Response rates and characteristics of CPs
Questionnaires were sent to 364 participants, out of whom 215 completed the questionnaire. The response rate was 70% and all responses were complete. Table 1 shows demographic and other characteristics of the CPs. Out of 215 respondents who completed the survey, 155 (72.1%) were females and 60 (27.9%) were males. The median age of participants was 29 years (IQR 28-31), with a median of 3 (2-5) years of experience as a community pharmacist. Most participants were of Chinese ethnicity (70.7%), worked in chain pharmacies (65.5%), were full-time employees (87.0%), had a bachelor’s degree (94.4%), and indicated that they had been trained in adverse drug events (ADEs) (82.3%) (table 1).
Pharmacy practices related to TCS
About 97% responded that “14 days or less” as maximum duration for TCS treatment and 85.6% of the CPS correctly three topical corticosteroids in decreasing order of their potency. About 1 in 10 CPS (10.2%) accurately identified scenarios that necessitate medical referrals. 98.1% of CPS perceived that “pharmacist’s explanation” and 90.2% “Internet” as patient’s main source of information on TCS. Respondents rated steroid-only topical corticosteroid as most sold compared to other steroid-combination products, followed by steroid-antibiotics or steroid-antifungals, steroid-keratolytic, and steroid-other combination. Pharmacists ranked medication misuse and medication characteristics, such as potency of topical corticosteroids, as the most common cause of adverse drug events; followed by patient characteristics, (patient’s age), and medication overuse. Dry skin and skin irritation were the most reported adverse drug event, followed by skin discolouration and skin infections. When patients contacted community pharmacists about adverse drug events caused by topical corticosteroids, 79.5% recommended them to discontinue the medication and advised them to see a doctor. Additionally, 76.7% of respondents indicated they would recommend treatment re-trial following a medication review and patient re-education. Only 27.0% of participants would report the event to the National Pharmaceutical Regulatory Agency (NPRA).
Dispensing characteristics of TCS, counselling about TCS use and barriers
Table 2 shows dispensing characteristics and barriers to counselling about TCS. Participating pharmacists estimated 60% (IQR 30.0 – 90.0) of topical corticosteroid sales are non-prescription, with half (50%, IQR 30.0 – 70.0) were sales by pharmacist’s recommendation. Pharmacists estimated spending a median of 5.0 minutes (IQR 5.0 – 8.0) to prepare for counselling. Counselling a patient on a prescription TCS took a similar median time of 5.0 minutes. The frequency of explaining to the patient about various aspects of TCS use are shown in table 3. The CPs most of the time explained that the medication was a TCS (86%), and its frequency and duration of use (>90%); however, information about potency, method of application including strength (dose), side effects were not explained most of the time to the patients (<50%) (table 3). A total 153 of 215 respondents reported of at least two barriers. Among 306 responses received patient’s negative perception towards TCS (65.4%), lack of time for counselling (49.7%), lack of counselling material (40.5%), and presuming patients already knew about TCS (30.7%) were commonly selected barriers by the CPs (table 2).
Factors associated with patients’ knowledge on TCS and counselling practice scores
Table 4 shows the bivariate comparisons of CPs counselling practice score with demographic factors and factors related to counselling about TCS. The scores were higher among younger CPs, those trained in ADE, those who spent more time preparing for counselling and counselling patients, those who perceived greater barriers to counselling and those with a higher knowledge score. Counselling practice score was associated with age, training on adverse dug events, time spent on counselling, knowledge, and perceived barriers (<0.05). On multivariate analyses, counselling practice score decreases with age with the odds reducing by 0.86 times for each one-unit increase in age (p= 0.001). Practice scores are also reduced by 0.11 times for each one-unit increase in topical corticosteroid supply by pharmacists’ recommendation (p= 0.037). Counselling practice scores are increased by 42% (p= <0.001) and 4% (p= 0.047) for time spent for counselling for prescription and non-prescription topical corticosteroid respectively (table 5).
Patient’s Experience Receiving Counselling from Community Pharmacists
A total of 30 patient responses were obtained. Nineteen respondents (63.3%) were female, 15 were of Malay ethnicity while 11 (36.7%) were Chinese and 16 respondents (53.3%) were prescribed a steroid only preparation while 12 were prescribed a combination of a steroid with an antimicrobial. Twenty (66.7) purchased TCS for their own use. Out of 30 patient respondents who completed the questionnaire survey, 11 (36.7%) were males and 19 (63.3%) were females. The mean age of patient participants was 43.3 years (SD= 10.9) and half the participants were of Malay ethnicity (50%). More than half of patients purchased steroid-only topical corticosteroids (53.3%), and 66.7% of patients purchased the medication for their own use. The content of counselling received by patients from a community pharmacist was also surveyed (Table 6). Patients were asked if they received specific counselling about their purchased medication from a pharmacist, such as skin conditions that the medication should not be used on, potency, dosage, frequency, and duration, and information about potential adverse events. All patients were informed of the frequency and duration of application of medication, and that the product purchased is a topical corticosteroid. Most patients were also counselled on the potency of the TCS, how to apply the prescribed medication, and dosage and potential side effects of the topical steroid. However, less than half were counselled on the appropriate action to take when an adverse drug event occurs, and the storage and use of leftover medication.