Introduction

Failure of patients to take medications as directed has been well established (Maskew et al., 2007; Pierre-Jacquest et al., 2008; Karamanidou et al., 2008; Schuz et al., 2011) regardless of age or social standing. The scope of non-compliance is rampant due to drug-related problems, including adverse effects and interactions (Bell et al., 2006; Cerveny et al., 2007).

Antibiotic misuse in particular is a world wide problem and varies from one country to another and seems to be more significant in developing countries (Midtvedt, 1991; Levy and Marshall, 2004). In Saudi Arabia, antibiotics are actually prescribed on a large scale and easily obtained over-the-counter, since the law is not always followed which encourages self medication and thus predisposes the population to the potential risk of such irrational therapy (Montastruc et al., 1997; Cook et al., 2000).

Although drug interactions have been studied in hospitalized patients (Vonbach et al., 2007; Blix et al., 2008; Reis and Cassiani, 2011), little is known about prescribing patient and rate of exposure to drug interactions in the larger, but less monitored in the out patient (De Smet et al., 2007).

Significant number of individuals suffers preventable adverse drug reactions that may lead to unnecessary expenditure, hospitalization, prolonged illness or even death (Juntti-Patinen and Neuvonen, 2002; Zhang et al., 2007). Thus a continued emphasis on developing the pharmacists role as a patient counselor for medications is required if pharmacists is to assume a significant place in the delivery of health care.

Of the many attributes associated with patient non-compliance and thus drug misuse, misunderstanding of directions by patients has been implicated as a frequent problem (Midtvedt, 1991; Monkastrue et al., 1997; Cook et al., 2000; Levy and Marshall, 2004; Pierr-Jacques et al., 2008). Therefore, opportunities for pharmacist intervention in drug therapy seem obvious since incorrect drug knowledge by the respondents and failure of pharmacist to monitor potential interactions are all possible contributions to this problem. Hence, a great need for health care practitioners to become involved in improving compliance with medications is required. However, many pharmacists do not regularly counsel patients and when they do, the extent and quality of counseling by pharmacists is inadequate (Alte et al., 2007).

To implement routine patient counseling and expanded services in traditional community pharmacies, certain requirements need to be met which often cited as barriers to preclude the extension of such services (Allan et al., 1992; Siganga and Huynh, 1997). With this in mind, the present study had the following objectives: (1) To determine the competence of community pharmacists in monitoring drug-drug interaction (2) To test the degree of adherence of community pharmacists to pharmacy regulations (3) To examine the extent to which community pharmacists engage in patience counseling and (4) To throw light on the elements required to provide expanded services and the barriers that currently prevent expanded services.

Methodology

To accomplish the objectives of the present study, the following procedures were utilized:

(1). A questionnaire was designed and distributed to 100 randomly selected licensed community pharmacies (chain and independent) in Riyadh city to obtain demographic and descriptive information on each respondent. In addition, respondents answered an open-ended questions to meet the study objectives. Data were gathered via the questionnaire which consisted of three parts. The first part was designed to test competence of the community pharmacists, while the second and third parts were concerned with the adherence to pharmacy regulations and the counseling behavior activity of the community pharmacists respectively.

(2) After the questionnaire had completed and collected, a pharmacist who assumed a patient role then visited each pharmacy to obtain a combination of tetracycline capsules and antacid without a prescription to further examine the reliability of the answers to the questionnaire items. Since a significant drug interaction documented with this combination (Sadowski, 1994) is considered as a valid measure to test the pharmacists knowledge and competence. Furthermore, since antibiotics are prescribed drugs in Saudi Arabia, dispensing tetracycline without a prescription indicates a non-adherence to Pharmacy Regulations Act. Likewise, these two medications were selected because they were prescribed commonly.

The observer was taught to note the conversation and other activities that occurred in the pharmacy during the encounter and take a passive role in interaction with the pharmacists answering questions but not initiating conversation. The observer then recorded these informations on written forms after leaving the pharmacy. Data were analyzed using a personal computer. Frequency program was used to tabulate the data.

Results

Population description

Measures of competence

Measures of adherence to pharmacy regulations

Measures of counseling behavior

Seventy nine percent of practitioners who responded to the questionnaire reported an active involvement in patient counseling as part of their work day and a substantial percentage are willing to do so (Table-3). The most frequently mentioned counseling behavior offered by the respondents includes dosage directions which were provided by all practitioners. Side effect warnings and proper method of storage were reported by 14% and 8% respectively. On the other hand, none of the pharmacists who dispensed the request did indicate any dosage directions or when tetracycline should be taken with regard to meals. Only five percent of pharmacists told the observer to continue taking tetracycline until all the capsules have gone, and none of the practitioners warned the observer about potential problems caused by taking certain foods (e.g., milk) or other drugs (e.g., antacids) in conjunction with tetracycline.

The practitioners identified certain perceived barriers that prevented the provision of patients counseling and education. The dimensions underlying these barriers are shown in Table-4. As shown in Table-4, the most frequently mentioned barrier was the lack of time devoted to patient counseling aggravated by heavy work load which prevent the community pharmacists to become more involved in patient care in the absence of supportive personnel necessary to perform basic technical functions.

In addition, half of the practitioners felt that physician’s attitudes must be favorably changed towards pharmacists’ role in patient care, in order to fulfill the drug information needs of their community. Moreover, one third of the respondents recognized their limitation secondary to the inadequacy of their drug information libraries and thus did not perceive them as competent to provide such services. In responding to the research question regarding elements that facilitate providing patient counseling, the most frequently mentioned requisites deal with pharmacists’ competencies and the need for additional education relative to services to be provided (Table-5). Other primary requisites include the need for more manpower improved attitudes and the implementation of computer systems in community pharmacies.

Figure 1

Table 1: Measures of competence according to the questionnaire response

Figure 2

Table 2: Measures of adherence to pharmacy regulations according to the questionnaire response

Figure 3

Table 3: Scope of counseling behavior according to the questionnaire response

Figure 4

Table 4: Barriers limiting pharmacist’s ability to provide patients counseling

Figure 5

Table 5: Elements that facilitate providing patient’s counseling

Discussion

The results obtained in the present study identified several potential hazards to health. One major problem identified was on the sale of antibiotics. Notwithstanding the awareness on restriction imposed on its sale without prescription, these drugs are available over the counter. Hence, marking symptoms of serious infection, possible toxicity to individual and the emergence of bacterial resistance can be expected in our society due to self medication with antibiotics as a result of free availability of such drugs through un-controlled OTC dispensing (Al- freihi et al., 1987; Pallasch, 2003).

The current practice in drug dispensing at private retail pharmacies is by commercial packs to contain a fixed number of contents (tablets, capsules or liquid). This is conducive to uncontrolled drug left over and the possibility of further misuse by the patient or by members of his family. This is dangerous as most medicaments are potent as well as specific. Prescribing and dispensing the exact amount of medicines must be the rule. This should help reduce misuse (Al-freihi et al., 1987).

The study pointed out that committees and workshops has to be established (i) to review the list of OTC drugs (ii) to ensure adherence of regulations (iii) health education campaigns stressing the dangers of self medication and improvement of physician’s current dispensing habits may be carried out (iv) Campaigns are also warranted on strict control on dispensing major therapeutic agents such as antibiotics (v) Finally, unless the

pharmacist assumes a more active role in the health care system, he would no longer justify his time-honored position as a professional person. He will find himself performing a technical task limited to pouring and counting if any role with which a six-month training program should be adequate for such a person. Most of us are not willing to settle for that type of career. We are not willing to accept a technician’s approach to the practice of pharmacy. The general public certainly does not want that kind of pharmacists. The public deserves and need the help that only a true pharmacist can provide (Baugher, 2000).

As a result of a rapidly increasing prescription volume which placed mounting demands on the pharmacists’ time and energy, a pharmacy technician can be trained and employed to relieve the community pharmacist of many of his traditional role responsibilities, while simultaneously freeing him to adopt other functions including that of consultant (Wilson et al., 2003). Improved methods of professional communications between patient, pharmacists and physicians are required to provide safe and rational drug therapy. Although legislation exists on prescription and non prescription medicines, it is very easy to get prescription medicines over-the-counter, since the law is not always followed which encourage self medication and predisposes the population to the potential risk and adverse effects of misuse (Montastruc et al., 1997; Cook et al., 2000).

In order to derive full benefit from prescriptions, patients need to be aware of their purposes, of any possible hazards and when and how to take them. Doctors and pharmacists have a collective responsibility to ensure that patients have this information. Our current survey confirms that they frequently fail to do so. Hence, a need was felt for improved coordination, education and advocacy involving patients, pharmacists and physicians in medication use (Pujol Ribera et al., 2006).

Although most of the pharmacists reported capability of counseling patients, they believed continuing education seminars are the most likely format to enhance pharmacists’ capability to perform patient counseling. Almost all pharmacists, who responded to the survey, reported performance of patient counseling and they believed that their patient counseling services are less effective. The level of pharmacist involvement is insufficient based on the information, if any, that is offered to the consumer. This is in accordance with other studies (Lamsam and Kropff, 1998; Awad et al., 2006) and is identified to be related with barriers like; lack of facilities of continuing education, paucity of time and dearth of sufficient staff.

To implement routine patient counseling by community pharmacists may require increases in personnel and extensive changes in pharmacy facility. Technician assistance in the dispensing activity has viewed as necessary by pharmacists to implement patient counseling. The extra time necessary to counsel patients could be found through technical assistance addressed in a regulation, as the technicians supports a more expanded patient care role (Wilson et al., 2003). In addition, pharmacists may need to recognize prescription processing to permit sufficient time to provide quality information. The impetus to increase the quality and quantities of patient counseling should come from pharmacy education, pharmacy association and pharmacy practitioners, not by a governmental regulation.

Despite of the increased clinical orientation of pharmacy education, community pharmacists are unable to provide expanded service. If the ability is a significant barrier to the provision of clinical services, educational programs should be initiated to provide the missing competencies of community pharmacists (O’ Neil and Berdine, 2007). Educators must realize that competence is more than knowledge; it includes skills, confidence, and knowing how to innovate and manage a clinical practice. Several weeks of clinical experiences in a baccalaureate program are not adequate to meet these needs. It is encouraging that some practitioners are willing to develop their competencies in the required areas, if they can be shown the need for those services. They also will require a convenient method to develop those competencies. Hence, external degree programs by the college of pharmacy should become a priority of the profession.

The willingness of pharmacists to provide expanded services as seen in the result of this study was likely caused by their desire to do more, but a variety of barriers preclude their performance of such services (Lamsam and Kropff, 1988). Pharmacists in this sample clearly perceive their primary role as doing distributors and then functions take precedence over other patient care services. It will take a change in educational philosophy and reimbursement to reorient those priorities.

The results may indicate that pharmacists have adopted the role of drug counselor to patient, but only to a limited extent. Several possible explanations for this behavior can be postulated. The first explanation is that pharmacists may feel that only certain patients need to be provided with voluntary counseling. Pharmacists may feel that these patients need more counseling because they are not able to take care of themselves, possibly due to their minimal educational attainment or because of the increased possibility of drug interactions stemming from their multi-drug therapy. Another possible explanation is that pharmacists, because of their workload, may not have time to counsel every one, so they counsel only those patients whom they perceive to have the greatest need of it. This explanation suggests that attempts to increase the extent of pharmacist counseling should focus on decreasing the pharmacists work load. Future research in this area is needed and could be quite useful in planning programs and approaches to increase the frequency of pharmacist counseling.