, the questionnaire was given to the pharmacists in charge with a verbal and written explanation of its aim. Pharmacists could either complete the questionnaire on site while the researcher waited or asked to return it within 4 weeks. They were International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Sumia S.E. Mohamed et al.
Table 1
3
Demographic characteristic of community pharmacists and pharmacies
Community pharmacists Characteristics Gender Female Male Age (years) 21–30 31–40 41–50 51–60 ≥61 Education B. Pharm Diploma M Pharm. PhD Years in Service 20 years Time (h/month) spent by pharmacists in updating their knowledge Nil 1–2 2–6 6–10 >10
Percentage
62.5 37.5 73.4 14.1 6.3 4.7 1.6 93.8 1.6 4.7 0 7.8 67.2 18.8 6.3
17.4 23.8 36.5 17.4 4.9
reminded by weekly telephone calls, and the researchers returned to collect completed questionnaires at 2 and 4 weeks.
Data analysis A coding frame for each response in the questionnaire was made, and data were entered in Microsoft Excel, checked for accuracy then loaded in SPSS (version 11.5) for descriptive statistics. The responses in each section were subjected to frequency analysis. A Likert-type summation of the scores and the average score of each item in each section were calculated on a scale range from 1 to 5. Scores above the midpoint of 3 were considered to be positive responses, and their percent frequency distribution was calculated. Reliability and internal consistency of attitude scales were measured using Cronbach’s α.[42] Student’s t-test was used to measure possible differences between socio-demographic characteristics and Likert scale attitude responses. P-values
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Sudanese community pharmacy practice and its readiness for change to patient care Sumia S.E. Mohameda,c, Adil A. Mahmoudb and Abdulazim A. Alic a Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, bDepartment of Pharmaceutics, Faculty of Pharmacy, National University, Khartoum, Sudan and cDepartment of Pharmaceutics, College of Pharmacy and Health Sciences, Ajman University of Science and Technology
Network, Ajman, UAE
Keywords community pharmacy; medicines management; patient safety; pharmaceutical care; professional practice Correspondence Dr Sumia S.E. Mohamed, College of Pharmacy and Health Sciences, Ajman University of Science and Technology Network, Fujairah Campus, Fujairah, P.O. Box 2202, UAE. E-mail: [email protected] Received June 1, 2013 Accepted September 9, 2013 doi: 10.1111/ijpp.12156
Abstract Objectives This study aims to describe the current state of Sudanese community pharmacy practice and explore the capacity of existing community pharmacies to foster the change to pharmaceutical care (PC) and to assess attitude and knowledge of community pharmacists regarding PC and identify barriers. Methods A structured, self-administered, piloted questionnaire was distributed to the pharmacists in charge of 274, randomly selected, community pharmacies in Khartoum state. The questionnaire included six domains: demographic characteristics, organizational structure of community pharmacies, current activities of community pharmacists, their attitudes and knowledge regarding PC, and potential barriers. Attitude responses were measured by a 5-point Likert scale. Key findings Response rate was 67%. Community pharmacies are short on some tools that are deemed necessary for PC implementation, e.g. consultation areas. Community pharmacists provide mainly product-focused services with no or little PC activities. However, there is a highly positive attitude among the majority of respondents towards practice change to include PC (mean positive score ± standard deviation = 4.39 ± 0.73, frequency (%) = 89%). Many barriers to implementation of PC were identified, e.g. pharmacists’ clinical knowledge and lack of understanding of pharmacist’s new role. Conclusion Sudanese community pharmacists favour practice change to include PC. Successful implementation of PC requires substantial organizational and structural changes in community pharmacies, including provision of clinical knowledge, strengthening of clinical training and new practice standards. This change in practice could benefit from involvement of academia, governmental bodies and professional organizations working together for the pharmacy profession.
Introduction The roles and responsibilities of pharmacists have expanded significantly over the years to include more patient-centered roles.[1,2] The concept of pharmaceutical care (PC) has been developed to encompass this shift.[3] These roles are well recognized and implemented in several countries.[4–18] In many other countries, pharmacists’ responsibilities are generally confined to drug dispensing and limited medication advice, despite favourable views towards PC.[19–27] Generally, the provision of cognitive services in community pharmacies © 2014 Royal Pharmaceutical Society
assumes an existing capacity to integrate such services and pharmacists who are ready for contribution to patient care.[28,29] A number of studies have explored application of different principles for change in community pharmacy practice in an effort to encourage proper implementation of PC.[30–33] In Sudan, the government health system is a three-tiered network: Federal, State and Local. Primary health care was adopted as a main strategy for healthcare provision in 1976 International Journal of Pharmacy Practice 2014, ••, pp. ••–••
2
and re-emphasized in the National Comprehensive Strategy for Health in 1992 and in the 25-Year Strategic Health Plan, 2003–2027.[34] Tertiary level care is provided in teaching, specialized, and general hospitals, which are located in State capitals. Health services provision was free prior to the 1990s, but this is no longer the case. The majority of the population goes first to community pharmacists for medical advice and treatment. This puts great responsibility on the pharmacists. Sudanese community pharmacists can sometimes be the sole healthcare providers for many patients due to several reasons, e.g. their economical status, location of pharmacy and rural and conflict areas. Therefore, they can have a positive role on prevention and early detection of many diseases as well as solving drug-related problems. During the last five decades, the number of pharmacists has expanded, e.g. pre-registered pharmacists (graduates who have taken the pre-registration training course) increased by 305% between the year 2002 and 2009. The majority of pharmacists (70%) work in the community sector, and about half of these are in the capital Khartoum. The Federal Ministry of Health in Sudan is interested in promoting PC and expanding community pharmacists’ services.[35] This together with the increasing public demand for services is encouraging patientfocused practice.[36] Few studies have been conducted in Sudan that describe community pharmacist’s current roles in relation to PC practice.[37–39] The aim of this study was to describe the current state of Sudanese community pharmacy practice and assess the readiness of community pharmacists to provide PC.
Methods The study was approved by the Faculty of Pharmacy, University of Khartoum Ethical Research Committee.
Study design A cross-sectional survey was conducted from September to December 2009 in community pharmacies located in Khartoum state, the capital of Sudan, which is divided administratively into seven localities, with an area of 20 140 km2 and population of 6 182 401.
Study population and sampling procedure A sample-frame was the list of 874 community pharmacies (1700 community pharmacists) in Khartoum obtained from the Directorate of Pharmacy, Ministry of Health, Khartoum. The list was stratified by location, and a random sample of 274 community pharmacies selected for the study.Sample size was determined with 95% confidence interval, 5% precision and 0.5 anticipated proportions and adjusted by Cochran’s correc© 2014 Royal Pharmaceutical Society
Sudanese community pharmacy practice change
tion formula.[40] Randomization was achieved using Naing sample size calculator for prevalence studies.[41] The number of pharmacies chosen,in the seven localities was as follows: Khartoum: 94; Eastern Nile: 32; Bahari: 51; Omdurman: 60; Um bada: 13; Karari: 12; Jabal Awlia: 12.
Data collection A six-section questionnaire was drafted. Each section of the questionnaire was preceded by briefing of what is meant by the heading where that was relevant. Demographic data of community pharmacies and pharmacists was collected. The availability of 13 items, related to pharmacy facilities, e.g. computers, Internet, registers and consultation rooms, was investigated. Eighteen statements were used in a 5-point Likert-type scale to measure frequency of activities performed by community pharmacists when dispensing prescriptions. Attitude of community pharmacists towards pharmaceutical care was assessed by asking respondents to indicate their degree of agreement with 11 statements in a 5-point Likert-type scale. Negatively worded items were reversed for analysis. Community pharmacists continuing professional development (CPD) was assessed by asking the respondents to indicate the time they spend each month for updating their professional knowledge (5-points ranging from ‘nil’ to >10 h) and to choose, from eight choices, the most frequent source of information they use. In the last section of the questionnaire, the respondents were asked to indicate the degree of importance of 21 potential barriers to the implementation of PC in community pharmacies using a 5-point Likert-type scale. At the end of the questionnaire, pharmacists were invited to express comments regarding development of community pharmacy practice. Content and face validity of the questionnaire were established by comparison of the statements with the literature and the input received from a panel of five community pharmacists and academics of professional experience in the field. Wording, relevance and interpretation of the statements were discussed and clarity was assured. A pilot study was then conducted on 20 community pharmacists to revise and finalize the questionnaire. Internal consistency was used to assess reliability of the questionnaire as the statements were measured on an interval/ratio scale. Data collected from the pilot study were analysed using SPSS (SPSS Inc, Chicago, Illinois, USA), and a reliability coefficient (alpha) was determined. Participants from the pilot study were not included in the final sample. The researcher trained four pharmacists to collect data. They all distributed the questionnaires in person due to the unreliable postal system in Sudan. In the first visit, the questionnaire was given to the pharmacists in charge with a verbal and written explanation of its aim. Pharmacists could either complete the questionnaire on site while the researcher waited or asked to return it within 4 weeks. They were International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Sumia S.E. Mohamed et al.
Table 1
3
Demographic characteristic of community pharmacists and pharmacies
Community pharmacists Characteristics Gender Female Male Age (years) 21–30 31–40 41–50 51–60 ≥61 Education B. Pharm Diploma M Pharm. PhD Years in Service 20 years Time (h/month) spent by pharmacists in updating their knowledge Nil 1–2 2–6 6–10 >10
Percentage
62.5 37.5 73.4 14.1 6.3 4.7 1.6 93.8 1.6 4.7 0 7.8 67.2 18.8 6.3
17.4 23.8 36.5 17.4 4.9
reminded by weekly telephone calls, and the researchers returned to collect completed questionnaires at 2 and 4 weeks.
Data analysis A coding frame for each response in the questionnaire was made, and data were entered in Microsoft Excel, checked for accuracy then loaded in SPSS (version 11.5) for descriptive statistics. The responses in each section were subjected to frequency analysis. A Likert-type summation of the scores and the average score of each item in each section were calculated on a scale range from 1 to 5. Scores above the midpoint of 3 were considered to be positive responses, and their percent frequency distribution was calculated. Reliability and internal consistency of attitude scales were measured using Cronbach’s α.[42] Student’s t-test was used to measure possible differences between socio-demographic characteristics and Likert scale attitude responses. P-values
