Societal perspectives on community pharmacy services in West Bank - Palestine.

BACKGROUND: Understanding the public's view of professional competency is extremely important; however little has been reported on the public's perception of community pharmacists in Palestine.
OBJECTIVE: To determine the perception of Palestinian consumers of the community pharmacist and the services they offer.
METHODS: This project used the survey methodology administered by structured interviews to consumers who attended the 39 randomly selected pharmacies, in six main cities in Palestine. The questionnaire had range of structured questions covering: Consumers' patronage patterns, consumers' interaction with community pharmacists, consumers' views on how the pharmacist dealt with personal health issues, procedure with regard to handling private consultations.
RESULTS: Of 1,017 consumers approached, 790 consumers completed the questionnaire (77.7 %). Proximity to home and presence of knowledgeable pharmacist were the main reasons for patients to visit the same pharmacy. Physicians were identified as the preferred source of advice by 57.2% and pharmacists by 23.8%. Only 17% of respondents considered pharmacists as health professionals who know a lot about drugs and are concerned about and committed to caring for the public. In addition, 49% indicated that pharmacists spoke more quietly cross the counter during counseling and almost one third reported that the pharmacist used a private area within the pharmacy. The majority of respondents would be happy to receive different extended services in the community pharmacy like blood pressure monitoring.
CONCLUSIONS: Palestinian consumers have a positive overall perception of community pharmacists and the services they offer. Awareness should be created amongst the public about the role of pharmacist and the added value they can provide as health care professional. There is a need to consider privacy when giving patient counseling to increase user satisfaction.

Introduction

The West bank has a land area of 5640 km2 (including East Jerusalem), estimated population of 2,274,929 and the annual growth rate is 3.1% according to the official Palestinian census-2007.1 The number of community pharmacies in West-Bank is approximately eight hundred twenty which means that there is more than sufficient pharmacy provider to population ratio. The large number of functioning community pharmacies leads to high business competition and sometimes non-scientific practice. Community pharmacies in Palestine are private and licensed from the Ministry of Health (MOH) based on the pharmacy practice law conditions which include that the owner must be a registered pharmacist.2

Many publications described the pharmacy practice in specific countries as in Britain, Japan, and Portugal.3,4,5,6 Unfortunately, in the Palestinian territories pharmacy practice is not up to current standards in clinical pharmacy due to lack of clinical training, drug information resources and continuing education programs.7,8

Community pharmacy holds a number of benefits as a setting for public health activities. With extended opening hours and no appointment needed for advice, community pharmacy can be more accessible than other settings. Although there is clear potential for pharmacy to contribute

in a unique way to public health, changes in the behavior of both pharmacists and pharmacy customers are likely to be required for the service to be successful.9 In Palestine, many patients seek medical advice directly from the community pharmacies because they are faster and less expensive than the physician's. This is even more obvious in urban areas where medical services are less developed. As such, the role of community pharmacies in Palestine appears to be similar to that of other countries in that they play a major and important role in public and community health issues and in the management of a wide range of illnesses.2,10

Understanding the public's view of professional pharmacist competency is extremely important. Fortunately, available information seems to indicate that people respect and appreciate pharmacists in different countries.11,12,13,14 Many studies have investigated public use of, and attitudes about, community pharmacy in Canada, Jordan, Estonia, UK, Malta, Saudi Arabia, and other countries.15,16,17 The main reason for using a particular pharmacy in Saudi Arabia was the presence of trusted and qualified pharmacists, while the most commonly offered reason in Jordan was the proximity of the pharmacy to the individual's home.15,16 More than 60% of customers in Malta and in Jordan stated that their primary reason for seeking pharmacist advice rather than physician was when the condition was not serious enough to visit the physician.15,17 In comparison, most Canadian customers considered pharmacists as health care professionals even if they practiced in retail settings. When evaluating pharmacists, one important aspect to consider is how things are said during the counseling process. This moves the focus from the content of the encounter (facts, clarifications and recommendations) to the subtleties of the communicative process (questioning style, and listening skills, conversation speed). Unfortunately, minimal information is available in these areas.

In their strategic plan, the Palestinian Ministry of Health has the intention to implement pharmaceutical care services to help improve patients' health outcomes. This will ultimately lead to improvement in the drug use process. If the transition to pharmaceutical care is to occur successfully, Palestinian's community pharmacists should make considerable efforts to raise public expectations about their professional role and must demonstrate the potential benefits of extending pharmacists' contributions to the medication use process beyond ensuring accurate dispensing and providing basic counseling.18 Knowledge about public utilization of community pharmacy services can assist pharmacists in meeting customers' needs, in enhancing the quality of their services and improving customer satisfaction.

To our knowledge consumers' perceptions of and attitude towards community pharmacy services have not been evaluated in Palestine. There is a great need to generate awareness in public as well as pharmacy personnel about their roles and responsibilities in the community healthcare system. Hence, the present study is aimed to assess the role of pharmacists in community healthcare service and consumer’s expectation and perception about them and their health services provided to the community.

Methods

Study sites

According to the Palestinian pharmaceutical association in 2010 more than 800 community pharmacies were registered in the West Bank. Eighty pharmacies (a 10 percent sample) were randomly selected by site from the register and contacted. Ultimately 39 pharmacies ended up participating in the study. An explanation of the study rationale was provided and pharmacists were assured that the survey would measure general attitudes towards community pharmacy practice. The consent of the pharmacy management was obtained to approach customers when they entered the pharmacy to ask them to complete the questionnaire while they were on the premises. The study was approved by ethical committee at Faculty of Pharmacy at Al-Quds University.

Questionnaire design

The survey questionnaire was developed from two similar studies conducted in the UK and Saudi Arabia.19,20 It was designed to measure consumers' current experience of pharmacy services and their opinion concerning possible future additional services. Pilot testing was conducted in 5 pharmacies to test the survey form, to revise and finalize the questionnaire. Following the pilot some questions were reworded, instructions on approaching the customers and completing the questionnaire were reviewed. The reliability of the instrument was assessed using Cronbach’s coefficient alpha, the internal consistency of the instrument was 0.60.15 The self completion questionnaire had 21 structured questions covering demographic data and questions on: Consumers' patronage patterns, consumers' interaction with community pharmacists, Consumers’ perception of the pharmacist as a healthcare provider, pharmacist accessibility and approachability, consumers' views on how the pharmacist dealt with personal health issues, and explanation offered by the pharmacist. Finally, five possible extended services were listed, and the consumers were asked to specify their preferences for extended services to be provided in community pharmacies (weight, height and temperature measurement or blood glucose monitoring or blood pressure monitoring or cholesterol level monitoring or patient medication record keeping). The consumers were also asked to select the statement was most representative current experience of pharmacy.

Data collection

Data collection took place between December 2009 and April 2010 with researchers collecting data simultaneously at the chosen cities (these included: Ramallah, Nablus, Hebron, Tulkarm Bethlehem and East Jerusalem). The questionnaire was administered to 1017 respondents in the 39 pharmacies over 5 month period. Consumers were approached on entering the pharmacies, the purpose of the study was explained for the consumers and they were invited to complete the questionnaire. Respondents were selected for inclusion by approaching every fifth person entering the pharmacy (every second person at less busy pharmacies). If respondents could not complete the questionnaire, the researcher offered to complete the survey form with them. The data was collected by three researchers (fifth year pharmacy students from Al-Quds University trained in interviewing skills and questionnaire administration). An assurance was given regarding the confidentiality of the data obtained. The researchers asked the prospective respondents if they had previous contact with community pharmacists and emphasized that the study was based on actual experience of community pharmacy. Data were collected and recorded over an eight hour period on one working day of the week for each pharmacy.

Data Analysis

The data were analyzed using the SPSS v18 database and analyzed using descriptive analysis. Categorical data were calculated as frequencies and percentages, and continuous data were calculated as means and standard deviations. The chi-square test was used to determine the significance of association between categorical variables. A p-value of 0.05 or less was considered significant.

Results

Sample characteristics

Thirty nine pharmacies agreed to participate in the study, twenty pharmacists refused, thirteen said that they did not have enough space and eight were closed. Of 1,017 consumers approached, 790 consumers agreed and completed the questionnaire (77.7%), 159 consumers refused and 68 consumers were excluded because of their questionnaires were incomplete. The demographic characteristics of respondents in the study sample are shown in (Table 1). Fifty-nine per cent were female. The mean age was 34 (SD=10.4) years. The majority of respondents were young adults (74.8%) while elderly participants (>60 years) constituted 2.4% of the sample.

Table 1

Respondents characteristics (n=790)

Demographic characteristics	Study n (%)	% National Census*
Age
18-25 years	248 (31.4)	40.3
26-40 years	343 (43.4)
40-60 years	180(22.8)	14.2
= 60 years	19 (2.4)	4.9
Gender
Male	323 (40.9)	50.7
Female	467 (59.1)	49.3
Place
Ramallah	186 (23.5)
Nablus	255 (32.3)	13.9
Bethlehem	87 (11.0)	7.5
Hebron	149 (18.9)	23.6
East Jerusalem	77 (9.7)	14.9
Tulkarm	36 (4.6)	6.9
Insurance
Government	579 (73.3)	43.2
Private **	140 (17,7)	25.8
Non	71 (9.0)	31.0
Marital Status
Married	489 (61.9)	53.4
Single	292 (36.9)	44.2
Other	9 (1.1)	2.4
Education
Primary	28 (3.5)	18.6
Elementary	80 (10.1)	20.5
Secondary	223(28.2)	10.4
College/university	445(56.3)	16.3
Other	14 (1.8)	34.2
Work
Employed	410 (51.9)	NA
Business /self-employed	103 (13.0)	NA
Student	166 (21.0)	NA
Housewife	88 (11.1)	NA
Retired	14 (1.8)	NA
Others	10 (1.2)	NA
*Palestinian Central Bureau of Statistics **Include UNRWA NA, Not Available

Pharmacy patronage and selection

Data analysis indicates that the primary reason for visiting a pharmacy was to obtain prescription medicines (55.3%) whilst (42%) of interviewees reported visiting a pharmacy primarily to purchase ove-the-counter (OTC) products. Only (28.0%) of all participants reported visiting a pharmacy to treat minor health problem (Table 2). No significant differences were found between males and females with regard to the main reason to visit the community pharmacy. However, participants that are older than 60 years were more likely to visit the pharmacy to purchase medications without prescription than the younger age group (71.4% vs. 48.3%; p<0.05)

Table 2

Type of advice requested from the pharmacists (n=970)*

Type of advice	Respondents (%)
Prescription medication	437 (55.3)
OTC medication	332 (42.0)
Minor health problem	221 (27.9)
First aid	150 (19.0)
Baby need	87 (11.0)
General	40 (5.1)
others	72 (9.1)
*Multiple answers; the percentage sum to be more than 100%

More than one third (38.8%) of respondents said that they always attended the same pharmacy; 49.1% said that they often or sometimes visited the same pharmacy. Moreover, as age increased so did loyalty to a particular pharmacy. Thus, approximately 52% of those age between 18-40 'always' or 'often' attended the same pharmacy, compared to 83.8% aged between 41 to 60 and 84.2% of the over 60 age group (p<0.05). There was no association between gender, education or occupation level and loyalty to a particular pharmacy.

The main reasons for using a particular pharmacy is proximity of the pharmacy to the individual's home or work (31.8%), wide range of products/services (24.5%), convenient working hours (19.0%) and efficient and prompt services (13.2%). Other reasons included presence of trusted and qualified pharmacist and friendly staff (Table 2). There was a significant difference with gender; with male participants reporting proximity to home (38.2% male vs. 27.5% female) and convenient working hours (25.3% male vs. 14.5% female) as being the main reasons for visiting the same pharmacy, whilst those female respondents seemed to be more influenced by the provision of wide range of products in a pharmacy (29.3% female vs. 17.6% male; p=0.003).

Consumers' perception of the pharmacist as a healthcare provider

For consultation about health problems, physicians were identified as the preferred source of advice by 57.2% and pharmacists by 23.8%. Other sources of information included family members (9.1%) and internet (5.8%). Consumers' perception of pharmacists by age, gender and educational levels were not significantly different.

Most participants perceived community pharmacists as health professionals who are interested in both health and business matters. One third of respondents (33.9%) perceived community pharmacists to be more concerned with the business side of things than health matters, while 28.1% perceived community pharmacists as health professionals with good balance between health and business matters (Table 3). There were no significant differences in consumers' views of community pharmacist by age, gender or educational levels.

Table 3

Respondents characteristics (n=790)

``I think that pharmacists . . .’’	% respondents n (790)
Are primarily business people who are more concerned with making money than with the health of their patients	110 (13.9)
Are interested in both health and business matters, but tend to be more concerned with the business side of things than health matters	268 (33.9)
Have a good balance between health and business matters	222 (28.1)
Are more concerned with the health of patients than with business side of their work	56 (7.1)
Are health professionals who know a lot about drugs and are concerned about and committed to caring for the public	134 (17.0)

Pharmacist accessibility and approachability

Two third of respondents (66.8%) reported feeling at ease about asking the pharmacist for advice as opposed to 19.0% that reported feeling awkward and uncomfortable about asking for pharmacist advice. Of the remaining respondents, 7.1% said the pharmacy premises prevented their inquiry and 7.1% said they did not get a chance to seek pharmacist advice. Consumers over 40 years were significantly more likely to report feeling at ease about asking the pharmacist for advice (80.1%) compared with younger consumers (61.1%; p=0.001).

The majority (72.9%) of customers that visited community pharmacies to dispense prescriptions reported that they received advice about their medications only when they asked for it. Only 11.1% of the respondents reported that pharmacists encouraged consumers to ask questions and express any concerns on dispensing.

Handling consultations and response to problems

In relation how the patient's problems were handled, 62% of respondents reported that the pharmacists did enter into some degree in discussion with the patients. While 19.1 % said that their pharmacists does not allow any time for discussion (Table 4). In dealing with private or personal matters, almost fifty percent of the respondents indicated that pharmacists spoke more quietly across the counter and 11.1% reported that the pharmacist used a private area within the pharmacy when discussing personal or private matters. The majority of respondents (62.8%) reported that the pharmacist was willing to discuss their health problems and tried to understand their feelings. Whilst only 9.1% percent of respondents indicated that the pharmacist did not do so (Table 4). More consumers with a higher educational level reported that pharmacists are not keen to deal with feelings, concern and anxieties compared to consumers with lower educational level.

Table 4

Handling consultations and response to problems (% respondents; n=790)

‘‘When I go to the pharmacy with a problem the pharmacist. . . ’’
Does not allow any time for discussion	150 (19.0)
Gives me a short time but does not appear to be listening and there are many interruptions	150 (19.0)
Gives me enough time but does not listen to me carefully	222 (28.1)
Gives me enough time to discuss my problem and listens to me carefully	268 (33.9)
‘‘When I raise a personal/private matter the pharmacist . . .’’
Continues to speak at his normal levels as if totally insensitive to my need for privacy	47 (5.9)
Speaks more quietly across the counter	393 (49.7)
Uses a more private area within the pharmacy	88 (11.1)
I have not raised such matters	262 (33.2)
‘‘When I raise my health problem, the pharmacist . . .’’
Does not discuss any physical health problem or my feelings at all	72 (9.1)
Only discusses issues about my physical health problem but is not keen to deal with my feeling	222(28.1)
Will discuss issues related to any physical health problems and may sometimes ask about how I am feeling	289(36.6)
Is willing to discuss fully my physical health problem and my feelings, concerns and anxieties	207(26.2)

New services

Consumers were asked if they would be happy to receive different extended services in the community pharmacy. Most of the proposed extended services appear to be in high demand with 72.9% requesting weight, height and temperature measurement, 87.5% blood glucose monitoring, 66.8% blood pressure monitoring and 59.1% cholesterol level monitoring. Only 35.3% agreed to keep patient medication record (PMR) at the community pharmacy (Table 5). Significantly more females (44.9%) elected not to keep PMRs at community pharmacy compared with male consumers (23.1%; p=0.001).

Table 5

Consumers' preference for new services

Types of service n (%)	Yes	No	Don’t know
Measuring weight, height and temperature	576 (72.9)	88 (11.1)	126 (15.9)
Monitoring glucose levels	691(87.5)	64 (8.1)	35 (4.4)
Monitoring blood pressure	528 (66.8)	134 (17.0)	128 (16.2)
Monitoring cholesterol levels	467 (59.1)	102 (12.9)	221 (28.0)
Patient medication record	279 (35.3)	289 (36.6)	222 (28.1)

Discussion

Overall, the study respondents had positive attitudes toward the community pharmacist in the West Bank. Two third of respondents (66.8%) reported feeling at ease about asking the pharmacist for advice as opposed to 19.0 % that reported feeling awkward and uncomfortable about asking for pharmacist advice.

The findings showed a trend towards loyalty to a particular pharmacy by older consumers. These findings are consistent with earlier studies which have shown a trend towards an increase in consumer loyalty to a particular pharmacy as the consumer's age increased.19,20,21

Fifty seven percent identified physicians as the preferred source of health advice, while less than one quarter (23.8%) recommended pharmacists. The majority of respondents who did not make pharmacists their first choice to answer health inquiries may have had unsuccessful experiences in seeking such information from pharmacists or may be unaware that the pharmacist has the knowledge to answer health or medication questions. Some members of the public are undoubtedly willing to take up the advice and services offered. Patients most likely to seek advice are ones that are already regular users of pharmacy service for prescribed medicine. This may be because this group of people visit the same pharmacy and hence establish a relationship with their pharmacist than younger group of people, who do not show as much patronage to individual pharmacy.22 Convenience of location, good and efficient services and convenient working hours will help in developing more general satisfaction in community pharmacy services.

In a major UK study involving interviews with 592 community pharmacy service users, the preferred source of advice for staying healthy' was the physician (77%). Only a small percentage (8%) elected pharmacist as the preferred source of advice.23 Interviews with 600 customers in 30 community pharmacies in Scotland24 showed a clear distinction in the proportion willing to seek advice on medicine-related topics. When asked why they were not willing to discuss health topics with the pharmacist, 22% said either that they did not see this as part of the role of the community pharmacist or that it had not occurred to them that pharmacists could provide such advice. A Swedish study investigated the views and expectations of customers regarding health information. Only 30% of the respondents expected to get information on general health issues from the pharmacy.25 In spite of this, 76% of the respondents believed that the pharmacies could influence people's willingness to improve their health.

The results of this study indicates that unless and otherwise asked by the customers, pharmacist do not deliver explanations on their own. This may indicate that Palestinian community pharmacists are dispensing prescription medications presuming that the patients are already well informed about their health conditions and about their medications. However, patient consultation by the community pharmacist when dispensing a prescription is of vital importance for the pharmacist’s image and consumer satisfaction.

Awareness should be created among the public to demand an explanation about the dispensed drugs. It should be noted, however, that consumers may not always freely divulge information. Lamb and Cantrill26 interviewed 50 patients with asthma in an outpatient clinic in England. The objective was to determine how asthmatic patients manage minor ailments such as colds, headaches, and joint pain. Of the 48 patients who had purchased OTC medicines, only 13 informed a pharmacist that they were asthmatic. It can be concluded that when OTC encounters are evaluated, it appears that pharmacists are most frequently implicated in failing to ascertain important clinical information from patients. This can be due to lack of knowledge or communication skill of the pharmacist. It is possible that pharmacist skills may be improved if they attend continuing education program in order to enhance the level of formal professional education.27,28

Problems in pharmacist consultation can occur when patients and pharmacists have different expectations about the pharmacist's role and pharmacy services. One study has demonstrated that patients who have low expectations for consultation with a pharmacist receive less consultation than patients with higher expectations. In addition, if patients with low role orientations do receive any consultation they might not comply with it, severing the effects that pharmacy services can have on patient outcomes.29 Therefore, the advancement of community pharmacy practice through the adoption of the pharmaceutical care model needs understanding of patients' perceptions of the pharmacist's role as well as of their utilization and views of community pharmacy services.

The respondents emphasized the view that pharmacists should devote more time to patient consultation and address their psychosocial as well as physical need. This is important, since patient satisfaction has been consistently found to be linked to ability and willingness of healthcare practitioner to deal with their emotional concerns.19 Moreover, almost half of the consumers (49.7%) reported that the community pharmacist spoke more quietly across the counter when discussing private matters. These findings indicate the willingness of the pharmacist to consult with their customers and help them get the most out of their medicines.

Results of the present study of community pharmacy users, suggests that the public may have a different view of what constitutes appropriate facilities to enable private discussions. Only 11.1% had found and used private area for discussion. If pharmacies are to meet the needs of patients, this is a crucial element in the service they must offer. This appears consistent with a study of the health information needs of people buying aspirin for heart disease prevention or receiving it on prescription. Kinghorn30 concluded that "pharmacy premises were considered by some to lack privacy".

The majority of women participating in surveys, interviews and focus groups in the USA, Canada and England reported that they were satisfied with their consultation with the pharmacist.31,32,33,34 Over 80% of women surveyed in the USA and Canada were satisfied with the amount of privacy in the pharmacy.33,34 However, several studies showed that some pharmacy users expressed concerns about the level of privacy in community pharmacies. They also indicated that a pharmacy might be selected, or deselected, depending on the facilities for private discussion. This was found to be particularly important in research on consumer attitudes to pharmacy advice on contraception, sexual health and woman health.14,35,36,37

With respect to new (extended) services, consumers responded positively regarding possible new services to be provided in community pharmacy. These services may include weight, height and temperature measurement, monitoring blood glucose and monitoring blood pressure and cholesterol levels. Interestingly, blood pressure measurement was the most demanded service (87.5%). An initiative is currently underway to attempt to include these services in pharmaceutical care practice in community pharmacies in the Palestinian territories. It is noteworthy, that patients appeared receptive to most pharmacy-based disease management programs in which the pharmacist provides care to consumers with diabetes, asthma, hypertension or hyperlipidemia indicates that such programs could lead to improved patient care and outcomes.38,39,40,41

Findings of the present study appear to show a different trend from an interview-based survey of 1000 members of the public was conducted in Northern Ireland.14 The survey intended to examine attitudes towards current and future roles of community pharmacists in health promotion and health screening. Just over half the respondents said they would be willing to pay for cholesterol testing and blood pressure measurement in the pharmacy, with older patients more likely to do so. Around 40% said they would be willing to make an appointment with their pharmacist for health promotion or screening.

There was general resistance to the idea of keeping PMRs in community pharmacies; particularly among female participants. Reasons for this may include social consideration in the Palestinian territories and lack of understanding of pharmacists' expertise and concerns regarding access to medical records.

The current study has got its own limitations. For example, the opinions expressed may not be representative of the larger population. Females were over-represented in the sample. In addition, younger respondents and those with higher educational levels were over-represented and the elderly were under-represented.

Conclusions

The present study indicates that patients most likely to seek pharmacist council and advice are ones that are already regular users of pharmacy service for prescribed medicine. Public awareness should be increased about the role of pharmacist and their level of knowledge and expertise. This may help increase the level of patient expectation for pharmacy services. Furthermore, it appears that patients are quite receptive to additional pharmacy services like blood pressure monitoring for example. Pharmacist need to improve their image as health care professional. Educators and professional bodies in the Palestinian territories should take the lead to implement continuing education program and restructure the syllabus of the various courses to meet the ever changing needs of pharmacy practice. Finally, there is a need to consider more privacy and confidentiality while giving advice to increase user satisfaction with these aspects.