Chapter I Introduction

A. Background of the Study Pharmacy is the health profession committed to ensuring the safe and effective provision and use of medication. It involves the interpretation of prescription orders; the compounding, labeling and dispensing of drugs and devices; drug product selection and drug utilization reviews; patient monitoring and intervention; and the provision of cognitive services related to use of medications and devices (Gennaro, 2000). The professional roles and responsibilities of pharmacists have evolved historically from a focus on medication compounding and dispensing to extended pharmaceutical care services. With the increasing demand for health, emerging of chronic medicines and poor adherence to prescribed medicines, the pharmacy profession has been forced to take a patient-centered approach. Helper and Strand defined the term pharmaceutical care, in 1990 and it took a great turn in the pharmacy profession making pharmaceutical care as a philosophy and standard of provision of care for patients. Several studies have presented patients perceptions of the roles of pharmacists to assess patient demand for the pharmacy profession and the provision of pharmaceutical care. Some of the studies suggest that pharmacists are important members of the health care system and patients are satisfied with their provision of pharmaceutical care (Reid et al. 1999, Cerulli 2002, Amsler 2001). It is important to determine patients perception because it reflects the expectations and needs of patients. These studies are mostly situated in developed countries where pharmacy profession is well recognized and

understood, whereas in developing countries, there are limited studies concerning the perceptions of the roles of pharmacists.

B.

Problem Statement Although the pharmacy profession has been recognized for its importance as a

health care provider in many developed countries, in most developing countries it is still underutilized (Anderson, 2002). The pharmacy profession in such developing countries is still struggling for the recognition of the role that can help improve the health care system (Azhar, 2009). In the Philippines, because pharmacists solely focus on the dispensing and compounding of medications, the roles of pharmacists in the healthcare system are not well understood and appreciated by the public (Ocampo, 2005). This research was guided by the following questions:
1. What are the perceptions of the respondents on the roles of the pharmacists in the

hospital setting?
2. How do respondent demographics affect their level of agreement on the roles of

hospital pharmacists?

C.

Objectives of the study

The objectives of the study included:

To determine the respondents perceptions on the roles of hospital pharmacists To describe the respondents agreement on the following roles of hospital pharmacists in: o monitoring patient progress and drug-related outcomes

o dispensing and compounding of medications o providing patient education and counseling

To explore the relationship between the respondent demographics and level of agreement on the roles of the hospital pharmacists

D.

Significance of the study The knowledge on the present perceptions of the patients in the Philippine setting,

both positive and negative, can help the hospital pharmacists build, plan, and formulate enhanced roles and responsibilities for their profession within the healthcare environment, providing the patients pharmaceutical care and services that are of good quality.

E. Scope and Delimitations

The one hundred and fifty respondents came only from the Philippine General Hospitals Pay Ward, Out-patient Department and Main Pharmacy. This study focused only on the perceptions and level of agreement of the patients and their caretakers, who had or are having direct interactions with the hospital pharmacists for the past 1-2 months of their hospital stay, regarding the pharmacists role in monitoring patient progress and drug related outcomes, in dispensing medications, and in providing patient education and counseling. Any other roles of the pharmacists which are not commonly being studied in the other literature are not included in this study.

Chapter II Review of Literature

This section discusses the practice of hospital pharmacists in developed as well as developing countries and the perceptions of the patients, both positive and negative, to the roles of the pharmacists. At the end of this chapter, the conceptual framework of this study, as well as its operational definitions, are presented.

A. Pharmacy Practice Pharmacy is the art and science of preparing and dispensing medications and the provision of drug-related information to the public. It involves the interpretation of prescription orders; the compounding, labeling and dispensing of drugs and devices; drug product selection and drug utilization reviews; patient monitoring and intervention; and the provision of cognitive services related to use of medications and devices (Gennaro, 2000). The current era of globalization has witnessed evolution in the professions of the health sector, one of which is in pharmacy (Azhar et al., 2009). The pharmacy profession, however, is in the midst of a transition. Pharmacy professionals are moving from a traditional role as drug dispensers towards a new role as providers of direct, patientcentered care - an essential role in the healthcare system (Reid et al., 1999). There are three major areas of pharmacy practice: Community, Industrial, and the focus of this study, the Hospital Pharmacy (Gennaro, 2000). According to a study by Siracuse in 2008, the professional roles of the hospital pharmacists include (1) providing of direct patient

care, (2) monitoring patient progress and drug related outcomes, (3) dispensing medications, and (4) providing patient education and counseling. The role of pharmacists in the provision of direct patient care has evolved over time, with increased emphasis on collaborative care and patient interaction. Pharmacists work directly with healthcare providers (includes physicians and additional members of the care team) and patients to offer services not only associated with dispensing of drugs. To give services of quality to the patients, hospital pharmacists are uniquely trained in therapeutics and in providing comprehensive drug management (Kaboli, 2006). Hospital pharmacists have the expertise to monitor progress and address drug related problems during and after hospitalization and they can counsel patients at discharge, detect and resolve medication discrepancies, and screen for non-adherence and adverse drug effects after discharge. Data from a study by Smith et al. (2006) suggest that counseling patients before discharge reduces medication discrepancies and improves adherence to medications. When the pharmacist gives counseling, medication reviews and telephone follow-ups on drug related outcomes regarding the patients condition, lower rates of preventable adverse drug events 30 days after hospital discharge were observed, likely through reduction in medication discrepancies (Schnipper, 2006). The roles of pharmacists in dispensing process not only comprise the selection and labeling of prepackaged medications ordered by the physician and dispensing it directly to the patient, (Department of Health and Senior Services, 2010) but also include a check on the safety and efficacy of each prescribed therapy. On many occasions, this cannot be clarified without consultations with the prescriber, and pharmacists usually contact the prescriber on legal prescribing clarification of items prescribed (Hawksworth et al.,

1999). Such dispensing process has the potential to provide a valuable contribution to the health care. A pilot study by Hawksworth and Chrystyn (1994) in one UK community pharmacy has revealed that out of 9000 items dispensed, the prescriber had to be contacted on 80 (0.89% of items dispensed) occasions to make clinical pharmacy interventions. Patient counseling and education by pharmacists is important for improving appropriate medication use and achieving desired patient outcomes (Schommer 1997) since they have a specialized training and have particular knowledge of medications and availability to the patients. Kotecki (2000) suggested that it is well recognized that pharmacists act as health advisors to the general public, and they are acknowledged as highly credible sources of health information. In many parts of the world, pharmacists have played a significant role in the provision of pharmaceutical care services. In addition, it is also widely believed that pharmacists can make a great contribution to the provision of the primary health care, especially in developing countries. Their roles vary in different parts of the world: some deal with the preparation and supply of medicines, while some focus on sharing on sharing pharmaceutical expertise with doctors, nurses and patients (Gilbert 2001). In developed countries, the pharmacy profession is recognized for its importance as a healthcare provider, however in most developing countries, it is still underutilized (Anderson 2002). Studies in the Philippines have shown that the role of the pharmacists in the healthcare system is not well understood and appreciated by the public. One factor which may have supported this fact is that the traditional practice of community pharmacy in the country focuses solely on the dispensing of medications (Ocampo 2005).

B. Perceptions on the roles of pharmacists There have been several studies that document the perceptions of the patients on the pharmacists. A pharmacists perception of patient demand is as important as the actual patient demand in determining the provision of patient-oriented pharmacy services, as noted by Carroll and Gagnon in their study in 1984. It is important, therefore, that patients perception on the practice of pharmacy be determined to assess patient demand. Patient perceptions are essential because what one person thinks of the other affects the second persons view of self. This was stated in one study by Assa and Shepherd in 2000 focusing on the interpersonal perceptions of patients to pharmacists view and pharmacists to patients view. This study elaborately discussed the role of pharmacists in the view of pharmacists and patients and determined the congruency between pharmacists and their patients perceptions of the benefits of pharmaceutical care. Using the Interpersonal Perception Method-Pharmaceutical Care Scale (IPM-PC), a 10-point scale of a 7-item questionnaire, pharmacists and their patients were asked from their own perspective of pharmaceutical care and what they believed would be the others perspective. As to the results, pharmacists and patients disagreed on the perceived benefits of pharmaceutical care services. Neither agreement nor pharmacist understanding was found to be a significant predictor of pharmacist- nor patient- reported pharmaceutical services. By identifying the patients perceived expectations or needs, not only does the pharmacist know of what is expected of him or her, but he or she can educate the patient as to the benefit of additional pharmaceutical care services. A study by Cerulli in 2002 suggested that 90% of the patients viewed their pharmacist to be an essential member of the health care team and 90% of all the patients

reported that the pharmacist was concerned about their health. These results compare favorably with those from the study conducted by Debrovner in 1993, indicating that 73% of 2,000 consumers believed that their pharmacist cared about their health and that 80% of the patients felt that their pharmacists cared about their health, a perception that is important to the establishment of a therapeutic relationship. The patients existing knowledge of pharmacists roles and responsibilities were also determined in the study. The results indicated that patients were familiar with some roles and responsibilities of the pharmacist, with the exception of assessing drug interactions and discussing prescriptions or medication treatment plans with subscribers. Of the total respondents, only 65% were aware that pharmacists evaluate every prescription for every drug interaction. A study of Chewning et al. in 1996 indicated that 52% of the patients believed this statement. Based from the study of Singhal et al. in 2002, patient satisfaction increases with the level of consultation provided by the pharmacists. This can also be correlated to the perception of the patients because they defined the patient satisfaction as a function of patient expectations and perceptions of the services rendered. A higher degree of directive guidance behaviors by pharmacists would be expected to be associated with greater patient satisfaction. The study determined that pharmacists who spend more time consulting with patients would be expected to have a competitive advantage over the other pharmacist in terms of patient satisfaction. Patient information: age, sex, ethnicity, number of disease or diseases requiring medication use in the last 3 months, method of payment of prescription drugs used and frequency with which the present pharmacy was

used in the last 3 months were gathered using a questionnaire. Patient satisfaction and perception did not differ for any of the patient characteristic variables. A study about pharmaceutical care in chain pharmacies in Midwestern United States was conducted by Amsler et al. in 2001. It aimed to discuss the beliefs of pharmacists and patients with reactive airways disease about pharmaceutical care and pharmacists role in health care, obstacles to providing pharmaceutical care in community pharmacies and strategies to overcome those obstacles. It was found that the pharmacists described pharmaceutical care as educating patients on medicines and disease states and telling patients why they take a medicine, the effects, the side effects, the outcomes and checking medication compliance. In the impressions of the pharmacists role in health care delivery, the patients said that they were satisfied with the care they have received from pharmacist and they even went beyond the call of duty. Patients thought that pharmacists and physicians should work together closely and that pharmacists are there to fill prescriptions and help the patients understand what to take and catch the doctors mistakes. With regards to counseling, pharmacists viewed it as an integral part of their job and the obstacles which prevented counseling on a consistent basis are lack of time and lack of area for private counseling. It was also observed that women were much more satisfied than men with the quantity and quality of interactions with pharmacists. Generally, the patients were very supportive of pharmacists being involved in the health care and were satisfied with their own pharmacists. The limitation of the study was that it was not able to examine factors associated with pharmacists and patients attitudes toward pharmaceutical care.

However, not all patients have positive perceptions or were at least aware of their pharmacists role in giving pharmaceutical services. In a study conducted in Wyoming, a survey states that more than half had experience with pharmacists giving information that scared patients out of taking medications, gave the patients wrong drug and wrong dosage, and reportedly made inappropriate comment about a prescribed medication in presence of patient and refilled prescriptions not indicated for refill (Reid et al. 1999). The study of Nau et al. in 2000 showed that patients perceptions might be optimized when pharmacists include objective assessments of the patients health in addition to information about medication risks and benefits. A study of Wilbur et al. in April 2010 in Qatar aimed to characterize the patient perceptions of pharmacists. Results have found that almost 1 in 7 did not know that medical complaints could be assessed by pharmacists (15.3%). In addition, 29.1% were not aware that certain medications can be safely recommended by pharmacists without having to see a physician. It is important to note that the respondents came from twentynine different countries. Although the respondents have a relatively knowledge on the roles of pharmacists, they have a positive perception on the pharmacists. Eighty percent of patients agreed with the statement that pharmacists give reliable advice about drugs compared with 38% who believed nurses give reliable medication advice. Sixty-six percent would be comfortable receiving medication directly from a pharmacist compared with 32% from a nurse. All ages of patients were more comfortable with advice and medication directly supplied by pharmacists, but those in 30-50 years age group expressed high rates of acceptability for nurses in these roles (46.6% and 44.4%) compared with the younger respondents (30.5% and 41.6%). It is also proved by

10

Culbertson et al. in 1988 that respondents categorized as less than age 35 and those categorized as age 35 and 49 both reported significantly higher expectations than those categorized as greater than age 65 for some pharmaceutical services. In Ohio, a study conducted by Schommer in 1997 concluded that patients view the pharmacists role as one that fits within their overall health care that is directed and controlled by their physician. There is much more work to be done to inform patients about what their pharmacist is capable of doing in the health care system and how pharmacist service can add value to a patients health care above and beyond what the patients physician can provide alone. Only when a patient is informed about services pharmacists are able to provide and about the fact that these services are not being provided by others will he or she come to have a view of pharmacists that is congruent with how pharmacists are viewing themselves. But according to CFP Report on Pharmacy Services (2004), in Canada, another developed country, 72% of the patients of the patients said that their understanding on the roles of pharmacist as a health care provider has improved for the last five years and 77% perceived pharmacists as health care professionals just like physicians and nurses. The public perceptions of pharmacists and their services have been improved. In addition to the statistics mentioned earlier, only 16% do not really know what a pharmacist does beyond counting pills. Also, in a lower percentage, 13% of the patients see pharmacists as just business people who sell products in a pharmacy. This may indicate that there is a positive trend in the perception of the consumers to the pharmacy profession as a whole. Although the consumers have a better understanding of pharmacist as a health care professional, there is still room for

11

enhancement. The pharmacists should consider educating the patients on the features and benefits of patient-focused services that will improve their quality of life.

12

Conceptual Framework

Perception On knowledge of the roles of hospital pharmacists On the current practice of patient counseling in the hospital setting

Agreement On the hospital pharmacists roles: In monitoring patient progress and drug related outcomes In dispensing and compounding medications In providing patient education

Respondents Demographics 1. Age 2. Sex 3. Educational attainment 4. Economic status Figure 1. Framework of the study

Respondent perceptions on the roles of hospital pharmacists and current practice of patient counseling of the hospital pharmacists were determined side by side with the level of agreement on the roles of hospital pharmacists in monitoring patient progress and drug related outcomes, in dispensing and compounding medications and in providing patient education. The relationship of patient demographics in the perceptions of the respondents was explored and that of the level of agreement was determined.

13

Operational Definitions This study measured three concepts which are operationally defined as follows:
1. Perception- the respondents (patient and caretakers) knowledge regarding the

professional roles of hospital pharmacists in monitoring patient progress and drug related outcomes, in dispensing and compounding medications, and providing patient education, and was measured using a semi-structured questionnaire.
2. Agreement- degree at which the participants respond positively or negatively to

statements describing the roles of hospital pharmacist which was measured using a questionnaire in a four-point Likert scale.
3. Demographic variables- include age, sex, educational attainment, economic

status. These are categorical variables that were measured using a questionnaire.

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Chapter III Methodology

A.

Research Design A descriptive research design was used to answer the objectives of the study. The

study was conducted from October 2010 to January 2011 in a level four government hospital after being approved by the Philippine General Hospital Expanded Hospital Research Office. The method of data collection used was a survey carried out by face-toface interview by the researchers.

B.

Population of Study and Sampling Procedure To calculate for the sample size requirement, the formula,

was used. A previous study of Debrovner in 1993 had indicated that 80% of patients perceived that pharmacists care about patients health. This perception is important in establishing the therapeutic relationship between patients and pharmacists and this value would be P1 or the estimated proportion of patients with positive perception towards pharmacists while P2 is 95% which is the assumed increase in perception towards pharmacists among different demographic groups. Assuming an alpha () of 0.05 in a two-sided test, it was calculated that 150 patients were needed.

15

Patients and care takers included in the study came from the Main Pharmacy, Outpatient Department and Pay ward of the Philippine General Hospital who had at least interacted with a hospital pharmacist once for at most 1-2 months prior to the conduct of the study and were capable of answering the questionnaire. Also, patients and caretakers with ages 18 and above were qualified as participants. The respondents were chosen based on their availability. Those who are in the Pharmacy during the data collection were the ones chosen for the study. Fifty participants each were selected from the three different pharmacies within the hospital.

C.

Data collection Procedures Before conducting data collection, the researchers sought approval from the

Director of the Philippine General Hospital and the Ethics Board Committee for permission to collect data. The data collection was conducted based on the availability of the researchers from November 2010 to January 2011 from 9:00 in the morning to 12:00 noon and 2:00 to 4:00 in the afternoon. Researchers conducted the data collection for ten days within the stated dates. The patients and caretakers were given necessary information about the study and their permission to participate was asked by filling up an informed consent attached to the questionnaire. The informed consent provides a proof that the patient willingly agreed to be a participant in the study. After filling up the informed consent, each patient was asked to answer the questionnaire prepared by the researchers by face-to-face interview for about five to ten minutes. The researcher was at

16

the bedside of the in-patient or caretaker during the entire interview. The researcher had a sit-down interview with an out-patient.

D.

Instrumentation A questionnaire, in Filipino, was used in conducting data collection. The

questionnaire was composed of three parts: respondents demographics, questions on perceived roles of hospital pharmacists and agreement on the roles of hospital pharmacists. A semi-structured type of questionnaire was utilized. The first part of the questionnaire asked about the sex, age, monthly income, educational attainment and the ward where the patient or their family was confined. The second part of the questionnaire was originally adapted from the study of Sharma et al (2009) to assess the role of pharmacists in community pharmacy services, and so it was modified to be more suited to answer the objectives of the study. Some of the questions from the original questionnaire were excluded when not applicable to the hospital setting or hospital practice. Questions pertaining to the reasons why people prefer to buy their medications in that pharmacy, perceived roles of pharmacists and questions pertaining to patient counseling were retained in the questionnaire. These questions were asked as open-ended questions and yes-no questions. The question about the difference between roles of community pharmacists and hospital pharmacists was added also. The third part of the questionnaire was originally adapted from the study of Awad et al. (2007) which was a questionnaire for physicians expectations of the roles of

17

hospital pharmacists measured using a 4-point Likert scale. The choices were strongly agree, agree, disagree and strongly disagree. The neutral response was not included to avoid confusion among the responses. Eight statements on the Likert scale about the carried out tasks by hospital pharmacists were slightly modified in such a way that it will be applicable to patients. Tasks that can only be observed by patients were included in the Likert scale. These statements describe the different roles of hospital pharmacists such as, dispensing medications, monitoring patient progress and drug-related outcomes, and in providing patient education and counseling. The roles leaning towards clinical practice of pharmacy that was included in the Likert scale was based on an interview with a clinical pharmacist in the hospital where the study was done. She described the tasks done by hospital pharmacists that were known by patients and their caretakers. These statements were pharmacists visit patients to ensure that the patient receives the correct drug at the right amount at the right time and pharmacists monitor the progress of patient's health. Pre-testing of the questionnaire was done to correct for flaws which may arise on the actual data collection. The pre-testing was administered to ten respondents in order to get feedback on ambiguous statements and to determine if the questions included were appropriate and can answer the objectives. After the pilot testing, the questionnaire had minor revisions so another pre-testing was done with another ten people. This time, the questionnaire need not be revised since all the questions were easily understood by the respondents.

E.

Analysis of Data

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After the collection of data, the results were tabulated using the Microsoft Excel 2007. The answers were coded during the input of the data in the software. Data were then analyzed using Statistical Package for Social Sciences or SPSS version 15.0. Descriptive statistics were generated for respondent demographics, perceived roles of hospital pharmacists and the current practices in patient counseling and in the agreement on the roles of hospital pharmacists. Cross-tabulations were obtained to determine which of the factors have variations in answers. Measures of central tendency and standard variation were calculated for responses in the agreement on the roles of hospital pharmacists. Non-parametric tests, Kruskal-Wallis and Mann-Whitney U test were used to determine if there is an association between the factors: age, sex, educational attainment, monthly income and ward and the agreement of the respondents to the roles of a hospital pharmacist. Non-parametric tests were performed since the data were considered ordinal in scale of measurement. The Kruskal-Wallis test was used for independent variables having more than two levels such as age, monthly income and educational attainment. The Mann-Whitney U test was used for independent variables having only 2 levels such as sex and ward. Significant difference is observed when p<0.05.

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Chapter IV Data and Results Demographics of Respondents Table 1 summarizes the demographics of the 150 patients and caretakers that were interviewed in the Out-patient Department, Pay Ward Department and Main Pharmacy. Majority of the respondents were females, aged 31-40 years old, High school graduate, Unemployed, and Charity patients.
Table 1. Respondents demographics distribution Demographic variables Age 18-30 31-40 41-50 51-60 Above 60 Sex Male Female Educational attainment Grade school undergraduate High school undergraduate College undergraduate Grade school graduate High school graduate Vocational course graduate College graduate No response Monthly income Unemployed / No income Below 1,000 1,000-5,000 5,001-15,000 15,001-25,000 Above 25,000 No response Ward Pay ward Charity ward Frequency (%) 36 (24.0) 41 (27.3) 31 (20.7) 25 (16.7) 17 (11.3) 53 (35.3) 97 (64.7) 4 (2.7) 16 (10.7) 25 (16.7) 3 (2.0) 40 (26.7) 5 (3.3) 56 (37.3) 1 (0.7) 53 (35.3) 18 (12.0) 21 (14.0) 34 (22.7) 15 (10.0) 6 (4.0) 2 (1.3) 65 (43.3) 84 (56.0)

Perceived Roles of Hospital Pharmacists

20

With regard to the respondents perceived roles of hospital pharmacists, dispensing of medications is the most well-known role of hospital pharmacists. The respondents thought that roles of community pharmacists do not differ from that of hospital pharmacists (Table 2). Majority of respondents go to the hospital pharmacy due to the lower prices of drugs available in the pharmacy (Table 5, Appendix D). A relatively high percentage of the respondents did not know that the pharmacists in PGH offer patient counseling, and consequently, a high number of respondents have not been counseled by a pharmacist before. For those who have experienced patient counseling, the names of the drug, dose of the drug, its indication, and directions for use were most frequently mentioned in patient counseling. The respondents thought that providing drug information by hospital pharmacists were useful (Table 2).

Table 2. Patients perceived roles of hospital pharmacists Questions asked and responses

Frequency

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Perceived roles of the hospital pharmacists Monitors patient progress and drug related outcomes Dispenses medications Provides patient education and counseling Others No idea on what pharmacists do

6 123 31 2 9

4.0 82.0 20.7 1.3 6.0

Perceived roles of the hospital pharmacists different from that of the community pharmacists 49 32.7 Yes 97 64.7 No 4 2.7 No response Awareness on patient counseling offered in PGH Yes No Have been counseled or not by a hospital pharmacist Yes No Drug information frequently asked to the hospital pharmacist Name of drug Dose strength of drug Instructions on how to use the drug (time and manner of taking the drug) Indication of the drug Proper storage of drug Contraindications of the drug Expiration date Others Usefulness of the drug information asked Very useful Useful Not much useful Not useful at all No answer 51 99 20 31 34.0 66.0 39.0 61.0

22 25 32 31 5 6 8 1 12 18 3 0 3 33 50 8 0 8

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Agreement on the Roles of Hospital Pharmacists

Table 3. Respondents agreements on roles of the hospital pharmacists Pharmacists roles Strongly Agree, Disagree, agree, Frequency Frequency Frequency (%) (%) (%) 1 Pharmacists can detect prescription errors 2 Pharmacists routinely counsel and educate patients regarding the safe and appropriate use of their medications 3 Pharmacists can take personal responsibility for monitoring and resolving any drug-related problem they discover with the patient 4 Pharmacists can suggest medication treating minor illnesses 5 Pharmacists collaborate with the physician to determine the appropriate drug for treatment of a disease 6 Pharmacists compound medications to be available in the pharmacy 7 Pharmacists visit patients to ensure that the patient receives the correct drug at the right amount at the right time 8 Pharmacists monitor the progress of patient's health 67 (44.7) 53 (35.3) 76 (50.7) 75 (50.0) 6 (4.0) 20 (13.3) Strongly disagree, Frequency (%) 1 (0.7) 1 (0.7) Mean SD

3.39 0.601 3.21 0.690

46 (30.7)

73 (48.7)

26 (17.3)

1 (0.7)

3.12 0.713

32 (21.3)

76 (50.7)

36 (24.0)

6 (4.0)

2.89 0.778 2.94 0.742

35 (23.3)

69 (46.0)

42 (28.0)

1 (0.7)

20 (13.3)

54 (36.0)

61 (40.7)

11 (7.3)

2.57 0.821 2.54 0.803

20 (13.3)

49 (32.7)

70 (46.7)

9 (6.0)

19 (12.7)

48 (32.0)

69 (46.0)

12 (8.0)

2.50 0.821

Most of the respondents agreed with the statements regarding the roles of the hospital pharmacists on detecting prescription errors, patient counseling and education, resolving drug-related problems in prescriptions, suggesting medications in treating

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minor illnesses and collaborating with physicians to determine optimal drug therapy. Majority of the respondents disagreed on the role of a pharmacist in compounding medicines in hospitals, this being a primitive role of a pharmacist. The highest disagreement found was observed in the role of the pharmacist in the monitoring of the drugs administered and in visiting patients to ensure right drugs are administered to patient.

Demographic characteristics affecting agreement on the roles of hospital pharmacists

Table 4. The factors affecting the respondents agreements on pharmacists. Test and p-value demographic variable 1 2 3 4 5 Mann-Whitney U Test Sex 0.208 0.337 0.054 0.959 0.629 Ward 0.399 0.538 0.434 0.982 0.169 Kruskal-Wallis Test Age 0.058 0.528 0.934 0.642 0.704 Monthly 0.817 0.811 0.798 0.782 0.344 income Educationa l 0.636 0.213 0.361 0.616 0.946 attainment the roles of the hospital

6 0.455 0.321 0.738 0.010* 0.148

7 0.415 0.033* 0.605 0.272 0.738

8 0.935 0.020* 0.601 0.245 0.739

* (p< 0.05), statistically significant The following correspond to the test variables used in the statistical tests 1: Pharmacists can detect prescription errors 2: Pharmacists routinely counsel and educate patients regarding the safe and appropriate use of their medications 3: Pharmacists can take personal responsibility for monitoring and resolving any drug-related problem they discover with the patient 4: Pharmacists can suggest medication treating minor illnesses 5: Pharmacists collaborate with the physician to determine the appropriate drug for treatment of a disease 6: Pharmacists compound medications to be available in the pharmacy 7: Pharmacists visit patients to ensure that the patient receives the correct drug at the right amount at the right time 8: Pharmacists monitor the progress of patient's health

Using the Mann-Whitney U test, it was found that classification of patients according to ward did have an association with the agreement with roles of hospital pharmacists in visiting patients to ensure correct drugs (p=0.033) and in monitoring the

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progress of patients health (p=0.020), but sex did not have an association with any of the roles. Monthly income was observed to have an association with agreement with pharmacist role in compounding (p=0.010) using Kruskal-Wallis test. Age and educational attainment do not significantly affect the agreement of respondents on any of the roles of hospital pharmacists.

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Chapter V Discussion This study aimed to determine patients and caretakers perceptions on the roles of hospital pharmacists. Results showed that the most well-known role of hospital pharmacists was to dispense medications, followed by the provision of patient education and counseling. This may be due to the high number of pharmacists practicing in the community in the Philippines where the primary role of pharmacists is focused solely on dispensing medications and hardly practice their role to counsel the patient about their medication. Patients and caretakers in the hospital then, have existing knowledge on the roles of pharmacists in dispensing and in patient counseling. They have not yet realized the role of hospital pharmacists in patient monitoring since that role is seldom practiced in the country. The subjects chosen for the study include patients and caretakers buying medications from the hospital pharmacy. For the reasons in going to hospital pharmacies in buying medications, based on the results obtained, most of the respondents go to the hospital pharmacy because of cheaper prices of drugs. People inside the hospital would normally tend to buy their medicines in the hospital pharmacy because of its proximity, aside from these reason, they perceive that drugs in PGH are cheaper than drugs outside the hospital. Majority of the respondents thought that hospital pharmacists roles do not differ from that of community pharmacists. This may be due to their general perception of pharmacists role in dispensing medications. Hospital and community pharmacists are perceived to be sellers of drugs in the botika, although they have roles other than dispensing of medications. The difference in the role of the pharmacists in the hospital and community that few of the respondents identified was that of the way pharmacists

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take time in preparing their medications. The respondents see this as a disadvantage in the practice of the hospital pharmacists. A relatively high percentage of the respondents did not know that the pharmacists in PGH offer patient counseling, and consequently, a high number of respondents have not been counseled by a pharmacist before although patient counseling services are already offered in PGH. They also noted that they only know of physicians to offer counseling service. Based on the study of Schommer and Chewning (1996), most frequently listed barriers to asking pharmacists questions regarding medications were client embarrassment and ignorance that it was appropriate to seek information from pharmacists. It may also mean that respondents in PGH were not properly informed of the patient counseling, one reason may be due to insufficient advertising and inadequate information dissemination by the hospital. Also, patient counseling offered to patients after discharge are only practiced in Pay patient wards in PGH particularly in the 7th floor so since the majority of the participants of the study were Charity patients, they were not familiar with this service. Although patient counseling is offered in PGH, it is only offered in the Out-Patient Department Pharmacy and there is limited time of consultation. There was a separate desk designated mainly for patient counseling and patients, after buying their medications, were not obliged to undergo patient counseling. During patient counseling, pharmacists most often give instructions on how to use the drug and its indication, and this implies that the information were considered essential to discuss with the patient before dispensing the medications. Majority of the respondents, regardless of the sex, age, educational attainment, income and ward acknowledge the role of the hospital pharmacists as dispensers of

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medications and perceived community and hospital pharmacists as having the same professional roles. All the categories in each of the variable have similar knowledge about the patient counseling in the hospital. The variables, therefore, may not affect the perception on the roles of hospital pharmacists. This can be attributed to the unbiased practice of hospital pharmacists in the hospital. The pharmacists have the same treatment, in terms of the services delivered, on all the respondents. This result was similar with a study that patient perception did not differ for any of the patient characteristic variables such as age, sex, ethnicity, number of disease and frequency with which the present pharmacy was used in last 3 months (Singhal, 2002). But according to the study of Singh et al in 1999, lower educational attainment and economic status have higher satisfaction and positive perception to the roles of the pharmacists. This is because of the lower expectation of the respondents under this category. Results obtained also showed that there were respondents who do not have any idea on what the pharmacists do. This result was the same with the study of Youmans et al in Older African Americans in 2007 in which one of the respondents do not know that pharmacists is existing with this answer: They do have a consultant on duty, and if you have questions about your medication, the special person will come and talk to you. Another objective of the study was to determine the respondents agreement on the ideal roles of hospital pharmacists. Most of the respondents agreed with the roles pertaining to patient counseling and education, monitoring and resolving any drug-related problems, and collaboration with other health care professionals. This is similar with one study of Amsler in 2001 which was conducted in U.S.A., where patients thought that pharmacists and physicians should work together closely and pharmacists are there to fill

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prescriptions and help the patients understand what to take and catch the doctors mistakes. According to the respondents, they expect hospital pharmacists to suggest drugs in treating minor illnesses. It is an indication that patients and caretakers are confident with pharmacists knowledge in drugs. In a study in Qatar in 2010 by Wilbur et al., patients were also aware that certain medications can be safely recommended by pharmacists without having to see a physician. Therefore, patients generally see pharmacists as a reliable source for drug information. The respondents agreed in the role of the hospital pharmacist on patient counseling and education. They expect that the hospital pharmacist offer patient counseling, however according to the results, majority of the respondents do not experience patient education service. Therefore this expectation from hospital pharmacists to counsel and educate patients reflecting as needs of patients was not being satisfied in practice. This finding did not match that of the study conducted by Schommer (1997) which summarized that patient had very low expectations and knowledge on the patient counseling services offered by pharmacists. The results also showed that although the patients and caretakers agreed that there should be collaboration with the doctors, they disagreed when asked if the pharmacist should visit the patients and monitor the patient progress. These roles were leaning towards clinical roles of hospital pharmacists which were practiced in selected areas in the hospital. Generally, this meant that clinical roles of hospital pharmacists were still not well-recognized and not well-accepted by the public. Many of the respondents said that these were tasks already performed by nurses and physicians. The level of agreement of respondents to the roles of hospital pharmacists were related with the demographic variables obtained. For the sex, the levels of agreement of

29

males on the tasks performed by the hospital pharmacists do not significantly differ from that of the females. For the age, there was also no significant difference between the age groups and the level of agreement of the respondents. Singh et al (1999) found out that satisfaction and positive perception increased with age of the patients but this was not proven by the study conducted. The interaction of older patient to the pharmacists might be a contributory factor to this. Also, Cordina et al (1998) concluded that respondents in the age group under 25 years are less likely to ask for advice to pharmacists which may be because of the less medications of the younger respondents than the older ones. The monthly income of the respondents was taken from the questionnaire provided and they were allowed to choose from a set of choices from a no income up to more than 25,000Php. A relationship between the monthly income and the roles of the hospital pharmacists was determined. The results obtained were tested for its significant difference or association. Based on the test conducted, the monthly income does not affect their agreement on visiting the patients and monitor the progress of the patient. A significant difference resulted in the agreement of the respondents on the role of the pharmacist as someone who compounds medications not readily available in the pharmacy. The unemployed respondents, generally, disagreed with the compounding role of the hospital pharmacist. The monthly income, therefore, affects the agreement to this role. The next factor is the educational attainment which was divided into grade school undergraduate, high school undergraduate, college undergraduate, grade school graduate, high school graduate, college graduate and a graduate of vocational. The highest number of respondents disagreed that pharmacists visit the patients and monitor the progress of the patients health. This may also be in connection to their perception that the

30

pharmacist is only a dispenser of drug. The frequencies obtained, although different as observed, did not have significant differences. The educational attainment of the respondents therefore, does not affect their agreement on the roles of a hospital pharmacist. Lastly, the type of ward, either charity or pay ward of the respondents were related to their level of agreement. This demographic variable is an indirect indicator of the economic status of the participants. There was an association with the type of ward of the respondents and the agreement on the role of the pharmacist to ensure correct medication through patient visits and the monitoring of the progress of the patient. The association obtained on the two roles was statistically significant, therefore, the type of ward of the respondents affected their agreement on the roles of hospital pharmacists leaning towards clinical practice. A higher percentage of pay patients than charity patients agree that pharmacists should visit the wards and monitor patient progress. This may be due to the reason that the hospital pharmacists are more focused on the pay wards and the respondents might have met them during one of the rounds. Patients in the pay wards, specifically in the 7th floor of PGH, were aware that they were visited by and had an interaction with hospital pharmacists. On the other hand, clinical functions of hospital pharmacists were also practiced in selected patients in charity wards but the pharmacists were not introduced to them as pharmacists. So, the hospital may have to consider widening the coverage of the clinical pharmacy services to patients of charity wards so that they would better appreciate and recognize the clinical functions of hospital pharmacists. Although this study had relevant results, it still had some weaknesses. Due to small sample size, the finding of this study cannot be generalized to all the patients and

31

caretakers who had an interaction to hospital pharmacists. Also, the hospital included in the study is only a government level four hospital. The results may or may not be the same with the findings in other hospitals especially the private hospitals. The type of sampling done can also be subjected to bias because the respondents were chosen based on the convenience sampling.

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Chapter VI Conclusion and Recommendations The perceptions on the roles of hospital pharmacists reflect the demands and expectations of patients and caretakers, based on what they observed about the functions of a hospital pharmacist. The results showed that a high percentage of the patients and caretakers thought of the role of the hospital pharmacist was to primarily dispense medications, and that the roles of the hospital pharmacists from those of the community do not differ. Many of the participants of the study were not familiar with the patient counseling services offered in PGH, and that more than half of those who were aware of such service were not counseled before. However, important drug information, directions for drug use and indication of the drug was provided by the pharmacist to the respondents during patient counseling. Sought reasons in choosing the hospital pharmacy where to buy medications was that the pharmacy offers the drugs and other medications in a lower price. When asked about the respondents perception, in general, on the hospital pharmacists roles, majority agreed that the pharmacists are expected to detect prescription errors, counsel and educate them regarding their medications, monitor drugrelated outcomes, suggest medications on minor illnesses, and collaborate with other health professional, while, majority disagreed on their roles in compounding medications, visiting patients, and monitoring progress. These results indicated that clinical roles of hospital pharmacists were still not well-accepted by the patients and caretakers at PGH. Respondents were still not aware and familiar of what their hospital pharmacists do and that their knowledge of such roles may be only those which are visible and apparent.

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Demographic factors such as monthly income and ward was observed to have an association with the agreement on the roles of hospital pharmacists in compounding and clinical roles, respectively. Pay patients had better recognition and appreciation of the clinical functions of hospital pharmacists than charity patients since pay patients were more exposed to or more aware of the clinical services offered by the pharmacists in PGH. However, sex, age and educational attainment did not affect agreement of the respondents in any of the hospital pharmacist roles. Since the participants chosen in this study are only 150, it is suggested that a larger number be obtained to provide a more statistically significant data and results which can be applied to relatively larger population. Participants can also be chosen from other wards in Philippine General Hospital. This study only focused on participants in a level 4 government hospital, Philippine General Hospital, and it would be better if respondents from other different hospitals, public and private, be interviewed to at least achieve more distribution or more variety in the types of participants interviewed with respect to their demographics and perceptions. The questionnaire made by the analysts can be modified so as to suit the type of hospital or respondents from which the data will be obtained. It is also recommended that a homogenous group of respondents be obtained, since for this study, a combination of patients and care takers were interviewed. Consequently, results can also be compared on whether the care takers perceptions and knowledge on the roles of the pharmacists differ from those of the patients in the hospital.

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It may also be recommended that clinical services of the hospital may be made more extensive to charity patients so that these patients would better appreciate and embrace the clinical functions of hospital pharmacists.

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References ABU-OMAR. S. et al., 2000. Pharmacists and their customers: A person or anonymous seervice? International Journal of Pharmacy Practice [Online] 8(2), 135-143. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.20427174.2000.tb00998.x/abstract [Accessed 28 July 2010]. AFONSO, M. et al., 2005. Consumers perceptions of community pharmacy in Portugal: a qualitative exploratory study. Pharm World Sci 27, 54-60 Available at http://resources.metapress.com/pdfpreview.axd? code=l174023n2982w6x3&size=largest [Accessed 28 July 2010]. AMSLER, MR et al., 2001. Pharmaceutical Care in Chain Pharmacies: Beliefs and Attitudes of Pharmacists and Patients. Journal of the American Pharmaceutical Association 41(6), pp.850-854. ANDERSON, S., 2002. The State of the Worlds Pharmacy: A portrait of the pharmacy profession. Journal of Interprofessional Care[Online] 16(4),pp. 391-404. Available at: http://www.informaworld.com/smpp/content~db=all~content=a713678737 [Accessed 28 July 2010]. ASSA, M. AND SHEPERD, E., 2000. Interpersonal Perception: A Theory and Method for Studying Pharmacists' and Patients' Views of Pharmaceutical Care. Journal of the American Pharmaceutical Association , 40(1),71-81. AZHAR, S., 2009. The role of pharmacists in developing countries: the current scenario in Pakistan. Human Resources for Health [Online] 7 (54), 1478-449. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714831/ [Accessed 28 July 2010]. CERULLI, J., 2002. Patients' Perceptions of Independent Community Pharmacists. Journal of the American Pharmaceutical Association , 42(2), 279-82. CHEWNING, B. et al., 1996. Increasing Clients Knowledge of Community Pharmacists Roles. Pharm Res. 13, pp.1299-1304 CULBERTSON, V.L., ARTHUR, T.G., RHODES, P.J., et al., 1988 Consumer preferences for verbal and written medication information. Drug Intell. Clin. Pharm., 22(5), 390-396. DEPARTMENT OF HEALTH AND SENIOR SERVICES. Dispensing Medications. Available at: http://www.dhss.mo.gov/LPHA/PHNursing/DispensingMeds_04.htm [Accessed 30 July 2010]

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GENNARO, A., 2000. Remington: The science and practice of pharmacy. Philadelphia: Lippincott Williams and Wilkins. p.3. GILBERT, L., 2001. To Diagnose, Prescribe and Dispense: Whose right is it? The ongoing struggle between pharmacy and medicine in South Africa. Current Sociology [Online] 49 (3), pp. 97-118. Available at: http://csi.sagepub.com/content/49/3/97.abstract [Accessed 29 July 2010] HAWKSWORTH, G. M., et. al.,1999. Clinical pharmacy interventions by community pharmacists during the dispensing process. Br J Clin Pharmacol [Online] 47 (6),pp. 695700, Available at: http://www3.interscience.wiley.com/journal/119092665/abstract? CRETRY=1&SRETRY=0 (Blackwell Science Ltd ) [Accessed 29 July 2010] HEPLER,C.D., STRAND L. M. (1997) Opportunities and responsibilities Pharmaceutical care. American Journal of Hospital Pharmacy [Online] 47, 533543. Available http://people.ufpr.br/~af/historia.af/opps_and_responsibilities.pdf [Accessed July 2010] HO, D., 2008. Pharmacists may win 20-year battle. New Straits Times Kuala Lumpur . KABOLI, P. J. et.al., 2006. Clinical Pharmacists and Inpatient Medical Care: A Systematic Review. American Medical Association [Online]. 166, pp. 955-964. Available at: http://archinte.ama-assn.org/cgi/reprint/166/9/955 [Accessed 31 July 2010] KOTECKI, J.E., et.al.,2000. Health Promotion Beliefs and Practices among Pharmacists. J Am Pharm Assoc. [Online] 40 (6). Available at: http://www.medscape.com/viewarticle/406703_1 [Accessed 31 July 2010] OCAMPO, L.,2005. Medexpress: An innovation in community pharmacy practice. Malaysian Journal of Pharmaceutical Sciences ,[online] 3 (2), 73-74. Available at: http://myais.fsktm.um.edu.my/7396/ [Accessed 31 July 2010] RANELLI, P.,2000. Physician's Perceptions of Communication with and Responsibilities of Pharmacists. Journal of the Americal Pharmaceutical Association , 40(5), 625630. RATIOPHARM, INC.,2004. Consumers Perception on Pharmacy. Available at http://www.ratiopharm.ca/pdf/cfp_eng.pdf [Accessed on 30 July 2010] RAZAK, D.,2008. Really, health is but just a business. New Straits Times Kuala Lumpur . in pp. at: 29

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REID, D.,1999. Patient's Satisfaction and their Perception of the Pharmacist. Journal of the American Pharmaceutical Association , 39(6), 835-842. SCHIPPER, J. L.,2006 Role of Pharmacist Counseling in Preventing Adverse Drug Events After Hospitalization. [Online] 166 (5), pp565-71. American Medical Association. Available at: http://archinte.amaassn.org/cgi/content/abstract/166/9/955. [Accessed on 30 July 2010] SCHOMMER, J.,1997. Patients Expectations And Knowledge of Patient Counseling Services That Are Available From Pharmacists. American Journal of Pharmaceutical Education [Online] 61, pp.402-406 SIMPSON, J. R.,2006. Challenges for Improving Medication Adherence. The Journal of American Medical Association.[Online] 296 (21). Available at: http://jama.amaassn.org/cgi/reprint/296.21.jed60074v1 [Accessed on 30 July 2010] SINGHAL, P. et al.,2002. Impact of Pharmacists Directive Guidance Behaviors on Patient Satisfaction. Journal of the Americal Pharmaceutical Association, 39, 407412 SMITH L, MCGOWAN L, MOSS-BARCLAY C, WHEATER J, KNASS D, CHRYSTYN H., 1997. An investigation of hospital generated pharmaceutical care when patients are discharged home from hospital. Br J Clin Pharmacol [Online] 44, 163-165. Available at: http://archinte.amaassn.org/cgi/content/abstract/166/5/565. [Accessed on 30 July 2010] YOUMANS, S. et al., 2007. Older African American perceptions of pharmacists. Ethnicity and Disease 17, 284-290.

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APPENDIX A

INSTRUMENT

39

40

APPENDIX B

INFORMED CONSENT FORM

41

42

APPENDIX C

PERMIT TO CONDUCT RESEARCH

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November 22, 2010 Rolando Enrique Domingo, MD Director Philippine General Hospital Taft Avenue, Manila Through Channels Dear Dr. Domingo, We are BS Pharmacy students of the University of the Philippines College of Pharmacy who would like to conduct a study on the patients perceptions towards the roles of hospital pharmacists of a level 4 government hospital. Our objective is to describe the patients perceptions toward different roles of hospital pharmacists. It is also our goal to explore the relationship between patient demographics and patients perception and also to describe patients knowledge towards the roles of hospital pharmacists. In line with this, we would like to request for your approval for us to conduct the survey by interview using a questionnaire from November 2010 to January 2011. The respondents would include representative sample from in-patients from the Pay-patient wards and out-patients from the Main Pharmacy and Out-patient Department Pharmacy of Philippine General Hospital. The findings of the study may be utilized by the PGH Department of Pharmacy for potential interventions to improve the practice of pharmacy. Thank you for your consideration. Truly yours, SCARLETTE DE LUNA GELYNNE MELENCIO JOAN KUH PINSON Researchers Contact information: 09266445639 / schylet_05@yahoo.com 09277629223 / geelynnee_14@yahoo.com 09277049320 / joankuh_1209@yahoo.com Noted by: Dr. MONET LOQUIAS Adviser College Secretary, College of Pharmacy Manila University of the Philippines Manila Favorably endorsed by: Dr. IMELDA G. PEA Dean, College of Pharmacy University of the Philippines

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45

APPENDIX D

TABLE SUMMARIES

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Table 5. Reasons for buying medications in the hospital pharmacy Responses It is near the doctors clinic The pharmacy offers drugs in low price I trust the efficacy of drugs in this pharmacy This pharmacy offers good service The pharmacist gives useful advice Others The drugs are available here The drugs are ordered directly from the pharmacy No response Frequency 32 59 4 4 2 1 25 26 % 21.3 39.3 2.7 2.7 1.3 0.7 16.7 17.3

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Table 6. Central tendency and variation of responses on the agreements on roles of the hospital pharmacists Pharmacists roles MeanSD Median Mode 1 Pharmacists can detect prescription errors 2 Pharmacists routinely counsel and educate patients regarding the safe and appropriate use of their medications 3 Pharmacists can take personal responsibility for monitoring and resolving any drug-related problem they discover with the patient 4 Pharmacists can suggest medication treating minor illnesses 5 Pharmacists collaborate with the physician to determine the appropriate drug for treatment of a disease 6 Pharmacists compound medications to be available in the pharmacy 7 Pharmacists visit patients to ensure that the patient receives the correct drug at the right amount at the right time 8 Pharmacists monitor the progress of patient's health 3.390.601 3.210.690 3.00 3.00 3 3

3.120.713

3.00

2.890.778 2.940.742

3.00 3.00

3 3

2.570.821 2.540.803

3.00 2.00

2 2

2.500.821

2.00

48