A qualitative evaluation of new emerging role and challenges for community pharmacist in Pakistan : A case study report

To evaluate the new emerging role of community pharmacist and the challenges they are facing among the profession and public. A qualitative study approach was adopted in three different cities of Pakistan for a period of four months; a questionnaire based interview guide was developed after extensively reviewing the literature and utilized to collect the data. The respondents were community pharmacists and all the interviews were conducted at the work places and a written consent was obtained from participants prior to the interview. The volunteered respondents were 16 community pharmacists among them ten were male and six were female and they were aged between 25 and 45 years and all of them were actively involved in dispensing and their average frequency of dispensing the prescriptions were 40 to 50 per day. After thematic content analysis of data 5 major themes were obtained: (1) Poor literacy rate in rural patients; (2) Lack of effective patient counseling; (3) Lack of practical training and coaching of pharmacist; (4) Centralized drug reporting system; (5) Potential opportunities. There is a lack of awareness among the other health care professionals and public in regard to the new emerging role of community pharmacists in Pakistan, there is a greater need to reduce the communication gap between the physicians and pharmacists in regard to drug information sharing which will ultimately improve the quality of life of patient. Pharmacists need to focus more on provision of quality pharmaceutical care services rather than focusing on management of their outfits.

assessment of health system performance globally and providing professional leadership (World Health Organization, WHO, 1946).Primary aspect of global health policy is the pharmaceuticals as medications are a key treatment modality for controlling many diseases (Oji and Oji, 2010).There is a need of modification in pharmacy education, exposure of faculty and students and community pharmacist to wide opportunities in global health, development in pharmaceutical care models and changes in the curriculum (American Academy of Clinical Pharmacy, AACP, 2011).
Globally pharmacists have been recognized as one of the critical member of health care team especially about the safe, effective and efficient use of medicines (International Pharmaceutical Federation, FIP, 2000).Traditionally the role of pharmacist was the safe compounding and dispensing of medications and pharmacist were not paid for cognitive services they were also not held responsible for their recommendations by means of documentation or monitoring, traditionally the focus of pharmacist was product management (Wiedenmayer et al., 2006).Rapid growth and development in the field of medicines and continuous efflux of new information's make it impossible for health care professionals to keep it updated in all aspects (Saddique, 2012).
Pakistan is sixth in the ranking of most populous country and its population is equivalent to 2.62% of the total world population (Chapman et al., 2008).In Pakistan pharmacist, has struggled a lot to be recognized as a member of health care team for many years, and ministry of health is the key authority for planning and implementation of health care strategies (Ghaffar et al., 2000).
It has been estimated that there are approximately more than 8500 qualified pharmacists who are practicing in various sectors like public, private and non-profit organizations (World Health Organization, WHO, 2007).Approximately less than 10% of them are engaged in community pharmacy as majority of the pharmacists after their graduation are engaged in pharmaceutical industry and some in marketing (Ahmad, 2009).
This study was designed in terms of qualitative approach to discover the perception of new emerging role of clinical pharmacist in health care setting of Pakistan and different strategies adapted to overcome those barriers.

METHODS
This qualitative study was designed and conducted during the period of four months from 15 th December 2014 to 15 th March 2015 to discover the perception of community pharmacist.A questionnaire based interview guide was developed after extensively reviewing the literature and utilized to collect the data (Ghaffar et al., 2000;World Health Organization, WHO, 2007).The participants in the study were community pharmacist and have volunteered to participate in the study.The study was conducted in Khan et al. 267 three different cities of Pakistan, Abbottabad, Peshawar and Lahore.All the interviews were conducted at the work places by the researcher (MSK) and a written consent was obtained from participants prior to the interview.The major focus of the interview was the practice of pharmacy and the services provided by the community pharmacist to the consumers other than the traditional role of pharmacist.During the interview, open ended questions were asked and respondents were given freedom to express their views and where ever it was necessary bridging and probing techniques of communication were used to gather sufficient information.Time span of every interview was 30 to 40 min and was conducted at the work place.All the interviews were conducted in English.Demographic evaluation of the respondents in study is represented in Table 1 and further elaborated in Figure 1.All the community pharmacist involved in the study was facing challenges in their role and its further elaborated in results and discussion.
Figure 2 represents the gender wise distribution of the respondents involved in the study.All the respondents included in the study were divided in three different categories depending on the nature of their employment status and elaborated in Figure 3.

RESULTS
A total of 16 community pharmacists were interviewed and among them ten were male and six were female and they were aged between 25 to 45 years and all of them were actively involved in dispensing and their average frequency of dispensing the prescriptions were 40 to 50 per day.Demographic features of respondents are in Table 1 among them there were ten who were associated to chain pharmacies and this trend was more dominant in cities like Lahore and Peshawar while six of them were associated to independently owned pharmacies.There were seven respondents whose experience in community pharmacy practice was > 10 years and nine were < 10 years.Employment status of the pharmacists is shown in Table 2.
From the data of the interviews a saturation point was reached after the 16 th interview and thematic content analysis of data yielded 5 major themes: (1) Poor literacy rate in rural patients; (2) Lack of effective patient counseling; (3) Lack of practical training and coaching of pharmacist; (4) Centralized drug reporting system; (5) Potential opportunities.

Theme 1: Poor literacy rate in rural patients
Most of the respondents expressed that patients coming from the far rural areas have a very poor literacy rate which ultimately effects their understanding towards therapeutic regime and leads to poor confidence level to explain their concerns about medication.
"There are patients with literacy rate below elementary level have a very poor understanding even about their disease state" (CP2)."Patients with a low literacy rate even feel shy to explain their symptoms due to social taboos to their health care provider which makes it difficult to select the rational therapeutic regime, and ultimately leads to worsen the disease condition and more economical burden on the patient and his/her family" (CP8).
"We are actively involved in patient counseling and considers it a key pillar of pharmaceutical care and we keep our pharmacist rotating so everyone gets the "Poor literacy rate leads to poor understanding about the medicines" (CP12).

Theme 2: Lack of effective patient counseling
In a community pharmacy counseling is provided by the pharmacist as he/she is the most appropriate person who can counsel the patient not the pharmacy technician.
"We are actively involved in patient counseling and considers it a key pillar of pharmaceutical care and we keep our pharmacist rotating so everyone gets the opportunity to counsel the patient in his/her working shift" (CP 1)."Yes, we provide proper advice and guidance regarding the dosage and frequency and educate the patient about drug-food interactions" (CP 9)."We educate the patient about any possible side effects and to inform our pharmacy if they find any side effects" (CP 7)."I always make sure that patient understands the counseling regarding the medicines and if there is a need to communicate in his/her local dialect I do so they can understand all the information provided to them.

Theme 3: Lack of practical training/coaching of pharmacist
Most of the pharmacists believe there is a lack of practical training of young pharmacy graduates and there are some new graduates who have lack of selfconfidence and communication skills.The curriculum of pharmacy is more theoretical and there is a need to revise the curriculum per the practical aspects of the profession.
"There is a need of training/coaching programs to be organized by health care settings where community pharmacy is more developed to practically train the new graduates which will make their confidence level better and will improve their communication skill."(CP 4) "Health awareness programs are organized for health care settings and they are usually sponsored by pharmaceutical manufacturers but there is a lack of training and refresher courses for community pharmacists."(CP 10) "Sometimes Academic institutes organize certain workshops and seminars in regard to community pharmacy but due to work load and insufficient number of pharmacists we do not find time to participate actively, there is a need of planning regarding the pharmacy education in Pakistan and the curriculum need to be redesigned to focus more on practical approach."(CP 13) Theme 4: Centralized drug reporting system All the respondents agreed that there is a need of centralized drug reporting system and all the reported cases need to be documented and shared, as mostly patients are not informing about the occurrence of any adverse drug reactions.
"Patients never inform about the ADR or even about the side effects as this culture needs to be changed and it should be communicated to the patient that if they observe any ADR or side effect report it to the pharmacy, and the community pharmacist on duty should be able to address it and document it" (CP 14).
"Very rare ratio of patients who are aware about the role of a pharmacist they report ADR." (CP 11)

Theme 5: Potential opportunities
There is no need to introduce the new role of community pharmacist as it is the heart of pharmaceutical care.
There are certain potential opportunities that need to be tackled to improve the current practice and status of profession in the country.
"To initiate and sustain the wind of progressive change there is always a need of strong leadership.We need to create that culture, assign the responsibility, set the expectation level and focus on the goal which is patient services."(CP 6) "Pharmacist should be the one who run the pharmacy and there is a need to create awareness about the importance of pharmacists in the community and among the health care team, not only the government but also every one of us should take the responsibility to participate in that awareness and education so people can recognize the role of pharmacist in community."(CP 16)

DISCUSSION
The provision of quality health care services to the consumers is one the primary focus of community pharmacist and the major indicator of good pharmacy practice is the consumer satisfaction.There were different opinions among the respondents regarding the provision of pharmaceutical care services in the country (Awad et al., 2006;Azhar et al., 2011).As majority of the population in the country belongs to rural areas and due to lack of literacy rate patients are not aware even about their disease status and they need more precise and clear information in terms of their disease along with the counseling of therapy.
It was suggested by the different respondents that pharmacists should actively participate in patient counseling sessions which can significantly reduce the non-adherence to therapy.All the respondents agreed that patient counseling should not be limited to counseling on dosage but it should be extended to provide complete pharmaceutical care services (Azhar and Hassali, 2009).
Most of the pharmacists believed there is lack of practical training and awareness programs for the pharmacist as most of the health awareness programs are organized by the hospitals and pharmacists are not appreciated for participation.There is a critical need of educational programs to create awareness among the public and health care team concerning what is the role of pharmacist as a member of health care team.The communication gap between the pharmacist and physician need to be overcome in relation to drug information to provide good pharmaceutical care services to the community.The entire community pharmacist has mentioned that there is need of extensive training and development of community pharmacist on global trends to overcome these challenges and in the long run curriculum of pharmacy education need to be revised on time to time bases to meet the global challenges.
It was observed that patients are not reporting the adverse drug reactions and there is a need of a centralized drug reporting and sharing center.
It was recommended by all the participants that pharmacy curriculum need to be revised per the new emerging and challenging role of pharmacist.The curriculum should be more focused on practical aspects not theoretical.

Limitation of the study
The present study involved only three cities of Pakistan.However, the perception in regard to the new emerging role of community pharmacist in other cities of the country would probably be the same.The findings of the present study may not be applicable to other community pharmacists working in other cities of the country.

Conclusion
Majority of the findings form this study revealed that community pharmacist is facing hurdles in their new role and there is a need of awareness among the public and health care team.There is a need to explore the pharmaceutical care concepts among the other health care providers.Pharmacist working in the community pharmacies need to keep their knowledge up-to-date to provide effective patient counseling and their services should be more focused on pharmaceutical care rather than on general management of their pharmacies.More over there is a need of awareness and education not only for public to understand the new and emerging role of pharmacist but also among the professionals to understand and accept their new role.There is a greater need to reduce the communication gap between the physicians and pharmacists in regard to drug information sharing which will ultimately improve the quality of life of patient.
Figure 2. Gender distribution of respondents.

Table 1 .
Demographic features of respondents.
Figure 1.Demographic features of respondents.