Community Pharmacists' Awareness toward Their Roles in Healthcare and Interaction with General Practitioners: A Cross-Sectional Study.

INTRODUCTION: There is a paucity of data on the extended role of community pharmacists (CP) in Malaysia. This study is aimed to evaluate CPs awareness toward their roles in healthcare and interaction with general practitioners (GPs).
MATERIALS AND METHODS: A cross-sectional design using a validated questionnaire was conducted nationwide among randomly selected Malaysian CPs. The questionnaire consisted of consisted of 32 questions with three sections. The Cronbach's alpha measure for the scale on awareness was 0.494 and 0.724 for the interaction between CPs and GPs. Descriptive statistics were reported. The Chi-square test, Mann-Whitney test, Kruskal-Wallis test, and post hoc analyses were applied at the alpha level of 0.05.
RESULTS: Of the 127 CPs who filled out the responses, 57.5% (n = 73) mentioned that they rarely or never interacted with GPs. Many CPs (n = 106, 83.5%) were aware of their role in providing patient education, and 109 (85.8%) indicated that they could suggest nonprescription medicines to patients, whereas 88 respondents (69.3%) were aware that they could suggest alternative medicines. A total of 117 respondents (92.1%) indicated their willingness to perform selected screening tests and identify and prevent prescription errors. A considerable number of CPs (n = 76, 59.8%) were aware of their ability to design and regulate prescribed regimens, and 89 (70.1%) showed their willingness to monitor these regimens. The total average score of the CPs' awareness toward their roles in providing healthcare for the 16 activities/items and the value of the interaction mean score was 12.00 (±2.92), with a median score of 12.00 (interquartile range: 9.5-14.5).
CONCLUSIONS: Malaysian CPs are fully aware of their role in providing healthcare and pharmaceutical care. Though the majority of them were willing to provide extended services, they are often unable to perform these roles due to the lack of interprofessional collaboration, lack of time, and absence of remuneration for their extended services. Training programs, practice guidelines, and professional service fee may encourage CPs to perform more extended services. Copyright:

INTRODUCTION

Community pharmacists (CPs) are positioned to openly communicate with patients and are accessible to provide advice and knowledge to the public and patients.[1] Their extended open hours and provision of health advice without an appointment makes CPs unique in terms of more accessible health-care professional.[2] One randomized controlled study on a community-pharmacy based intervention from Canada reported CP interventions improving cholesterol management in high-risk patients.[3] In general, patients support the concept of extended community pharmacy services and look for information on prescribed medicines and minor symptoms.[4] Incorporating more cognitive services to a community pharmacy will create unique opportunities for pharmacists to practice their profession. However, pharmacists need to identify the limits of their expert capabilities and practice only according to these competencies and refer patients to other health professionals when needed,[5] maintaining a clear professional divide in handling patients. The community pharmacy practice in Malaysia must be viewed in a unique manner: in Malaysia, the general practitioners (GPs), i.e., private doctors, carry out the dual role of prescribing and dispensing medicines and pharmaceutical products,[67] which often limits the role of CPs. Although this should be balanced against the scarcity of resources being used by patients, the main rationale behind doctors’ dispensing is to achieve ease of access to medicines and patient convenience.[6] It is imperative that both GPs and CPs appreciate their roles and responsibilities in providing healthcare in a professional manner, with the ultimate aim to improve public health.

There is strong evidence that GPs tend to misunderstand the CPs’ role[8] and thus create barriers in practicing “interprofessional collaboration.”[9] Studies have indicated the lack of communication and information exchange between the GPs and CPs.[101112] This lack of communication has become the main barrier to CPs’ carrying out their roles in providing healthcare. In personal observations of the researchers’ encounters with CPs, it appeared that CPs were clearly aware of their roles when they adhered to counseling standards, but they face some barriers in carrying out this role when they tended to inappropriately dispense medicines. A study from Malaysia recommended training and continual support in terms of continuing professional development and lifelong learning to empower the CPs.[13] There is a paucity of studies assessing the awareness of Malaysian CPs towards their roles in providing healthcare and the barriers facing them in performing these roles. The awareness of CPs of their roles in providing healthcare and their experiences with different barriers in performing these roles is worth exploring. This study is aimed to evaluate the interaction of CPs with GPs on therapeutic issues, their awareness of their roles in healthcare, and their experiences while carrying out these roles.

MATERIALS AND METHODS

Study design

This study used a cross-sectional design using a questionnaire to determine the awareness of CPs of their roles in the provision of healthcare, and evaluated the interaction between CPs and GPs on the availability of medicines and medication use issues from the perspective of CPs. The study was conducted within the period from May 2015 to September 2015.

Ethical consideration

Ethical approval was obtained from the Joint Ethics Committee of the School of Pharmaceutical Sciences, USM-Hospital Lam Wah Ee on Clinical Studies (Approval number: USM-HLWE/IEC/2011(0004). An explanatory statement for CPs was attached to the questionnaire regarding the aim and the nature of this study, along with a written consent form from the authors.

Study population, sample size calculation, and time frame

The population of this study was the CPs working in CPs in all states of Malaysia. The sample size was calculated using the approach of confidence intervals developed by Cochran:

In making finite population corrections for proportions, the sample size (n0) was adjusted using the second equation, where n0 is the sample size of CPs and N is the population size:

The sample was selected by systematic random sampling from an edited list of CPs compiled by the Malaysian Pharmaceutical Society.[14] The total population of CPs according to this list was 1,856, and the calculated sample size was 319. After the addition of 20% drop-out, the total sample size was found to be 383. The questionnaire was mailed to the sample of CPs selected and distributed to all 14 Malaysian states according to sample size calculation in each state. Selangor State had the highest number of CPs (n = 355, 19.1%), followed by Penang (n = 297, 16.0%) and Kuala Lumpur, the capital city of Malaysia (n = 194, 10.5%), while Perlis, the smallest state, had the lowest number of CPs (n = 14, 0.8%). All registered CPs were included in the selection list. CPs were excluded if they refused to participate i.e., did not provide consent.

Development of the study tool

The questionnaire was developed and modified from a previous research in Pakistan.[15] It consisted of 32 questions, divided into three sections: (i) CPs’ collaboration (interaction) with GPs on medicine availability and medication use problems; (ii) awareness of their roles as healthcare providers; and (iii) demographic characteristics. The section on collaboration was presented as a 4-point Likert scale: 1 = very low to 4 = very high. It consisted of five items of interactions in terms of availability of medicines, alternative medicines, drug interactions, side effects, and drug dosage. The section on awareness was structured to include 16 questions with “yes” or “no” answers. The fourth section included 11 demographic items.

Validation of the study tool

Supervisors, experts in the ethical committee, and postgraduate students in the Discipline of Social and Administrative Pharmacy at Universiti Sains Malaysia, Penang, evaluated the questionnaire contents. The questionnaire was mailed to 30 CPs in Penang to assess the content and provide feedback. In addition, 5 pharmacists working in the university panel of pharmacies were also solicited. All comments and feedback were considered for improvement. These participants were not included in the final study. Cronbach's alpha was estimated for the questionnaire. The coefficient alpha for the scale of interaction between CPs and GPs was 0.724, and it was 0.494 for the section on awareness.

Data analysis

Descriptive analysis was conducted using SPSS for Windows, version 26 (SPSS Inc. Released 2019. SPSS for Windows, Version 26.0. Chicago, IL, USA). Frequency (percentage), mean ± standard deviation (SD), and median with interquartile range (IQR) values are reported. Data were tested for normality distribution using Kolmogorov–Smirnov test and were found not distributed normally (P = 0.000). Accordingly, the Chi-square test, Mann–Whitney test, Kruskal–Wallis test, and post hoc analyses using Mann–Whitney test were applied at the alpha level of 0.05.

RESULTS

Demographic characteristics and pharmacy profiles of community pharmacists

Of the total of 383 questionnaires mailed to the sample CPs in all Malaysian states, 111 were returned, of which 12 questionnaires were not completed and were rejected. A further 28 questionnaires were later returned after reminders. The final response rate was 33.2% (n = 127), which is considered adequate.[16] The study findings demonstrated that most of the respondents were female (52.8%), aged 35 years or less (34.6%), Chinese (63.0%), graduated from local universities (55.1%), and had experience of 15 years or less (70.1%). In a 4-week period, a majority of the respondents claimed that they received fewer than 25 prescriptions from GPs (90.6%) and were asked by customers for over-the-counter (OTC) medications in >500 OTC visits (34.6%). More information about the demographic characteristics of CPs are indicated in Table 1.

Table 1

Community pharmacists’ demographic profile

Demographic	Groups, median (IQR)	Frequencies (n=127), n (%)
Age**, median=38.00 (34-47)	≤35	44 (34.6)
	36-45	41 (32.3)
	>45	42 (33.1)
Gender*	Male	60 (47.2)
	Female	67 (52.8)
Ethnic background**	Malay	42 (33.1)
	Chinese	80 (63.0)
	Indian	2 (1.6)
	Other	3 (2.4)
Place of graduation*	Locally	70 (55.1)
	Overseas	57 (44.9)
Specialty status*	Specialized	11 (8.7)
	Not specialized	116 (91.3)
Number of Rxes**, median=2.00 (0-10)	≤25	115 (90.6)
	26-50	3 (2.4)
	>50	9 (7.1)
Number of OTC**, median=300.00 (100-500)	≤250	48 (37.8)
	251-500	35 (27.6)
	>500	44 (34.6)
Experience**, median=11.00 (8-7) years	≤15	89 (70.1)
	16-25	34 (26.8)
	>25	4 (3.1)
Number of CPs around**, median=3.00 (2-5)	≤5	109 (85.8)
	6-10	15 (11.8)
	11-20	3 (2.4)
	>20	0 (0.0)
Number of GP around, median=5.00 (3-10)	≤5	73 (57.5)
	6-10	49 (38.6)
	11-20	16 (12.6)
	>20	4 (3.1)
Frequency of CP-GP interaction**	Rarely or never	73 (57)
	Sometimes	49 (39)
	Always	5 (4)

*Mann-Whitney test, **Kruskal-Wallis test was conducted at α=0.05. IQR: Interquartile range, OTC: Over-the-counter, CPs: Community pharmacists’, GP: General practitioner

Interaction between community pharmacists and general practitioners in issues related to medication use

The reasons for the interaction between CPs and GPs within the 4-week period are indicated in Table 2. These reasons of interaction included drug availability, alternative medicines, drug interactions, side effects, and drug dosage. In general, the responses indicated that Malaysian CPs had very low rates of interaction (collaboration) with GPs for the above-mentioned reasons [Table 2].

Table 2

Reasons and levels of community pharmacists’-general practitioners interactions on therapeutic issues

Reason for interaction	VL, n (%)	L, n (%)	H, n (%)	VH, n (%)	Mean±SD
Drug availability	105 (82.7)	6 (4.7)	12 (9.4)	4 (3.1)	1.46±1.097
Alternative drugs	105 (82.7)	6 (4.7)	9 (7.1)	7 (5.5)	1.48±1.161
Drug interactions	117 (92.1)	6 (4.7)	4 (3.1)	0 (0.0)	1.14±0.560
Side effects	119 (93.7)	5 (3.9)	2 (1.6)	1 (0.8)	1.12±0.544
Drug dosage	109 (85.8)	9 (7.1)	5 (3.9)	4 (3.1)	1.31±0.915

SD: Standard deviation, L: Low; VL: Very Low; H: High; VH: Very High

Factors affecting community pharmacist–general practitioner interactions

The factors that influenced the interaction between the two healthcare professionals within the 4-week period are shown in Table 3.

Table 3

Community pharmacist and general practitioners interaction

Number	P*
	Gender	Specialization	PG	Age	Et	Yr	NRX	NO	NCY	NCL	DPI
1.	0.621	0.162	0.209	0.890	0.861	0.002	0.009	0.927	0.957	0.333	<0.001
2.	0.953	0.655	0.185	0.214	0.832	0.937	0.294	0.545	0.023	0.124	<0.001
3.	0.057	0.008	0.040	0.557	0.237	0.327	0.889	0.496`	0.033	0.092	0.319
4.	0.119	0.008	0.473	0.749	0.346	0.780	0.291	0.288	<0.001	<0.001	0.011
5.	0.880	0.480	0.777	0.648	0.172	0.644	<0.001	0.247	0.967	0.580	<0.001

*Chi-Square, (P<0.05). 1. Drug availability, 2. Alternative drugs, 3. Drug interactions, 4. Side effects, 5. Drug dosage. PG: Place of graduation, Age: Age of the CP, Et: Ethnic background, Yr: Years of experience, NRx: Number of prescription, NO: Number of OTC medicines, NCY: Neighboring pharmacies, NCL: Number of private clinics, DPI: GP-CP interactions. CP: Community pharmacist, GP: General practitioner

In general, our data show that gender, age, ethnicity, and number of OTC medicines did not influence the medicine issues discussed (i.e., reasons for interaction) during the interaction. However, the factors that were highly influential were frequency of interaction (i.e., associated with 4 out of 5 reasons for interaction), followed by the number of neighboring pharmacies, number of prescriptions received, whether the pharmacist has any specialization, place of graduation, and number of private clinics nearby [Table 3].

The dimension of community pharmacists and general practitioners’ interactions

The value of the collaboration mean score was 1.30 (±0.627). The minimum and maximum expected values were 1 and 4, respectively, and the midpoint was 2.5. A value below midpoint was defined to be a low interaction value.

Significant differences were seen between the average score of CPs’ reasons for interaction and CP's specialty (P < 0.001). Those who specialized CPs had a better interaction with GPs on medication use and availabilities issues than those who are not specialized [Table 4].

Table 4

Average score of community pharmacists’ interaction with general practitioners

Factors	Group	Frequency	Median (IQR)	P
Gender*	Male	60	1.0 (1.0-1.4)	0.127
	Female	67	1.0 (1.0-1.0)
Place of graduation*	Locally	70	1.0 (1.0-1.25)	0.869
	Overseas	57	1.0 (1.0-1.3)
Specialty status*	Specialized	11	1.6 (1.0-1.8)	0.009
	Not specialized	116	1.0 (1.0-1.2)
Age (years)**	≤35	44	1.0 (1.0-1.2)	0.717
	36-45	41	1.0 (1.0-1.4)
	≥45	42	1.0 (1.0-1.4)
Experience years**	≤15	89	1.0 (1.0-1.5)	0.224
	16-25	34	1.0 (1.0-1.0)
	≥26	4	1.1 (1.0-1.35)
Ethnic**	Malay	42	1.0 (1.0-1.45)	0.543
	Chinese	80	1.0 (1.0-1.2)
	India	2	1.3 (1.0-1.6)
	Other	3	1.0 (1.0-1.0)
Number of GP clinics**	≤5	68	1.0 (1.0-1.0)	0.065
	6-10	39	1.0 (1.0-1.4)
	11-20	16	1.0 (1.0-1.6)
Number of prescriptions	≤25	115	1.0 (1.0-1.2)	0.056
	26-50	3	1.6 (1.0-2.6)
	≥51	9	1.2 (1.0-2.3)
Number of pharmacies**	≤5	109	1.0 (1.0-1.2)	0.256
	6-10	15	1.0 (1.0-1.2)
	11-20	3	1.8 (1.0-2.6)
Number of OTC**	≤250	48	1.0 (1.0-1.4)	0.418
	251-500	35	1.0 (1.0-1.6)
	≥501	44	1.0 (1.0-1.0)
Frequency of CP-GP Interaction	Never	73	1.0 (1.0-1.0)	<0.001
	Sometimes	49	1.2 (1.0-1.8)
	Always	5	1.8 (1.4-3.1)

*Mann-Whitney test, **Kruskal-Wallis test was conducted at α=0.05. GP: General practitioner, IQR: Interquartile range, OTC: Over-the-counter, CP: Community pharmacist

Factors affecting community pharmacists’ awareness of their extended roles

Table 5 presents the findings of awareness of CPs toward their roles in providing healthcare.

Table 5

↱ Community pharmacists’ awareness of their roles

Item number	Frequency (n=127)		P*			P**
	Yes, n (%)	No, n (%)	Gender	Specialty	PG	Age	Ethnicity	Yr	NRX	NO	NCY	NCL	DPI
1	106 (83.5)	21 (16.5)	1.000	0.690	1.000	0.021	0.313	0.769	0.669	0.687	0.384	0.718	0.463
2	109 (85.8)	18 (14.2)	0.459	0.362	0.319	0.489	0.074	0.559	0.741	0.829	0.177	0.398	0.324
3	88 (69.3)	39 (30.7)	0.700	0.736	0.052	0.576	0.068	0180	0.502	0.004	0.299	0.532	0.305
4	68 (53.5)	59 (46.5)	0.859	1.000	0721	0.248	0.854	0.627	0.020	0.551	0.899	0.089	0.358
5	124 (97.6)	3 (2.8)	1.000	1.000	0.252	0.335	0.114	0.362	0.852	0.349	0.776	0.899	0.910
6	117 (92.1)	10 (7.6)	0.332	0.599	0.510	0.598	0.704	0.955	0.824	0.848	0.408	0.539	0.320
7	117 (92.1)	10 (7.6)	1.000	0.599	0.342	0.469	0.560	0.599	0.568	0.243	0.164	0.922	0.308
8	76 (59.8)	51 (40.2)	0.595	0.210	0.596	0.560	0.534	0.166	0.231	0.004	0.477	0.719	0.410
9	89 (70.1)	38 (29.9)	0.702	0.171	0.846	0.362	0.085	0.110	0.440	0.092	0.228	0.965	0.455
10	93 (73.2)	34 (26.8)	0.693	0.036	0.316	0.495	0.326	0.907	0.533	0.685	0.794	0.235	0.791
11	99 (78.)	28 (22.0)	0.671	0.121	0.527	0.397	0.906	0.962	0.173	0.120	0.365	0.496	0.602
12	59 (46.5)	68 (33.5)	1.000	1.000	0.378	0.058	0.560	0.289	0.004	0.194	0.493	0.852	0.160
13	121 (95.3)	6 (4.7)	0.420	1.000	0.592	0.545	0.188	0.617	0.035	0.945	0.870	0.214	0.337
14	110 (86.6)	17 (13.4)	0.312	0.358	0.375	0.904	0.085	0.892	0.010	0.887	0.547	0.118	0.177
15	97 (76.4)	30 (23.6)	0.096	0.721	0.202	0.521	0.326	0.777	0.280	0.562	0.874	0.335	0.943
16	45 (35.4)	82 (64.6)	0.853	0.195	0.266	0.941	0.906	0.627	0.424	0.143	0.417	0.415	0.560

*Fisher’s exact test, **Chi-Square test, (P<0.05). 1. Providing patient education, 2. Suggesting the use of nonprescription medications to patients, 3. Suggesting the use of alternative (but equivalent) prescription medications, 4. Assisting physicians to prescribe appropriate medications when they consult them, 5. Diagnosing and treating minor illnesses such as headache and common cold, 6. Performing selected screening tests such as sugar and cholesterol tests, 7. Identifying and preventing prescription errors, 8. Designing and regulating prescribed pharmacotherapeutic regimens for patients, 9. Monitoring outcomes of these pharmacotherapeutic regimens, 10. Maintaining medical records and profiles for following up patients, 11. Filling the medication order (prescription) only, 12. Giving advice on smoking cessation, 13. Giving advice on healthy nutrition, 14. Giving advice on physical exercise, 15. Following certain guidelines for different services in his pharmacy, 16. Involved in designing guidelines for other pharmacies. PG: Graduation country, Yr: Years of experience, NRX: Number of prescriptions received, NO: Number of OTC, NCY: Number of pharmacies around, NCL: Number of clinics around, DPI: Pharmacists-doctor interaction. OTC: Over-the-counter

Further analysis has indicated that providing patient education by CPs was correlated significantly with age (P = 0.021). Maintaining medical records and profiles for patients was associated significantly with the specialization status of a CP (P = 0.036). CPs assisting inappropriate prescription by GPs was associated significantly with the number of prescriptions received from GPs (P = 0.020). Counseling to promote patient quality of life was associated significantly with the number of prescriptions received by a CP. The focus of counseling included smoking cessation (P = 0.004), healthy nutrition (P = 0.035), and encouraging physical exercise (P = 0.010). OTC encounters experienced by CPs were associated significantly with suggestions by CPs for patients to use alternative medicines (P = 0.004) and CPs designing and regulating the prescribed regimens (P = 0.004).

The dimension of community pharmacists’ awareness of their roles

The total average score of the CPs’ awareness toward their roles in providing healthcare for the 16 activities/items and the value of the interaction mean score was 12.00 (± 2.915). The median score was 12.00 (IQR: 9.5–14.5). The minimum and maximum expected values were 0 and 16, respectively. The midpoint at 50% of correct answers equaled 8.0, and a value above the midpoint was defined to be a high awareness value.

As shown in Table 6, A significant difference was seen, based on the average score of CPs’ awareness, in the number of prescriptions they received from GPs (P = 0.003) and in the frequency of pharmacist–doctor interaction in 4 weeks (P = 0.034). Post hoc analysis was conducted, and the result showed that there was a significant difference between CPs who received fewer than 25 prescriptions from GPs and those who received 26–50 prescriptions in 4 weeks (P = 0.022). Those who received 26–50 prescriptions were more likely to have an awareness of their role as health-care provider than CPs who received fewer than 25 prescriptions in 4 weeks.

Table 6

Average score of community pharmacists’ awareness towards their roles

Factors	Group	n	Median (IQR)	P
Gender*	Male	60	12.0 (9.0-13.0)	0.474
	Female	67	11.0 (9.0-13.0)
Place of graduation*	Locally	70	12.0 (9.0-13.0)	0.608
	Overseas	57	11.0 (10.0-13.0)
Specialty status*	Specialized	11	12.0 (12.0-13.0)	0.110
	Not Specialized	116	11.0 (9.0-13.0)
Age** (years)	≤35	44	12.0 (10.0-13.0)	0.252
	36-45	41	12.0 (9.5-13.0)
	≥46	42	10.5 (8.0-13.0)
Experience years**	≤15	89	12.0 (10.0-13.0)	0.284
	16-25	34	10.0 (8.0-14.0)
	≥26	4	11.5 (7.75-13.0)
Ethnic	Malay	42	10.0 (8.75-13.0)	0.100
	Chinese	80	12.0 (10.0-13.0)
	India	2	15.0 (14.0-16.0)
	Other	3	14.0 (6.0-14.0)
Number of GP clinics	≤5	68	12.5 (6.75-14.0)	0.477
	6-10	39	11.0 (10.0-12.75)
	11-20	16	11.0 (8.5-13.0)
	≥21	4	12.5 (6.75-14.0)
Number of prescriptions	≤25	115	11.0 (9.0-14.0)	0.003
	26-50	3	10.5 (9.25-12.75)
	≥51	9	11.0 (8.0-12.0)
Number of pharmacies	≤5	109	10.0 (8.0-14.0)	0.875
	6-10	15	11.0 (10.0-13.0)
	11-20	3	12.0 (9.0-13.0)
	≥21	0	0
Number of OTC	≤250	48	12.0 (10.0-13.0)	0.411
	251-500	35	11.0 (9.0-12.0)
	≥501	44	11.0 (9.0-13.0)
Frequency of CP-GP Interaction	Never	73	11.0 (9.0-13.0)	0.034
	Sometimes	49	12.0 (10.5-13.5)
	Always	5	12.0 (9.5-14.5)

*Mann-Whitney test, **Kruskal-Wallis test was conducted at α=0.05. GP: General practitioner, IQR: Interquartile range, OTC: Over-the-counter, CP: Community pharmacist

DISCUSSION

The study has focused on the CPs’ awareness of their role to offer extended services and their level of interaction with medical doctors in private clinics, i.e., GPs. Pharmacists’ roles have expanded over time to include more direct patient care, such as primary care and disease management services, and their roles continue to evolve.[17]

The community pharmacy practitioners in the study were dominated by Chinese, female, locally graduated, generalists and those with 15 years of experience or less. These characteristics are typical in Malaysia. Many of the Chinese community will enter the business arena, and practicing in the community pharmacy setting is preferable to the public sector, which generally has a lower income. The trend of students in universities is for females to predominate in most of the programs. Malaysia has >15 recognized pharmacy degree programs,[18] and the government does not encourage sending Malaysian students abroad for the bachelor's degree in pharmacy.

For achieving the goals of pharmaceutical care, it is vital for pharmacists to communicate and interact with physicians. These goals include taking responsibility for treatment outcomes and intervening in cases of medication errors, contraindications, and ambiguous prescription.[19] In Malaysia, there is no separation between the prescribing and dispensing of medications due to a lack of clear policy.[20] Medical doctors in private community practices have had the right to prescribe and dispense since the independence of the country. This has affected the basic role as well as the extended role of CPs because of these overlapping roles between pharmacists and physicians. Interaction between physicians and pharmacists is often substandard due to the less than satisfactory relationships between the two professions. This study indicated that fewer prescriptions were received from GPs. This result was similar to the findings of other researchers in Malaysia,[21] indicating the underutilization of CPs as a safety net for medication use in the community. In some cases, not even one patient with a prescription visited a pharmacy each day in a 4-week period. This will lead to dangerous consequences in the form of adverse effects on patients’ care and outcomes.[22] Conentionally, the prescription chit is the main factor or means of interaction between physicians and pharmacists and forms the foundation of the communicative relationship between the two professions.[23] It is clear from the present study that the interaction between CPs and GPs is rare. That is due to the lack of prescriptions sent from private clinics, which are legally permitted to dispense medicines. On the other hand, customers asked CPs for OTC medications in >500 OTC visits.

The study respondents were aware of their role in providing patient education. They answered that they could suggest nonprescription medicines to patients, could suggest alternative medicines when requested by their patients, were ready to assist physicians in appropriate prescription of medicines, were able to diagnose and treat minor illness such as the common cold and headache, were willing to perform selected screening tests, prevented prescription errors, were willing to monitor medication regimens, were able to devote time to maintaining medical records and profiles for their patients and were keen to give advice to patients and consumers on quality of life and healthy lifestyle matters. Ting et al. reported that CPs have some knowledge of the adverse drug reaction (ADR) reporting system in Malaysia and agreed that it is the responsibility of pharmacists to report an ADR. Taha et al. also discovered that CPs have a positive attitude toward travel medicine, which can be an extended service to the public and visitors, as Malaysia is promoting tourism. Malaysia as is a multiracial country and the use of herbal supplements in the community is popular. CPs have a vital role in educating their customers about the rational use of herbal supplements.[24] However, CPs should focus more on other potential areas for extended services, such as osteoporosis disease-state management,[25] cardiovascular health,[26] weight management services,[27] and diabetes self-management.[28]

Patients and consumers can play a very important role in allowing Malaysian CPs to performing their extended roles. One study found that Malaysian patients were generally more satisfied with value-added services than traditional counter services.[29] Another study reported that CPs mentioned that patients often requested nonprescription drugs such as anti-inflammatory agents, painkillers, and medicines for cough and flu.[30] In most cases, medicines were dispensed as requested. In another study, patients or customers often requested medications with brand names, asked for advice on minor health problems, and sought health supplements.[21]

Collaboration between pharmacists and physicians has been suggested as the most useful way to provide drug therapy-related services for improving therapeutic effects.[31] Although this study found that interaction is rare or nonexistent, those few CPs who communicated with GPs were found to assist them in issues such as medicine availability, alternative medicines, and drug dosage. The frequency of pharmacist-doctor interaction was a direct determinant of the responses of CPs to GPs asking about all therapeutic issues except for drug interactions. The more interactions with GPs and prescriptions they received, the more aware they were of their roles in extended services.

Trained pharmacists can perform direct patient care activities such as preventing undesired drug interactions, leading to reduction of costs.[32] Those specialized CPs in this study preferred to assist in preventing drug interactions and side effects as a patient care activity. Place of graduation, whether locally or overseas, also influenced CPs in helping GPs about drug interactions. Factors such as CP's years of experience, number of prescriptions received from GPs, and frequency of pharmacist–doctor interaction were determinants of CPs helping GPs in matters of medicine availability.

The proximity of pharmacies and clinics in one area creates opportunities for CPs and GPs to collaborate.[33] In this study, CPs who were neighbored by a few pharmacies and clinics had the tendency to interact with GPs on therapeutic issues, especially alternative medicines and side effects. Specialization of a CP and the frequency of interaction between CPs and GPs were the main factors influencing the CPs’ interaction with GPs in providing healthcare.

When used rationally, medicines can play a vital role in the realization and preservation of health. This should be ensured by healthcare providers such as doctors and pharmacists.[34] To participate fully in developing healthcare, pharmacists should improve their awareness, expressed beliefs, and attitudes toward their roles in the health-care system.[35] Pharmacists can contribute to positive therapeutic outcomes by adopting pharmaceutical care in educating and counseling their patients by training and encouraging them to follow their medication regimens and monitoring plans.[36] Malaysian CPs in this study were aware of their role in providing patient education. However, what matters are the policies that protect CPs, which can allow them to offer extended cognitive services.

Pharmacists are the most accessible health-care providers who have been trained to educate patients toward avoiding drug interactions with food and other drugs in both prescribed and OTC medications.[37] It was quite normal for Malaysian CPs to suggest nonprescription medicines and alternative medicines when requested by their patients. They also pointed to their readiness to assist physicians in appropriate prescription of medicines and identifying and preventing prescription errors. All those who received more prescriptions showed a tendency to assist physicians in appropriate prescriptions. The presence of clinical pharmacists within the health-care team helps in the early discovery of prescription errors and thus possible avoidance of negative therapeutic outcomes.[38] CPs showed their ability to diagnose and treat minor illnesses and their willingness to conduct different screening tests. In the USA, some states permit pharmacists to diagnose and treat minor illnesses in children by acquiring the authority to write and conduct pharmacy-based evaluation and treatment, leading to improved healthcare access of children with minor ailments. This treatment, when evaluated, seemed to be both safe and acceptable.[39] Clinical pharmacy services provided by CPs in the dispensing procedure can provide a valuable contribution to healthcare and improvement in clinical outcomes.[40] The CPs in this study were also aware of these clinical roles, such as designing and regulating prescribed regimens and their keenness to monitor these regimens and maintain medical records and profiles for their patients. The specialty of a CP was associated significantly with the role of maintaining medical records and profiles for patients. They did not agree limiting their role to filling medication orders.

Concerning counseling about quality of life, CPs stated their keenness to give advice to patients and consumers on smoking cessation, healthy nutrition, and physical exercise. Such advice increases with receiving prescriptions. Finally, they expressed their readiness to follow certain guidelines for different services provided by them, since training programs and guidelines seem to have positive effects on their performance, especially advice on lifestyle issues when patients request medications from pharmacists.[41]

Self-medication involves the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms. The increase in self-medication is related to many factors, which include socioeconomic factors, lifestyle, access, potential to treat ailments via self-care, environmental factors, public health, the large number of existing medicines, and demographic factors.[42] The provision of patient education by CPs was correlated with CP's age, a demographic factor. Moreover, the number of OTC encounters, another demographic factor, was correlated with the CP advising patients on the use of alternative medicines as well as designing and regulating the prescribed regimens. The number of prescriptions received by CPs and their frequency of interaction with GPs regarding the use of medicines were the main factors influencing the CPs’ awareness of their roles in providing healthcare.

Extending CPs’ roles could result in improvement in the quality of care, optimization of drug therapy, a decrease in GP workload, and a reduction in the long-term healthcare costs.[434445] GPs have been supportive of CP involvement in certain extended activities.[46] Thus, the focus should be on strengthening the competence of the CPs and working on the extra-organizational factors that stop the profession from moving forward.

This nationwide study provides information about CPs’ awareness and perspectives on providing extended services. It also contributes additional evidence from a low- and middle-income country.

Study limitations

This study had a few limitations. The sample size and social desirability bias might be encountered. The response rate was low and this might be due to the workload and the busy schedules of the CPs. Further, Cronbach's alpha value was moderate and this might due to the problem of heterogeneous constructs.

CONCLUSION

CPs rarely interacted with GPs on medication-use issues and availability of medicines, but not to the extent shown by GPs. Although Malaysian CPs in this study were fully aware of their role in providing healthcare and pharmaceutical care, they could not fully adopt these roles to contribute to positive therapeutic outcomes for patients. That may be due to barriers in providing healthcare and pharmaceutical care, such as lack of collaboration and cooperation with GPs and other healthcare providers, lack of time due to dispensing and other responsibilities, lack of training programs and certifications from professional and national accreditation bodies, lack of standard practice guidelines, and lack of economic and financial incentives for providing extended services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.