The SC visited a total of 132 community pharmacies but only 100 community pharmacies were included in the present study. The remaining 32 community pharmacies were excluded due to various reasons: pharmacists were on leave or not available during the visits (24) and pharmacies closed or ceased operation (8). Characteristics of the 100 community pharmacists and pharmacies visited by the SC are shown in Table 1.
Table 1
Characteristics of the community pharmacists and pharmacies (N = 100)
Characteristics | Percentage |
Sex | |
Female | 62 |
Male | 38 |
Location | |
Ampang Jaya | 5 |
Selayang | 7 |
Klang | 8 |
Shah Alam | 8 |
Kajang | 9 |
Petaling Jaya | 12 |
Subang Jaya | 13 |
Kuala Lumpur | 38 |
Ownership | |
Individual non-pharmacist | 2 |
Individual pharmacist | 42 |
Group of pharmacists | 33 |
Corporate bodies | 23 |
Number of branches | |
1 | 33 |
2 to 10 | 23 |
11 to 50 | 19 |
51 to 100 | 8 |
101 to 200 | 9 |
400 to 500 | 8 |
Provision Of Pharmaceutical Care Services
The practice of the five principles of pharmaceutical care by the community pharmacists in the present study is shown in Table 2.
Table 2
Community pharmacists who fulfilled the practice principles of pharmaceutical care (N = 100)
Components of each pharmaceutical practice principle | Frequency (%) | Frequency (%) of practice principle fulfilled |
Patients' data collection | | 0 (0.0) |
Who the medicine is for? | 38 (38.0)a | |
Age of patient? | 17 (17.0) | |
Symptoms of cough (i.e. dry or phlegm cough)? | 97 (97.0) | |
Any other symptoms? | 29 (29.0) | |
How long the patient has the cough? | 27 (27.0) | |
What medication has been taken for the current cough? | 10 (10.0) | |
Any known allergy to any medications? | 8 (8.0) | |
Does the patient have other medical conditions/history? | 25 (25.0) | |
What other medications the patient is taking? | 13 (13.0) | |
Lifestyles such as occupation, smoking or other daily activities | 22 (22.0) | |
Medical information evaluation | | 13 (13.0) |
The possibility of medication-induced cough was identified | 9 (9.0) | |
A possible non-medication-induced cough was explained | 8 (8.0) | |
Formulating a drug therapy plan | | 15 (15.0) |
Pharmacist recommended medication(s) for cough | 98 (98.0) | |
Pharmacist suggested a non-medicine treatment plan | 6 (6.0) | |
Referred to a doctor due to cough duration or medication-related problem | 11 (11.0) | |
Implementing a drug therapy plan by providing counselling on the followingb | | 0 (0.0) |
Possible cause of cough | 12 (12.2) | |
Name of medicationc | 13 (13.3) | |
Dose of the medicationc | 85 (86.7) | |
Frequency of medication to be takenc | 88 (89.8) | |
Duration of the therapy | 3 (3.1) | |
Side effects or precautionsd | 0 (0.0) | |
Mechanism of action | 3 (3.1) | |
Storage conditions of the medicine | 0 (0.0) | |
Non-pharmacological management | 6 (6.1) | |
Advice to visit a health care provider if symptoms persist | 11 (11.2) | |
Monitoring and modifying the plan | | 3 (3.0) |
Pharmacists provided contact details and requested the client to return for a follow-up | 3 (3.0) | |
Pharmacists requested the client's contact details for follow-up | 0 (0.0) | |
a Before being prompted whether the medication is suitable for the simulated client's father. |
b n = 98 as 2 pharmacists did not recommend any medication or product |
c With both label and verbal communication. |
d Only if a sedative medication was given. |
Table 2. Community pharmacists who fulfilled the practice principles of pharmaceutical care (N = 100)
Ten questions which should be asked by the community pharmacists were included under patients' data collection (Table 2). The number of questions asked by the community pharmacists ranged from 0 to 8. As the data were not normally distributed, the median (IQR) of 2.00 (3.00) questions asked was generated. None of the community pharmacists asked the SC all the questions required before deciding on the recommendation.
Of the 100 community pharmacists, three did not ask any questions before recommending medications to the SC while one pharmacist still did not ask any questions even though the SC tried to prompt him/her by asking whether the medication could be used by the SC's father. Two of the pharmacists did not recommend any medication or product to the SC as one of them suspected that the cough could be medication-induced and suggested that SC should bring the father's medications to the pharmacy before he/she could recommend anything. The other pharmacist refused to recommend any medication and advised SC to bring the father to see a medical doctor.
In addition, 62 community pharmacists (62%) assumed that the cough medication was for SC but 22 of these pharmacists realized that the medication requested was for SC’s father upon further questioning while another eight pharmacists only realized this when they were asked by SC whether the medication could be used by his father. However, the remaining 32 pharmacists continued to recommend medication as though SC was the patient even after being prompted if the medication could be used by the SC's father.
Of the 98 community pharmacists who recommended a medication, 92 (93.9%) initiated counselling on the medication without being asked by the SC, but none of the pharmacists provided all the 10 counselling elements under the practice of implementing the drug therapy plan principle (Table 2). The number of counselling elements provided by these pharmacists ranged from 0 to 6, with a median (IQR) of 2.00 (1.00).
Number Of Clients And Time Spent On Consultation
During the SC visits, 74 community pharmacies (74%) did not have any other clients in the pharmacies while 26% had 1 to 9 clients. However, 63% of the community pharmacists spent only one minute or less while the other 37% spent more than one minute but less than four minutes responding to the minor ailment presented by SC.
Medications Recommended For Cough
A total of 112 medications or products, which consisted of 36 different brands (Additional file 3) were recommended by the community pharmacists and purchased by the SC during the study. Three of the recommended medications did not have any name indicated. Various dosage forms of medications or products were recommended by community pharmacists, with Tussidex Forte™ (dextromethorphan hydrobromide) linctus being the most common.
Medicines containing dextromethorphan were the most commonly recommended for the treatment of dry cough (49%), followed by cloperastine (17.4%), pholcodine (15.3%), and diphenhydramine (6.1%). Among the 98 community pharmacists who recommended a medication(s) or product(s) to the SC, 86 (87.8%) recommended one medication or product, while another 10 (10.2%) recommended two, and two (2%) recommended three medications or products. The median (IQR) cost of treatment was RM10.00 (8.10) and ranged from RM2.00 to RM39.80.
Appropriateness Of Medicine Recommended
Based on the online Martindale database, cough suppressants such as pholcodine, dextromethorphan and cloperastine hydrochloride, as well as sedative antihistamines such as diphenhydramine in compound preparations, are commonly used and indicated for the complaints mentioned in the simulated case. The appropriateness of the medications recommended was evaluated based on the indications for dry cough [27, 28]. The medication should not impair the ability to drive or operate heavy machinery since the SC’s father is a taxi driver, and safe (without contradictions or precautions) for use in patients with hypertension, hyperlipidaemia and diabetes mellitus based on MIMS Drug Reference [29] or the product inserts.
Of the 98 pharmacists who recommended medications to the SC, only 67 (68.3%) recommended appropriate medications for a patient who also has hypertensive, hyperlipidaemia, diabetes mellitus and the need to drive or operate machinery. However, three (3.1%) pharmacists dispensed the medications as loose tablets or capsules without the name of the medications on the label and explanation. Among those who had recommended appropriate medications, five (7.5%) also recommended other medications or products for indications such as nasal congestion, running nose or phlegm which were not mentioned by the SC and hence, not indicated in this case.
Factors Associated With The Number Of Questions Asked And Counselling Elements Provision
Possible characteristics of pharmacists (sex, age group) and pharmacies (type of ownership, location) which might be associated with the number of questions asked were analysed using univariate and multivariate Poisson regression (Table 3). Only the location of the community pharmacy was significantly associated with the number of questions asked by the pharmacists.
Table 3
Possible factors associated with the number of questions asked by the pharmacists (n = 98)a
| Univariate Poisson regression | | Multivariate Poisson regression | |
Factors | IRR (95% CI) | p-value | IRR (95% CI) | p-value |
Sex | | | | |
Female | 1.188 (0.929, 1.519) | 0.170* | 1.024 (0.782, 1.339) | 0.865 |
Male | As reference | | As reference | |
Age | | | | |
40 and above | 1.026 (0.806, 1.304) | 0.837 | - | - |
Below 40 | As reference | | - | |
Ownership | | | | |
Company/corporate | 1.347 (0.987, 1.839) | 0.164* | 1.375 (0.999, 1.894) | 0.148 |
Individual pharmacist | 1.198 (0.907, 1.582) | | 1.170 (0.878, 1.558) | |
Group of pharmacists | As reference | | As reference | |
Location | | | | |
Shah Alam | 1.607 (0.867, 2.980) | 0.023* | 1.682 (0.903, 3.135) | 0.044** |
Subang Jaya | 1.374 (0.759, 2.485) | | 1.470 (0.809, 2.672) | |
Klang | 1.071 (0.554, 2.071) | | 1.144 (0.580, 2.254) | |
Selayang | 1.020 (0.515, 2.020) | | 1.109 (0.556, 2.209) | |
Petaling Jaya | 0.923 (0.491, 1.734) | | 0.981 (0.520, 1.852) | |
Kuala Lumpur | 0.923 (0.526, 1.618) | | 0.949 (0.538, 1.676) | |
Kajang | 0.635 (0.310, 1.301) | | 0.707 (0.342, 1.462) | |
Ampang Jaya | As reference | | As reference | |
Number of branches | 1.000 (1.000, 1.001) | 0.268 | - | - |
a Two respondents from other ownership groups of non-pharmacist were excluded from the analysis due to insufficient number for statistical comparison
* p equal or < 0.25
** p < 0.05
IRR - Incidence rate ratio
CI - Confidence interval
The incidence rate ratio (IRR) of the number of questions asked by community pharmacists practising in Shah Alam was 2.378, 1.772 and 1.714 times significantly higher than those in Kajang, Kuala Lumpur and Petaling Jaya, respectively. Whereas, such IRR for those practising in Subang Jaya was 2.078 and 1.548 times significantly higher than those in Kajang and Kuala Lumpur (Table 4).
Table 4
Significant associations of pharmacy location and number of questions asked by the pharmacists (n = 98)a
Location | IRR (95% CI) | p-value |
Shah Alam | 2.378 (1.303, 4.341) | 0.005** |
Subang Jaya | 2.078 (1.176, 3.672) | 0.012* |
Kajang | As reference | - |
Shah Alam | 1.772 (1.174, 2.674) | 0.006** |
Subang Jaya | 1.548 (1.075, 2.229) | 0.019* |
Kuala Lumpur | As reference | - |
Shah Alam | 1.714 (1.052, 2.795) | 0.031* |
Petaling Jaya | As reference | - |
a Two respondents from other ownership groups of non-pharmacist were excluded from the analysis due to insufficient number for statistical comparison
* p < 0.05
** p < 0.01
IRR - Incidence rate ratio
CI - Confidence interval
Possible associations between the characteristics of pharmacists or pharmacies and the number of counselling elements provided are shown in Table 5. However, there were no significant associations.
Table 5
Factors associated with the number of counselling elements provided by the pharmacists (n = 96)a
| Univariate Poisson regression | |
Factors | Odds Ratio (95% CI) | p-value |
Sex | | |
Female | 1.178 (0.888, 1.562) | 0.255 |
Male | As reference | |
Age | | |
Below 40 | 1.030 (0.777, 1.366) | 0.837 |
40 and above | As reference | |
Ownership | | |
Company/corporate | 1.209 (0.862, 1.695) | 0.544 |
Group of pharmacists | 1.094 (0.799, 1.498) | |
Individual pharmacist | As reference | |
Location | | |
Shah Alam | 2.167 (0.892, 5.264) | 0.457 |
Subang Jaya | 1.590 (0.663, 3.810) | |
Klang | 1.167 (0.448, 3.036) | |
Selayang | 1.524 (0.596, 3.894) | |
Petaling Jaya | 1.333 (0.545, 3.262) | |
Kuala Lumpur | 1.524 (0.665, 3.493) | |
Kajang | 1.185 (0.464, 3.029) | |
Ampang Jaya | As reference | |
Number of branches | 1.000 (0.999, 1.001) | 0.434 |
a Two pharmacists did not recommend treatment and thus their counselling was not studied, 2 respondents from other ownership groups of non-pharmacist owned were excluded from the analysis due to insufficient number for statistical comparison