Pharm World Sci (2010) 32:146153 DOI 10.

1007/s11096-009-9360-6

RESEARCH ARTICLE

Health promotion and education activities of community pharmacists in Kuwait

Abdelmoneim Awad Eman Abahussain

Received: 12 September 2009 / Accepted: 20 December 2009 / Published online: 29 December 2009 Springer Science+Business Media B.V. 2009

Abstract Objectives To investigate self-reported practice of pharmacists regarding health promotion and education activities, explore the barriers that may limit their involvement in health promotion and education, and identify their willingness to participate in continuing education programs related to health education. Setting Community pharmacies in Kuwait. Method A descriptive cross-sectional study was performed using a pre-tested questionnaire on a sample of 223 community pharmacists. Main outcome measures The extent of the pharmacists involvement in counselling patients about health promotion and education topics, their preparation to counsel patients in health promotion and education topics, and their perceived success in changing the patients health behaviour. Results The response rate was 92%. Information on medication use was the most frequent reason for consumers seeking community pharmacists advice. The majority of respondents believed that behaviour related to the proper use of drugs was very important. There was less agreement on the importance of other health behaviours. Respondents indicated they were involved in counselling patients on health behaviours related to use of drugs as prescribed/directed, weight management, medicine contents and side effects, diet modication and stress reduction, but were less involved in counselling on other health behaviours. Respondents perception of themselves as most prepared to counsel patients closely reected their involvement. Pharmacists reported high levels of success in helping patients to achieve improvements in using their drugs properly compared to low levels in changing patients personal health behaviours. The
A. Awad (&) E. Abahussain Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait e-mail: amoneim@hsc.edu.kw

majority of respondents believed that pharmacists had a responsibility for counselling consumers on health behaviours (97%, 95% CI 9599%), and indicated their willingness to learn more about health promotion (84%, 7888%). Lack of pharmacists time was reported by about 58% of respondents as the major barrier limiting pharmacists provision of health promotion. Conclusion The role of community pharmacists in health promotion and education is primarily focused on pharmaceutical issues rather than health behaviour modication. The majority of respondents have a positive attitude towards counseling the population on health behaviours and indicated their willingness to learn more about health promotion. Keywords Community pharmacist Health education Health promotion Kuwait

Impact of ndings on practice Pharmacists in Kuwait are willing to learn more about health promotion. Community pharmacists in Kuwait think that perceived barriers for the provision of health promotion can be overcome.

Introduction In 1989, health promotion was dened as the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is dened as a balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness,

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change behaviour and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change. [1]. This denition emphasises the importance of cooperation between different groups and individuals to achieve these aims. In developed countries, pharmacists have already started working with other health care professionals to maintain and promote public health [2]. Pharmacists activities and responsibilities in promoting and maintaining public health have been addressed by the American Society of Health System-Pharmacists [2]. Health promotion plans focus on community based interventions and partnerships to maintain wellness and to help modify individual behaviours such as unhealthy lifestyles [3]. Community pharmacies are being recognised as highly suitable health promotion settings due to the high volume of the population that use their services [4]. In Australia, community pharmacies are the most accessible with over 90% of the population visiting at least once each year [5]. In developed countries, community pharmacists have been identied as health advisors and highly credible sources of health information to the general public [610]. In contrast to the situation in developed countries, pharmacists in developing countries are still underutilized. They are struggling for the recognition of their role in contributing to the health care system [1114]. In some Middle East countries, patients rarely consider community pharmacies as primary health care facilities due to the limited communication between pharmacists and patients [13, 14], while in others such as Lebanon, the pharmacists are the most trusted health professionals as a result of the good pharmacist-patient interaction [15]. The International Pharmaceutical Federation adopted guidelines for the achievement of good pharmacy practice in developing countries, which was recognised by the World Health Organization [16, 17]. In some Middle East countries, community pharmacies are the most accessible health care service by the population to purchase prescription or nonprescription medicines in a much similar way as purchasing food from a supermarket (1214). Self-medication studies conducted in two Arab countries reported that most of the self-medicated patients obtained the prescription drugs directly from community pharmacies [1821]. In Kuwait, the involvement of pharmacists in the application of the emerging roles has not been impressive. Although pharmaceutical care has become a preferred mode of practice, most pharmacists still hardly offer signicant patient-oriented services [12, 22]. Community pharmacies are widely used by the population in Kuwait, many patients seeking medical advice directly from the community pharmacies [12]. Also here, medicines can be purchased as OTCs without any prescription, except for a very limited

number of items such as narcotics and major tranquilizers [12, 14]. There is evidence for pharmacist involvement in helping to improve and promote health in a wide variety of areas like infection control, substance abuse prevention, education and treatment, immunization, smoking cessation, coronary heart disease, skin cancer prevention, sexual health (including emergency hormonal contraception), mental health, accidental injury prevention, diabetes, lipid management, nutrition and physical activity [2, 2326]. Health promotion is not explicitly dened as part of the role of community pharmacist. However, elements of health promotion are included in tasks like general health counselling, counselling patients in medications and selfmedication, and health education. Due to the ongoing change in the health care systems, professional pharmacy associations are becoming increasingly interested in health promotion and disease prevention as a way to effectively position the profession in the twenty-rst century to better serve the societys public health needs [27]. Most of the studies on the pharmacists role in health promotion have been conducted in developed countries and there is a lack of information on this role in developing countries. Little is known on the opinions and perceived barriers towards the provision of health promotion and education activities among community pharmacists in the Middle East region including Kuwait.

Aim of the study This study sought to investigate self-reported practice of community pharmacists on different aspects of health promotion and education activities, their involvement and preparedness in counselling, explore the perceived barriers that may limit their involvement in health promotion and education activities, and identify their willingness to participate in continuing education programs related to health promotion and education.

Method A descriptive, cross-sectional survey was conducted during December 2006November 2007 in Kuwait. This extended study period was mainly due to the fact that the questionnaires were distributed and collected by hand from 223 community pharmacies within the ve governorates. The study participants were given 1 week to complete the survey; however, most of the respondents completed the surveys within 2 weeks. We feel that the time period may not affect the validity of the study since health promotion/

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education campaigns towards the pharmacists or the public were not conducted during data collection. The study population included full-licensed pharmacists working at community pharmacies in Kuwait. The ethical clearance for this study was obtained from the Human Ethical Committee, Health Sciences Center, Kuwait University. This work was conducted in compliance with the requirements of the facilitys Institutional Review Board/ Human Subjects Research Committee. The sample size was determined using Java Applets for Power and Sample Size [28]. It was calculated that a sample size of 186 pharmacists would be required to determine a 20% difference in population between two groups (e.g., male vs. female) with an 80% power and a 5% signicance level. Due to the lack of lists with the names and addresses of community pharmacists in Kuwait, the community pharmacies lists at different governorates was obtained from the Ministry of Health (current at the time of the study) and were used for sample selection. A larger sample of 223 community pharmacies was selected to adjust for possible non-response, using stratied and systematic random sampling. The stratication was at the level of the governorates within Kuwait. A pharmacy employing more than one registered pharmacist, only one is included. The basis of developing the study questionnaire was obtained from a study that investigated the health promotion beliefs and practices of pharmacists in the USA [26]. The questionnaire contained both closed and open-ended questions. It was pre-tested for content, design, readability, and comprehension on 15 community pharmacists, and modications were made as necessary so that that the questionnaire was simple to answer, yet gave accurate data. The modications included (a) deleting non-relevant background information and inclusion of questions about basic and postgraduate qualications in pharmacy; (b) opinions on the main purpose of consumers visits to community pharmacy were included in the study instrument, which were not in the original tool; (c) the original tool used 23 health-related items to measure the importance of different health promotion activities. Four items were excluded due to cultural reasons or irrelevance to the community in Kuwait. In addition, 3 items were modied and included within the context of similar categories, (d) the extent of involvement, preparedness and success of the community pharmacists was measured using the same health-related items as in the original tool, but using a 5-point Likert scale instead of a 4-point Likert scale. Sociodemographic and other characteristics data collected included gender, age, basic and postgraduate qualications and years practiced as a pharmacist. Opinions on the main purpose of consumers visits to community pharmacy was measured by listing 16 purposes for visits to

pharmacy regarding drugs and personal health behaviours (Table 2) and asking respondents to indicate on a 5-point scale (strongly disagree, disagree, neutral, agree, strongly agree) their opinion on each item. The importance of different health promotion activities was measured by listing 16 health-related items (Table 3) and asking respondents to indicate on a 4-point scale (very unimportant, unimportant, important, very important) the importance of each. A 5-point Likert scale (very uninvolved, uninvolved, uncertain, involved, very involved) was used to measure the extent of respondents involvement in counselling patients on nine health-related behaviours (Table 4). The extent to which pharmacists felt prepared to counsel patients on these nine health-related behaviours was also measured on a 5-point Likert scale (very unprepared, unprepared, uncertain, prepared, very prepared) (Table 5). A 5-point Likert scale (very unsuccessful, unsuccessful, uncertain, successful, very successful) was used to measure the extent to which pharmacists believed they were successful in helping patients change health behaviours (Table 6). Pharmacists were also asked to indicate the barriers that could limit their participation in health education and promotion activities into daily practice and strategies that could help to overcome the reported barriers. Finally, they were asked whether they would be willing to participate in continuing education programs to learn more about health education and promotion and what would be convenient methods to deliver continuing education. On approaching a pharmacy, the data collectors (pharmacists) briey explained the purpose of the study to the community pharmacist on duty. Pharmacists were free to refuse to participate in the survey. Those who agreed to take part in the study were given the questionnaires and collected from them after being completed within 12 weeks. The participants were asked to return the questionnaires anonymously. They were assured for condentiality and gave written consent to participate in the study. Incentives were not offered for completion of the questionnaire. Data analysis Data were entered into the Statistical Package for Social Sciences (SPSS, version 17) and descriptive analysis conducted. Responses are presented as means and standard deviations; and percentages and 95% condence intervals. While the data have been analysed as means, it is recognised that some authors would consider this inappropriate for ordinal data, preferring the use of medians or modes. However, the use of means provided more differentiation of the results but medians have been presented in the tabulated results for completeness.The condence intervals were computed using EpiCalc 2000 (Centers for Disease Control and Prevention, Atlanta, GA).

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149 Table 2 Responses to the main purpose of consumers visits to community pharmacy (n = 205) Seeking advice about Use of medications Drug dosage Drug indication Drug availability Weight management Drug side effects Diet Drug identication Stress reduction Drug interactions Drug stability Drug overdose Exercise habits Tobacco use Annual preventive medical examination Alcohol use
a

Results A total of 205 community pharmacists agreed to participate in the study (92%), their median age and experience as practitioners were 34 years and 8 years, respectively. Table 1 shows the characteristics of respondents. Pharmacists opinions on the purposes of visits emphasized those related to drugs; use of medications, drug dosage, indication and availability were ranked rst, second, third and fourth, respectively (Table 2). Of those purposes related to personal health-related behaviours, weight management and diet were the highest ranked. Table 3 shows the respondents perception to the importance of the 16 health-related behaviours. Taking drugs as prescribed was ranked rst. Of the 14 personal health-related behaviour items, maintaining normal cholesterol level, maintaining a normal blood pressure, the food balance with physical activity to maintain or improve weight, stopping smoking, choosing a diet with plenty of cereals and choosing a diet low in saturated fat, and cholesterol were the highest ranked. Of the 205 pharmacists 198 (97%, 95% CI 9599%) expressed the view that counseling patients on healthrelated behaviours should be a responsibility of pharmacists. The results of their involvement in counseling patients on nine health-related behaviours are presented in Table 4. Pharmacists were involved in counseling on
Table 1 Characteristics of study participants (n = 205) Frequency Gender Male Female Age (years) 2040 4160 B. Pharm M. Pharm Diploma Master degree B10 [10 162 43 202 3 7 3 132 73 79 21 98 2 3 2 64 36 42 20 17 15 7 Percentage (%)

Mediana 5.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 2.0

Mean (SD)a 4.5 (0.7) 4.4 (0.8) 4.3 (0.9) 4.3 (0.9) 4.2 (0.9) 4.2 (0.9) 4.2 (0.9) 4.0 (1.0) 3.6 (1.2) 3.5 (1.3) 3.4 (1.3) 3.3 (1.4) 3.3 (1.3) 3.2 (1.3) 2.8 (1.3) 2.6 (1.4)

Measured on a 5-point Likert scale: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree

136 69

66 34

Basic qualication in pharmacy

Postgraduate qualication(s) in pharmacy

Experience as practitioners (years)

Location of pharmacy (governorates) Hawalli 85 Al-Farwaniyah Al-Ahmadi Capital Al-Jahra 40 35 30 15

taking drugs as prescribed (mean [SD]; 3.9 [0.5]) and on knowledge about drug contents and side effects (mean [SD]; 3.6 [0.9]). Of the seven personal health-related behaviours, weight management, diet modication and stress reduction were ranked highest. The pharmacists perceptions on their preparedness to counsel patients on health-related behaviours are presented in Table 5. The perceived preparedness was highest for counseling on taking drugs as prescribed (mean [SD]; 4.7 [0.5]), and knowledge about drug contents and side effects (mean [SD]; 4.5 [0.8]). Of the rest weight management and diet modication had the highest rankings. The respondents perceived success in helping patients change their health-related behaviours was higher for the use of medications compared to their success in helping patients change their personal health-related behaviours (Table 6). The respondents indicated that the anticipated barriers to integrate health promotion activities into their daily practice were: lack of pharmacists time (58%), lack of patients time (41%), lack of information and/or training (33%), lack of privacy or physical design of the pharmacy (26%) and lack of patients trust on the ability of pharmacists (11%). One hundred forty-ve (71%, 6477%) respondents admitted that these barriers could be overcome through increasing the number of staff, participation in effective continuing educational programs, educating patients about the role of pharmacists in counselling on health-related behaviours and designing of private areas for counselling. One hundred seventy-one (84%, 7888%) respondents indicated their willingness to participate in

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150 Table 3 Responses to the importance of the promotion of healthrelated behaviours (n = 205) Health behaviour Take drugs as prescribed/directed Maintain normal blood cholesterol level Maintain normal blood pressure Balance the food he/she eats with physical activity to maintain or improve weight. Stop smoking Mediana Mean (SD)a 4.0 3.0 3.0 3.0 4.0 3.8 (0.5) 3.4 (0.6) 3.4 (0.6) 3.4 (0.6) 3.4 (0.7) 3.4 (0.7) 3.4 (0.7) 3.4 (0.6) 3.3 (0.6) 3.3 (0.7) 3.3 (0.6) 3.3 (0.7) 3.2 (0.7) 3.2 (0.7) 3.2 (0.7) 3.2 (1.0)

Pharm World Sci (2010) 32:146153 Table 5 Respondents preparedness to counsel patients on healthrelated behaviours (n = 205) Health behaviour Take drugs as prescribed/directed Know drug contents and side effects Weight management Diet modication Stress reduction Exercise habits Tobacco use Annual medical examination for preventive screenings Alcohol use
a

Mediana 5.0 5.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0

Mean (SD)a 4.7 (0.5) 4.5 (0.8) 4.3 (0.7) 4.3 (0.8) 4.2 (0.9) 4.1 (1.0) 4.0 (1.0) 4.0 (1.1) 3.9 (1.1)

Be knowledgeable about drug contents and side 3.0 effects Choose a diet with plenty of cereals containing bers, grain products, vegetables and fruits Choose a diet low in saturated fat, and cholesterol Maintain ideal weight Avoid undue stress Choose dairy products with low fat Choose a diet moderate in sugars 3.0 3.0 3.0 3.0 3.0 3.0

Measured on a 5-point Likert scale: 1, very unprepared; 2, unprepared; 3, uncertain; 4 prepared; 5, very prepared

Table 6 Respondents success in helping patients change their health-related behaviours (n = 205) Health behaviour Take drugs as prescribed/directed Know drug contents and side effects Diet modication Weight management Stress reduction Exercise habits Annual medical examination for preventive screenings Tobacco use Alcohol use
a

Engage in exercise (e.g. basic walking) three or 3.0 more times a week Have an annual medical examination for 3.0 preventive screenings Choose a diet moderate in salt and sodium 3.0 Always use seat belts when driving or riding in a 3.0 car
a

Mediana 5.0 5.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0

Mean (SD)a 4.6 (0.6) 4.4 (0.8) 3.9 (1.0) 3.9 (1.0) 3.9 (1.0) 3.7 (1.2) 3.7 (1.2) 3.4 (1.3) 3.3 (1.3)

Measured on a 4-point Likert scale: 1, very unimportant; 2, unimportant; 3, important; 4, very important

Table 4 Respondents involvement in counselling patients on healthrelated behaviours (n = 205) Health behaviour Take drugs as prescribed/directed Weight management Know drug contents and side effects Diet modication Stress reduction Exercise habits Annual medical examination for preventive screenings Tobacco use Alcohol use
a

Mediana Mean (SD)a 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 2.0 3.9 (0.5) 3.7 (0.8) 3.6 (0.9) 3.6 (0.9) 3.6 (0.9) 3.5 (1.0) 3.2 (1.1) 3.1 (1.1) 2.7 (1.2)

Measured on a 5-point Likert scale: 1, very unsuccessful; 2, unsuccessful; 3, uncertain; 4, successful; 5, very successful

and seminars (21%) and receiving distant learning packages (16%).

Discussion This is the rst study to our knowledge to be conducted in Kuwait, and probably in the Middle East region to describe the opinions and perceptions of community pharmacists regarding the provision of health promotion activities and to identify the barriers that may limit their involvement in health promotion and education. The results showed that the most important purpose of consumers visits to community pharmacy was related to seeking pharmaceutical advice about use of medications, drug dosage, indication and availability. This may be due to the fact that patients perceive pharmacists as drugs experts providing services related to OTC drug counseling

Measured on a 5-point Likert scale: 1, very uninvolved; 2, uninvolved; 3, uncertain; 4 involved; 5, very involved

continuing education programs to gain more knowledge and skills about health education and promotion. Of these, 63% reported that receiving regular newsletters will be the most convenient method to deliver continuing education for them, followed by participation in lectures, workshops

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and delivery of prescription drugs. The strong agreement among respondents in relation to consumers visits to seek advice regarding personal health-related behaviours was low. This could be due to the possibility that people accessing health advice from convenient sources other than pharmacists, and they may be less inclined to discuss these issues with a pharmacist [29]. Furthermore, the lack of patients trust in the pharmacists ability to provide good health advice as indicated by the respondents could be another factor [12]. Health behaviour related to the proper use of drugs was considered the most important area followed by maintaining a normal blood pressure and cholesterol level, the food balance with physical activity to maintain or improve weight, stopping smoking and choosing a diet with plenty of cereals and low in saturated fat and cholesterol. The importance of these areas have been widely discussed both in professional and lay press. There was less agreement on the importance of the other health behaviours. The inconsistency among respondents may result in conicting perceptions to the community of the relative importance of various health practices. The majority of respondents believed they should be responsible for counseling patients on health promotion and education topics. This could indicate the interest of community pharmacists in broadening their roles beyond the traditional functions of dispensing and distribution of drugs. Despite this high belief, respondents indicated less involvement in counseling on personal health-related behaviours compared to behaviours related to use of medications. These ndings are comparable to those reported by a study conducted in the USA [26]. The low involvement of respondents in counseling patients on personal health-related behaviours is unfortunate, since pharmacists are potentially well suited in an ideal position to inuence the lifestyle practices of the consumers due to their easy accessibility and frequent contact with the patients and the general population [9, 10, 27, 30, 31]. The present ndings revealed that the perceived preparedness of the respondents was highest in helping patients to achieve changes that result in better use of drugs. Somewhat fewer perceived to be very successful in this task compared with results from adherence studies pharmacists seem to overestimate their success rate [32]. Interestingly, respondents did not perceive a similar high level of preparation and success in helping patients change their behaviours related to personal health-related behaviours. These ndings are comparable to those reported by the study conducted in the USA [26]. The low levels of respondents success in changing personal health-related behaviours is not surprising, since the modication of embedded behaviours can be difcult and requires more time and efforts by both parties [26].

The lack of pharmacists time as a main barrier, identied in this study, needs to be overcome. Lack of time is the most signicant obstacle standing against the implementation of nontraditional roles of pharmacists worldwide [3335]. Kuwaiti pharmacies are relatively small usually with only one pharmacist on duty at a time. However, it has been suggested that pharmacists could make more time if there was better delineation between the roles of the pharmacist and the technician. If pharmacists were less involved in dispensing and preparation duties, this would free-up time for patient-focused care [36]. It may be cost effective to employ more pharmacists if this will attract more customers by extended services provided by pharmacists. It was reported that the lack of time priority as a barrier diminished with increased knowledge in pharmaceutical care issues that have been recently included in pharmaceutical education [33]. Lack of patients time and trust on the ability of pharmacists were also reported as barriers, which may result in poor response from patients. It was reported that the public in Kuwait has a poor image of pharmacists due to the limited interactions between pharmacists and patients, which has resulted in lack of recognition for pharmacy services by patients [12]. This could be overcome by educating patients about the role of pharmacist in counselling about personal health-related behaviours. But rst, pharmacists need to become better prepared for these new roles. In a study by Kotecki et al. the most important perceived barriers to integrating health education and promotion activities into pharmacy practice were constraints while working, lack of reimbursement, physical design of the pharmacy, lack of information or training, and insufcient management support [26]. In our study lack of remuneration and insufcient management support were not reported by the study participants. The lack of time as a main barrier in this study may be due to that respondents would want remuneration for something they see as an extra activity since compensation is an issue for many pharmacists in international studies. More than three quarters of respondents indicated a willingness to learn more about health promotion. However, most of them claimed that the convenient method of delivering continuing education is through receiving regular newsletters. This may not be effective since health education is not only concerned with the communication of information, but also with fostering the motivation, skills and condence necessary to take action to improve health. A joint sustained collaboration between the Ministry of Health, the Pharmaceutical and Medical Associations and Kuwait University is essential to design and implement effective educational programs towards sharpening pharmacists skills in public health promotion. It was reported that the strong cooperation between the professional

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associations, faculty of pharmacy, continuing education centers, and practicing pharmacists contributed effectively in the development of community pharmacy services [37]. This should be supported by overcoming of key barriers to conducting health education in community pharmacies of Kuwait. Attention should also be given in the teaching of undergraduate pharmacy students to ensure that they are equipped with the knowledge and skills needed for the roles of health promotion and disease prevention [38, 39]. The high willingness shown by respondents to learn more about health promotion, in addition to their declaration that perceived barriers could be overcome would certainly be an advantage to the provision of health promotion activities in community pharmacies of Kuwait. Furthermore, pharmacists who effectively perform health promotion activities need to be identied so that they may act as a role model for others. Limitations We acknowledge that this type of study, using a selfadministered questionnaire, has its limitations. The information given by respondents may be inuenced by what is perceived to be the right answer to give. The extent of truthful answers or verifying respondents claims is not possible in this type of study. Some of the health-related items are inter-related and there is a possibility that respondents would not be able to differentiate between them, particularly given that some respondents would not be uent in English. Since the data were collected anonymously there is also a possibility of offering less favourable answers without fear of being labeled. It appears that this was not a problem in our study.

Conicts of interest statement Authors have no conicts of interest with regard to the data produced.

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Conclusion The role of community pharmacists in health promotion and education is primarily focused on pharmaceutical issues rather than health behaviour modication. The majority of respondents have a positive attitude towards counseling the population on health behaviours and indicated their willingness to learn more about health promotion. The perceived preparedness needs to be improved and supported by various activities. Lack of time was perceived to be the major barrier limiting community pharmacists in health promotion activities.
Acknowledgements We appreciate the work done by the data collectors; without their effort the study would not have been completed. We owe a gratitude to Pharmacist Mai Al-Thauwaini for the help in pre-testing of the questionnaire. We thank Professor Hannes Enlund for revising this manuscript.

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