Drug Information Services in Low-Resource Setting: A Responsibility of Pharmacists or Pharmacologists or Both the Professions Conjointly.

OBJECTIVE: The objective of this study was to assess the pharmacy professionals' understanding and viewpoints on drug information center (DIC) services and differences, if any, with pharmacologist's survey conducted earlier.
MATERIALS AND METHODS: An electronic cross-sectional knowledge, practice, and attitude survey was carried out. A questionnaire in the form of the hyperlink was sent to pharmacy professionals through e-mail, Facebook messenger, and WhatsApp. Factors linked to pharmacy professionals' vision in expanding countrywide DIC services were studied with logistic regression in R.
RESULTS: A total of 125 pharmacy professionals responded. The participant believing in the published literature as a standard reference for establishing and running the DIC services; participants identifying more challenges in the day-to-day DIC functioning; and participants believing in the ability of DIC in reducing morbidity, mortality, and cost of care had 4.76 (95% confidence interval [CI] = 0.97-6.44), 4.24 (95% CI = 0.97-6.44), and 2.43 (95% CI = 0.97-6.44) times association with good knowledge score. Good attitude scores were discovered of participants working in fully and partially functional DIC (odds ratio [OR] = 9.66, CI = 0.97-6.44 and OR = 9.49, CI = 0.97-6.44) to participants not involved in DIC duties. The participant who understood DIC services' real purpose had 2.83 (95% CI = 0.97-6.44) times association with good practice scores. Overall, pharmacy professionals carried better attitude scores, but lesser knowledge, and practice scores than pharmacology professionals.
CONCLUSION: Lower knowledge and practice score of pharmacy professionals asks for training in critical appraisal of published literature and due modifications in graduate and postgraduate curricula. A collaborative approach between pharmacists and pharmacologists is needed to improve the quality of drug information services and evidence-based medicine practice in low-resource countries like India. Copyright:

INTRODUCTION

Should a clinician look for righteous pharmacotherapy guidance in one's own previous experience or published research? Newer drugs, newer safety information, efficacy communication, and recent adverse events are regularly updated in the medical literature almost every day.[1] The clinicians from a developing country like India regularly face problems with evidence-based drug information. The government's low expenditure on health care, lesser collaborative research, scarce funding for the research, and a lesser number of doctors for the country's growing population are some of the critical roadblocks in evidence generation on drug use for quality practice.[2] The concept of a drug information center (DIC) initiated by the University of Kentucky, USA, in 1962 is one solution to many problems. The potentials of this kind of patient- and clinician-oriented service include dosing guidance, dose modification, drug-drug interaction check, the establishment by causality between a drug and an adverse event, interpretation of antibiotic susceptibility tests, therapeutic drug monitoring evaluation, and opinions on trough level concentrations, policy-making for a hospital in the selection of P drug, and many more.[3] The DIC concept is relatively underexplored by the pharmacy and pharmacology educators of India.[4] In addition, very few centers worldwide contribute to reducing morbidity, mortality, and pharmacoeconomic burden reduction with rightful drug information provision.[5] In India, pharmacy pharmacology graduates and postgraduates are regularly taught the concept of drug information service without stressing critical appraisals of published drug literature.[6] Our previous study showed that the thorough evaluation of published drug literature was an uncharted arena for pharmacologists and needed the training.[3] A subsequent study is planned to assess the pharmacists’ thoughts, aptitude, and behavior in catering DIC services.

MATERIALS AND METHODS

The study was planned as a cross-sectional questionnaire-based study assessing the knowledge, attitude, and practice regarding the applications, utility, and prospects of DICs among the Indian pharmacy educators and practitioners. The pan-India participants were invited to participate in the study from September 1 to December 31, 2018. The questionnaire validated in a previous pharmacologist survey study was modified a little to suit pharmacy educators’ understanding. The questionnaire was transcribed into an electronic format and was circulated to the pharmacist through e-mail, Facebook messenger, or WhatsApp. The Institutional Ethics Committee approved the study and the electronic informed consent procedure with approval number INT/IEC/2018/001059.

A methodology was kept the same to compare the results between this and the previous study. The questionnaire broadly contained four domains: demographic domain, knowledge domain, attitude domain, and practice domain. Each domain's responses were coded into discrete numbers with higher numbers assigned for better response. The questions, along with its options and recoding pattern, are provided in Table 1.

Table 1

The descriptives of the questions and responses along with recoding of the variables

Multiple choice questions and the options	Coding assumed for individual option as per method plan
Email address
DQ1. Designation
a. Hospital pharmacist	0
b. Assistant professor	0
c. Associate professor	0
d. Professor/director - professor	1
e. Research associate	0
DQ2. Is there any DIC in your institute/hospital?*
a. No	0
b. Yes, working to its full extent	2
c. Yes, but not functioning	0
d. Limited functioning	1
DQ3. Workplace city according to HRA classification
a. A-1	2
b. A	1
c. B-1	1
d. B-2	0
e. C	0
KQ1. The important purpose of DIC is/are to
a. Provide unbiased information of drugs	0
b. Train pharmacology postgraduates to serve as effective providers of drug information	0
c. Control irrational use of drugs	0
d. All	1
KQ2. Is patient privacy important in a case of inquiring drug-related information from DICs?
a. Yes	1
b. No	0
c. Don’t know	0
d. May be in some situations	0
KQ3. Can the promotional literature (i.e., advertisement by medical representative) of a drug be used as a source for drug information?
a. Yes	0
b. No	1
c. Don’t know	0
d. May be	0
KQ4. Do DICs have the responsibility of ADR reporting (pharmacovigilance)?
a. Yes	0
b. No	1
c. May be	0
d. Don’t know	0
KQ5. Do you think DICs can serve the community by providing authentic individualized, accurate, relevant, and unbiased drug information to the consumers and health-care professionals for safe health care?
a. Yes	1
b. No	0
c. Don’t know	0
d. May be	0
AQ1. Do you think DICs can bring awareness of rational drug use to various health-care professionals?
a. Yes	1
b. No	0
c. Don’t know	0
d. May be	0
AQ2. Do you think DICs should be taught in detail to budding pharmacy professionals?
a. Yes	1
b. No	0
c. Don’t know	0
d. May be	0
AQ3. Do you think an effective DIC can control the irrational use of medicines through proactive outreach activities?
a. Yes	1
b. No	0
c. May be	0
d. Don’t know	0
AQ4. What is your opinion about establishing and running DICs in every hospital or every pharmacy institute?
a. Should be in every hospital	1
b. Not necessary in every hospital	0
c. One in a city is sufficient	0
d. Depends on the requirement in the hospitals	0
AQ5. Have you ever referred to literature on how to establish DICs in the department of pharmacology?
a. Yes	1
b. No	0
c. Tried but could not find	0
d. Have plans to refer in the future	0
PQ1. If you are given an opportunity to act as a drug information practitioner in a DIC, what do you think would be the common challenge? (mark more than one if needed) (less than or equal to any one options marked will be scored 0 while 2-4 options marked and equal to or>5 options will be scored as 1 and 2, respectively)
a. Lack of recognition
b. Lack of permanent financial support
c. Lack of quality assurance programs
d. Outdated drug information sources
e. Lack of trained manpower
PQ2. Do you think services of DICs can affect the health care in terms of cost, morbidity, and mortality reduction?
a. Yes	1
b. No	0
c. May be, sometimes	0
d. Don’t know	0
PQ3. Which modes of communication would you like to use for DIC service? (multiple marking allowed; less than or equal to any two options will be scored 0, while equal to or more than 3 options will be scored as 1)
a. Phone calls (landline/mobile)
b. Emails
c. WhatsApp/SMS
d. Dedicated website
PQ4. Should DICs be allowed to generate funds on account of information catered?
a. Yes	0
b. No	0
c. Free for basic drug information and fees for specialized drug information	1
d. Free for doctors working in government set up and fees for private doctors	0
PQ5. How to generate your own funds for the establishment and maintenance of DIC service (less than or equal to any two options will be scored 0 while equal to or more than 3 options will be scored as 1)
a.
Regular drug information trainings in the form of workshops/CMEs for pharmacology postgraduates working in other institutions
b. Running observership programs on critical appraisal of published literature
c. Setting up DIC with chargeable fees for any pharmacotherapy consultation
d. Training of industry personals on drug information

DICs: Drug information centers, HRA: House rent allowance, CMEs: Continuing medical education

In addition to assessing the participants’ responses, we also wished to identify predictive factors for particular knowledge, attitude, and practice behavior patterns among the pharmacists. Hence, we intended to create variables with binary values representing “better” and “poorer” category participants in each domain. The methodology creation is as follows: the values of the options in knowledge, attitude, and practice domain were initially summed and were then averaged to determine the mean. Based on each domain's mean value, the participants were divided into below average and above average (AA) in knowledge, attitude, and practice domain, respectively. These newly computed columns were denoted with a notation of “Classification Knowledge Domain,” “Classification Attitude Domain,” and “Classification Practice Domain” for knowledge, attitude, and practice domain, respectively [Table 2].

Table 2

Descriptives of options opted by the participants along with the association of all multiple-choice question responses with knowledge, attitude, and practice domain

Characteristic	Knowledge, n (%)			Attitude, n (%)			Practice, n (%)
	0, n=59	1, n=65	Pb	0, n=35	1, n=89	Pb	0, n=67	1, n=57	Pb
City
0	36 (61)	39 (60)	0.4	22 (63)	53 (60)	0.3	42 (63)	33 (58)	0.9
1	21 (36)	20 (31)		9 (26)	32 (36)		21 (31)	20 (35)
2	2 (3.4)	6 (9.2)		4 (11)	4 (4.5)		4 (6.0)	4 (7.0)
Designation
0	45 (76)	55 (85)	0.3	27 (77)	73 (82)	0.7	56 (84)	44 (77)	0.5
1	14 (24)	10 (15)		8 (23)	16 (18)		11 (16)	13 (23)
DIC functioning
0	37 (63)	46 (71)	0.6	28 (80)	55 (62)	0.030	41 (61)	42 (74)	0.3
1	10 (17)	10 (15)		6 (17)	14 (16)		13 (19)	7 (12)
2	12 (20)	9 (14)		1 (2.9)	20 (22)		13 (19)	8 (14)
KQ1
0	20 (34)	4 (6.2)	<0.001	8 (23)	16 (18)	0.7	18 (27)	6 (11)	0.039
1	39 (66)	61 (94)		27 (77)	73 (82)		49 (73)	51 (89)
KQ2
0	47 (80)	6 (9.2)	<0.001	21 (60)	32 (36)	0.025	30 (45)	23 (40)	0.8
1	12 (20)	59 (91)		14 (40)	57 (64)		37 (55)	34 (60)
KQ3
0	56 (95)	50 (77)	0.010	26 (74)	80 (90)	0.053	59 (88)	47 (82)	0.5
1	3 (5.1)	15 (23)		9 (26)	9 (10)		8 (12)	10 (18)
KQ4
0	59 (100)	58 (89)	0.027	34 (97)	83 (93)	0.7	67 (100)	50 (88)	0.010
1	0	7 (11)		1 (2.9)	6 (6.7)		0	7 (12)
KQ5
0	8 (14)	0	0.007	6 (17)	2 (2.2)	0.008	5 (7.5)	3 (5.3)	0.9
1	51 (86)	65 (100)		29 (83)	87 (98)		62 (93)	54 (95)
AQ1
0	6 (10)	4 (6.2)	0.6	9 (26)	1 (1.1)	<0.001	8 (12)	2 (3.5)	0.2
1	53 (90)	61 (94)		26 (74)	88 (99)		59 (88)	55 (96)
AQ2
0	12 (20)	6 (9.2)	0.13	15 (43)	3 (3.4)	<0.001	10 (15)	8 (14)	>0.9
1	47 (80)	59 (91)		20 (57)	86 (97)		57 (85)	49 (86)
AQ3
0	8 (14)	9 (14)	>0.9	13 (37)	4 (4.5)	<0.001	13 (19)	4 (7.0)	0.082
1	51 (86)	56 (86)		22 (63)	85 (96)		54 (81)	53 (93)
AQ4
0	14 (24)	19 (29)	0.6	25 (71)	8 (9.0)	<0.001	18 (27)	15 (26)	>0.9
1	45 (76)	46 (71)		10 (29)	81 (91)		49 (73)	42 (74)
AQ5
0	35 (59)	26 (40)	0.049	31 (89)	30 (34)	<0.001	29 (43)	32 (56)	0.2
1	24 (41)	39 (60)		4 (11)	59 (66)		38 (57)	25 (44)
PQ1
0	55 (93)	50 (77)	0.042	29 (83)	76 (85)	0.9	66 (99)	39 (68)	<0.001
1	3 (5.1)	12 (18)		5 (14)	10 (11)		1 (1.5)	14 (25)
2	1 (1.7)	3 (4.6)		1 (2.9)	3 (3.4)		0	4 (7.0)
PQ2
0	19 (32)	10 (15)	0.046	13 (37)	16 (18)	0.042	22 (33)	7 (12)	0.013
1	40 (68)	55 (85)		22 (63)	73 (82)		45 (67)	50 (88)
PQ3
0	33 (56)	29 (45)	0.4	18 (51)	44 (49)	0.8	56 (84)	6 (11)	<0.001
1	11 (19)	14 (22)		8 (23)	17 (19)		10 (15)	15 (26)
2	15 (25)	22 (34)		9 (26)	28 (31)		1 (1.5)	36 (63)
PQ4
0	35 (59)	42 (65)	0.7	17 (49)	60 (67)	0.082	46 (69)	31 (54)	0.15
1	24 (41)	23 (35)		18 (51)	29 (33)		21 (31)	26 (46)
PQ5
0	49 (83)	43 (66)	0.044	22 (63)	70 (79)	0.2	62 (93)	30 (53)	<0.001
1	8 (14)	12 (18)		9 (26)	11 (12)		5 (7.5)	15 (26)
2	2 (3.4)	10 (15)		4 (11)	8 (9.0)		0	12 (21)
ClassifyASum
0	19 (32)	16 (25)	0.5				19 (28)	16 (28)	>0.9
1	40 (68)	49 (75)					48 (72)	41 (72)
ClassifyPSum
0	37 (63)	30 (46)	0.10	19 (54)	48 (54)	>0.9
1	22 (37)	35 (54)		16 (46)	41 (46)
ClassifyKSum
0		19 (54)	40 (45)		0.5	37 (55)		22 (39)	0.10
1				16 (46)	49 (55)		30 (45)	35 (61)

aStatistics presented: n (%). bStatistical tests performed: Chi-square test of independence. DIC: Drug information center

Statistical analysis

The analysis was computed using R version 4.0.2 (a free software for statistical computing, from R Foundation, University of Auckland, New Zealand), and the base package, ggplot2,[7] readxl, ez,[8] sjPlot,[9] catspec,[10] and gridExtra[11] were used. Categorical variables were expressed as a number and column percentages, and the continuous variables were expressed as mean ± standard deviation. Binary logistic regression models were built to predict the knowledge, attitude, and practice traits using all the other remaining domains and the demographic data. For example, in the knowledge prediction model, we used the attitude, practice, and demographic domain questions and did not use the knowledge domain. The question's selection was based on univariate analysis, which consisted of a Chi-square test for categorical variables and an unpaired t-test for continuous variables.

For a survey, assuming that the pharmacist's intended population is 10 lakh, with a confidence interval (CI) of 95% and a margin of error of 9%, the required sample size for arriving at a meaningful conclusion is 119. Keeping a dropout rate of 10%, it was planned to send a questionnaire to 131 individuals.

RESULTS

One hundred and fifty pharmacy professionals were contacted through e-mail, WhatsApp, and Facebook messenger. Repeat reminders were sent 1 week later up to three times through other portals than previously used. One hundred and twenty-four participants (82%) responded and were included in the final analysis after checking for the data's completeness. The range for K score and A score was 0 to 5, while for the P score, it was 0 to 7. The average K score, A score, and P score for the study population were 2.52 ± 0.84, 3.88 ± 1.13, and 2.48 ± 1.61, respectively.

Association of knowledge

Participants believing in referring to the published literature for DIC service establishment and expansion; participants identifying more challenges in the DIC's daily functioning; and the participants believing in the ability of DIC in reducing morbidity, mortality, and cost of care had 4.76 (95% CI = 0.97–6.44), 4.24 (95% CI = 0.97–6.44), and 2.43 (95% CI = 0.97–6.44) times association with AA in “K score.” The odds of association did not turn significant between knowledge scores and ways proposed for generating our own funds to establish and maintain DIC service (odds ratio [OR] = 2.29, CI = 0.92–5.98) [Figure 1].

Figure 1

Association testing of knowledge domain versus attitude and practice domain, attitude domain versus knowledge and practice domain, and practice domain versus attitude and knowledge domain. *P < 0.05. **P < 0.01

Association of attitude

The participants who were working in limited functioning DIC and in fully functional DIC had 9.66 (95% CI = 0.97–6.44) and 9.49 (95% CI = 0.97–6.44) times association with AA in “A score” as compared with participants who were not catering DIC service. Pharmacy educators showed a nonsignificant attitude score association with identifying patient privacy preservation policy and noneligibility of promotional drug literature as a standard reference while answering drug information queries (OR = 2.37, CI = 0.84–6.72 and OR = 2.07, CI = 0.82–5.27). The study observed a negative association between good attitude score and the opinion on allowing DIC to generate their own funds for sustainable DIC services (OR = 0.29, CI = 0.08–0.99) [Figure 1].

Association of practice

The participant who understood the real purpose of the DIC (i.e., to provide unbiased drug information, to train postgraduates, and to control irrational drug use) had 2.83 (95% CI = 0.97–6.44) times association with AA in “P score” as compared with participants who did not believe so. A nonsignificant association was discovered between good practice scores and understanding DIC's ability to curb the irrational drug use practice (OR = 2.79, CI = 0.89–10.57) [Figure 1].

DISCUSSION

The present study was carried out to understand the differences and the similarities between pharmacists and pharmacologists driven drug information services. India is a heterogeneous country for individuals’ genetic makeup, multiple languages used, varied eating patterns, and region-wise resource disparity.[8] It becomes pertinent to study health-care professionals, pharmacy and pharmacology, in catering to the drug information service. The present study's pharmacy participants showed lesser knowledge and practice scores than pharmacologists in our previous study.[3] The finding depicts the difference in inland and the western pharmacy teaching because the establishment of the DIC concept was first proposed and imbibed by the pharmacists’ group of the University of Kentucky, USA.[12]

The present study also identified that the average attitude scores were lesser, with pharmacologists catering DIC services compared to pharmacy professionals. The pharmacologists of India are health-care professionals who have a basic medical background, i.e., Bachelor of Medicine and Bachelor of Surgery. Through all the clinical specialties, the internship rotations make the patient care and practical approach clearer for the medical graduates who later specialize in pharmacology to become pharmacologists looking after DIC operations ultimately.[13] Pharmacy programs in India expose postgraduate and doctorate students to patient care facility rounds, but it is still in a nascent stage.[14] It would be apt when both pharmacists and pharmacologists join hands together to strengthen DIC services further. Exchange of enriched attitude of pharmacists with an excellent knowledge and practice concepts of pharmacologists is the need of an hour for India [Table 3]. The current study pharmacy participant with good knowledge score believed in referring to published literature on how to establish and strengthen the DIC services; identified more number of challenges in the day-to-day functioning of DIC; and also believed in the potential of DIC in reducing morbidity, mortality, and cost of care. On the other hand, Praveen Kumar et al. from India showed that the pharmacologists bore good knowledge and practice scores and identified hurdles in DIC service strengthening and economic benefits for the patient and hospital.[3] Besides assessing opinions, the actual financial benefits were earlier demonstrated by Kinky et al. study with DIC facilities and dedicated pharmacists looking after the same.[15] Low-resource setting countries like India have to understand challenges in catering DIC services. A few are lack of financial support, limited access to online paid resources, and extra work undertaken by pharmacology and pharmacy divisions.[13] Amundstuen Reppe et al. had earlier explained the ever-changing role of and responsibilities of Scandinavian DICs. With newer and newer forms of therapies becoming available and deficient skills at physician's end for critical evaluation of medication, literature creates an alarm for both pharmacists and pharmacologists to come forward for the rescue and guide clinician colleagues. Especially in the coronavirus disease 2019 pandemic like scenario where off-label drug use is rampant, pharmacists and pharmacologists need to update with all new drug information and disseminate the same to local physicians.[16]

Table 3

Comparison of average knowledge, attitude, and practice score of previous study and present study

Authors	Target population	Knowledge score	Attitude score	Practice score
Kumar et al.	Pharmacologists	3.06±0.96	3.73±0.98	3.36±1.36
Current study	Pharmacists	2.52±0.84	3.88±1.13	2.48±1.61

Values expressed here as mean±SD. SD: Standard deviation

Pharmacy participants who were working in a fully functional DIC showed a positive association with a good attitude score. In contrast, participants with good practice scores understood the real purpose of the DIC: to provide unbiased drug information, train postgraduates, and control irrational drug use to strengthen evidence-based medicine practice. Praveen Kumar et al. study showed a positive association of good knowledge score with an understanding of DIC concepts.[3]

Lower knowledge and practice scores of pharmacists again emphasize upon much-needed critical appraisal of published literature guidance.[26] Pharmacy curricula similar to pharmacology curricula lack this primary section on evaluating medical literature for arriving at robust conclusions regarding safety and efficacy related to a drug. The curricula can be modified to include these sections and regular meetings of two disciplines to share knowledge, attitude, and practice experiences in the form of drug information workshops, conferences, and short-term training programs. The study is not without limitations. The findings need to be validated in other heterozygous country settings with pharmacologists and pharmacists catering to the same DIC services. The content validity index, ratio, and reliability score calculation were not done for the questionnaire instrument used.

CONCLUSION

Collaborative efforts from clinical pharmacists and pharmacologists complement each other and can revolutionize evidence-based medicine practice in low-resource settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.