Abstract
Background:
To the best of our knowledge few published studies have been conducted to evaluate customer’s care services in community pharmacies in the United Arab Emirates (UAE) using the pseudo-customer model. This further indicates that there is a paucity of information available about the current care services provided by the community pharmacists particularly for pregnant women with migraine.
Objective:
The main objective was to evaluate, the effectiveness of the pseudo-customer method on the care services (counseling, advice, and management) provided by the community pharmacists for migraine during pregnancy.
Methods:
This was a cross-sectional study conducted in community pharmacies with a cluster sampling of pharmacists. A sample of 200 community pharmacists was recruited from three emirates in the United Arab Emirates. Pregnant woman-related migraine management was assessed using the pseudo-customer model. The used script is not of a real patient but a fake/scripted used to describe the study.
Results:
No association was found between the gender and nationality of community pharmacists and the ability to be proactive (P =0.5, 0.568) and between the utilization of source of information and gender (P =0.31). The ability to prescribe by community pharmacists without probing or only after a probe was independent of job title (P =0.310); gender (P =0.44) and nationality (P =0.128). The community pharmacists who have offered written information have had significantly higher odds to dispense medication compared to those who have not (OR =45.547, 95% CI: 2.653 - 782.088, P =0.008). Furthermore, the pharmacists who have been reported to ask for precipitating factors of migraine had significantly higher odds to dispense medication compared to those who have not (OR =11.955, 95% CI: 1.083-131.948, P =0.043). The main outcome was the responses of the community pharmacists to the pseudo-customer visit (pregnant woman with migraine).
Conclusions:
The community pharmacist’s care services (counseling, advice, and management) offered to the pseudo-customer visits was effective for dealing with migraine during pregnancy.
Keywords: community pharmacist, community pharmacy, migraine, pseudo-customer, pregnant woman
INTRODUCTION
Approximately 25% of females of reproductive age are affected by migraine.1 Several pregnant females suffering from migraine reported an improvement in the symptoms of migraine, and almost one third experience complete remissions.2,3 A common symptom for which customers may seek pharmacist advice for self-medication is headache, as global burden disease.4 Migraine symptoms must be differentiated from other types of headaches due to the fact that different treatment options may be required. Additionally, a severe headache, which is not a migraine, because of its distinctive character, may indicate a more serious underlying condition.5 In order to recommend the right type of treatment or to advice for further medical care, community pharmacists must be able to differentiate migraine from typical headaches. The medical literature sets clear differentiations between these symptoms.6,7 These distinctions refer to the character of the pain, pain location, the frequency of pain, the intensity of the pain and accompanying symptoms.6-8 Treating these conditions has also been linked to most reported cases of toxicological effects due to overdose of medications taken by patients.9,10 Nowadays, the delivery of appropriate patient counseling is considered as an integral part of healthcare provision.11 The community pharmacists are the primary source of drug supply, permitting potential opportunities for interventions to address the risk of irrational drug use and therefore reduce the financial burden of health care costs. Quality assurance of the services provided by community pharmacists has been a major concern in many countries.12,13 Guidelines of pharmacy practice usually recommend that pharmacists provide patient’s counseling regarding the appropriate use, potential risks, and cautions of drugs as well as promote drug adherence.14-16 Nevertheless, these guidelines are not fully implemented in day-to-day pharmacy practice.17,18
Rationale
The current study has adopted the pseudo-customer model due to its validity and occurrence in the real world practice. Nevertheless, to the best of our knowledge few published studies have been conducted to evaluate customer’s care services in community pharmacies in the United Arab Emirates (UAE) using the pseudo-customer model. This further indicates that there is a paucity of information available about the current care services provided by the community pharmacists particularly for pregnant women with migraine. Therefore, there was a necessity to cover the gap of knowledge in the care service provided by the community pharmacies in the UAE.
Aim
The main aim was to evaluate, the effectiveness of the pseudo-customer model on the care services (counseling, advice and management) for migraine during pregnancy provided by community pharmacists in the UAE.
Ethics approval
Ethics approval was granted by the College of Pharmacy at Ajman University-UAE, (Reference number: D-F-H-19-4-21 on 1/06/2019).
METHODS
This was a cross-sectional study, conducted in community pharmacy (between June 2019 and September 2019) in three main cities in the UAE: Dubai (regulated by the Dubai Health Authority), Sharjah, and Ajman (both regulated by the Ministry of Health). A sample of 200 community pharmacists was recruited from the above-mentioned community pharmacies. We have used cluster sampling of community pharmacists where sub-groups of the community pharmacies population were used as the sampling unit. The community pharmacist population was derived from three clusters (Ajman [49], Dubai [388] and Sharjah cities [287]. The yellow pages were used to obtain the contact details and locations of community pharmacies in the above-mentioned three cities. Stratified sampling of every 4th pharmacy on the list of each of the three cities was used to ensure representativeness. Community pharmacies were stratified by city then pharmacies from each city (stratum) were sampled. The final sample of community pharmacists (200) was represented as (99) for the Emirate of Dubai, (75) for the Emirate of Sharjah and (26) for the Emirate of Ajman. We have obtained the consent of community pharmacists working at the specified community pharmacies in order to participate in the study. Prior to participation, the head mangers of each potential participating pharmacy was visited by the main researcher and was informed about the objectives of the study and that a pseudo- customer will visit their pharmacies in a given period of time (within 6 weeks’ period). The head managers were informed of the pseudo-customer scenario which will be used. They were assured that all results of the model of interaction would be kept strictly confidential.
The pseudo-customer role has been conducted by three trained research assistants (who have visited the 200 community pharmacies) from the College of Pharmacy, Ajman University-UAE. We have tested the pseudo-customer model for a pregnant woman with symptoms of migraine. The pseudo- customer was waiting for any prescribed or offered medication and then if the community pharmacist offered paracetamol then the pseudo-customer replied that she already had it but with no benefits. We have used a pre-defined structured scenario with questions to obtain the relevant information for the management of migraine in pregnant women, (Appendices 1 and 2). The scenario script is not of a real patient but a fake/scripted used to describe the study.
A pilot study of 10 visits to community pharmacies was conducted. Depending on the feedback from this pilot study, the scenario was refined, items on the data collection form were adjusted to suit the scenario, and the coding scheme (including inter-rater coding) for the type of provided information by the community pharmacist was discussed and further refined. Results obtained in the pilot were excluded from data analysis.
Statistical analysis
Descriptive statistical analyses were used to summarize the result (mean standard deviation [SD]). Analysis of association (Chi-squared test χ2) and Binary logistic regression were used to analyze data using statistical package for social science software (SPSS version 23). The odds ratio (OR) and 95% confidence interval (CI) were executed to assess the independent risk factors for the outcome variables. P-value <0.05 was considered statistically significant.
The accuracy of data entry was checked during an initial screening. Errors in data entry were minimized by employing cleaning and validation procedures and using frequency tables and random checks of data entry for the questions. The data was also rechecked after the completion of this process. Using frequency tables enabled the identification of data entry errors. For example, variables that were coded with two numbers (i.e. gender), thus having only two possible answers, were in some cases noted to display a third value. Manual location and correction of errors were conducted in this case.
RESULTS
Among the 200 participants (163, 81.5%) were in-charge community pharmacists, nearly half were males (139, 46.3%), and two third were non-Arab (150, 75.0%). The majority of participating pharmacists were under 31 years of age (158, 79%). The mean age of the sample was 27.5 ±4.4. The work experience as a community pharmacist was above 5 years for more than three quarters (153, 76.5%). Regarding the educational level, more than half of participated pharmacists hold Bachelor of Pharmacy (112, 56%) versus (88, 44.0%) holds Doctor of Pharmacy (Pharm-D). The vast majority of community pharmacists work between 8 to 10 hours a day (192, 96%). Below half of community pharmacists have had guidelines for migraine management to use during their work (88, 44%). Average client waiting time (in minutes) was between 6 to 10 minutes for below three quarters of participated pharmacies (143, 71.5%, Table 1).
Table 1.
The demographic characteristics of the participants
| Socio-demographic characteristics of community pharmacists | Frequency (%) | P-value |
|---|---|---|
| Age (years) | ||
| 22–30 | 158 (79.0) | 0.833 |
| 31–40 | 42 (21.0) | |
| >40 | 0 | |
| Gender | ||
| Female | 61(20.3%) | 0.447 |
| Male | 139(46.3%) | |
| Nationality | ||
| Arab | 50 (25.0) | 0.500 |
| Non-Arab | 150 (75.0) | |
| Job title | ||
| Not in-charged pharmacist | 37 (18.5) | 0.513 |
| In-charge pharmacist | 163 (81.5) | |
| Work experience in (years) | ||
| <1 years | 8 (4.0) | 0.00 |
| 1–5 years | 39 (19.5) | |
| >5 years | 153 (76.5) | |
| Length of working time (in hours) | ||
| 1–8 h | 8 (4.0) | 0.487 |
| 8–10 h | 192 (96.0) | |
| Average client waiting time (in minutes) | ||
| 1–5 min | 57 (28.5) | 0.00 |
| 6–10 min | 143 (71.5) | |
| Educational qualification of community pharmacists | ||
| Bachelor of pharmacy (B-Pharm) | 112 (56.0) | 0.00 |
| Doctor of pharmacy (Pharm-D) | 88 (44.0) | |
| Community pharmacists who had guidelines for headache management | 0.00 | |
| Yes | 88 (44.0) | |
| No | 112 (56.0) |
%: percent
The respective recorded questions asked by the contacted community pharmacist to the pseudo-customer have reported ten items. The first question was about the symptoms (5 questions) described by the pseudo-customer, whereby (101, 50.5%) of the contacted pharmacists have persuaded them. Below three quarters of the community pharmacists (143, 71.5%) ask about duration of symptoms without a probe. The majority of the community pharmacists (172, 86.0%) have enquired about other conditions that might co-exist with the migraine such as sinusitis, cold, hay fever, nausea, vomiting, and photophobia. Conversely, the majority of community pharmacists (166, 83.0%) did not enquired but only after have been probe about the potential factors that could trigger the attack of migraine such as type of food, alcohol, stress, and hormonal change or eye problems (denoted the aura as neurological signs of migraine). Almost nearly half of community pharmacists (96, 48.0%) were proactive to ask if the pseudo-customer has taken any treatment to resolve the pain. Another example of the questions asked by the community pharmacists was relevant to recent fall of faint, which was reported only after the pseudo-customer probed them (196, 98.0%). The details of the questions relevant to initial symptoms were presented in, (Table 2).
Table 2.
The medical information relevant to the pseudo-customer’s symptoms provided by the community pharmacist (n =200)
| Information relevant to counselling | Frequency (%) | P-value |
|---|---|---|
| The community pharmacist asked the pseudo-costumer for the symptoms | 0.487 | |
| Yes | 101 (50.5) | |
| No, only after a probe | 99 (49.5) | |
| The community pharmacist asked the pseudo-costumer for the age | 0.487 | |
| Yes | 114 (57.0) | |
| No, only after a probe | 86 (43.0) | |
| The community pharmacist asked the pseudo-costumer for the duration of symptoms | 0.477 | |
| Yes | 143 (71.5) | |
| No, only after a probe | 57 (28.5) | |
| The community pharmacist asked the pseudo-costumer for time of the symptoms | ||
| Yes | 15 (7.5) | 0.477 |
| No, only after a probe | 185 (92.5) | |
| The community pharmacistasked the pseudo-costumer about how often the symptoms occur | ||
| Yes | 69 (34.5) | 0.491 |
| No, only after a probe | 131 (65.5) | |
| The community pharmacist asked the pseudo-costumer about previous history of similar symptoms | ||
| Yes | 70 (35.0) | 0.411 |
| No, only after a probe | 130 (65.0) | |
| The community pharmacist asked the pseudo-costumer about a recent fall or faint | ||
| Yes | 4 (2.0) | 0.447 |
| No, only after a probe | 196 (98.0) | |
| The community pharmacist asked the pseudo-costumer about other medical problems | ||
| Yes | 172 (86.0) | 0.426 |
| No, only after a probe | 28 (14.0) | |
| The community pharmacist asked the pseudo-costumer about precipitating factors | ||
| Yes | 34 (170) | 0.447 |
| No, only after a probe | 166 (83.0) | |
| The community pharmacist asked the pseudo-costumer if an action taken by pseudo-costumer | ||
| Yes | 96 (48.0) | 0.447 |
| No, only after a probe | 104 (52.0) |
%: percent
The management section refers to the care services (counseling, advice and management) action taken by the community pharmacist to manage migraine headache which has included nine questions to check pharmacist’s action if he/she prescribes medication. In addition to, advising the patient about the dose, frequency, duration of treatment and potential adverse effect, drug-drug/ drug-food interactions and the advice about the use of non-pharmacological approach. About two third of the pharmacists (126, 63.0%) was able to prescribe medication to the pseudo- patient without a probe. Patient education about the dose of the prescribed medication and the frequency of the treatment were offered to the pseudo-patient without any probe (114, 57.0% and 107, 53.5% respectively). None of the community pharmacists have informed the patient about the possible potential drug-drug and drug-food interactions. Almost (80, 40.0%) of community pharmacists have advised the pseudo-customer for non-pharmacological treatment. The most commonly prescribed medication for migraine headache was paracetamol (102, 80.9%). A minority of community pharmacists have prescribed Ibuprofen (9, 7.1%) and mefenamic acid (5, 3.9%). Vitamin C and magnesium effervescent tablets were prescribed with paracetamol, (3, 2.3% and 7, 5.5%) respectively. Using vicks® vapour rub, hot and cold towels, ice pack, rest in dark room, aromatherapy, tiger® balm and yoga are the most recommended non-pharmacological treatment. Referral questions clarifies if the pharmacist did not offer a treatment and refers the pseudo-customer to the physician, which was the act for almost three quarters (74, 37.0%) as shown in table 3.
Table 3.
Information relevant to pharmaceutical care element offered by the pharmacist (n =200)
| Information relevant to pharmaceutical care offered | Frequency (%) | P-value |
|---|---|---|
| The community pharmacist asked the pseudo-costumer if he/she has allergies to medication (n=200) | 0.447 | |
| Yes | 22 (11.0) | |
| No, only after a probe | 178 (89.0) | |
| The community pharmacist dispensed medication (n=200) | 0.447 | |
| Yes | 126 (63.0) | |
| No, only after a probe | 74 (37.0) | |
| The community pharmacist provided the dose of dispensed medication (n=126) | 0.447 | |
| Yes | 72 (57.0) | |
| No, only after a probe | 54 (43.0) | |
| The community pharmacist provided frequency of the medication (n=126) Yes | 107 (53.5) | 0.447 |
| No, only after a probe | 19 (46.5) | |
| The community pharmacist provided the duration of the treatment (n=126) | 0.447 | |
| Yes | 73 (36.5) | |
| No, only after a probe | 54 (63.5) | |
| The community pharmacist mentioned the common side effects (n=126) | 0.447 | |
| Yes | 15 (7.5) | |
| No, only after a probe | 111 (92.5) | |
| The community pharmacist did inform patient about drug interactions (n=126) | 0.447 | |
| Yes | 0 | |
| No, only after a probe | 126 (100.0) | |
| The community pharmacist provided other non-pharmacological treatment (n=200) | 0.447 | |
| Yes | 79 (39.5) | |
| No, only after a probe | 121 (60.5) | |
| The community pharmacist referred the patient to the physician (n=200) | 0.488 | |
| Yes | 74 (37.0) 126 | |
| No, only after a probe | (63.0) |
%: percent
Communicative skill section describes the overall impression about the care service, eye contact and attention of community pharmacists towards the pseudo-customer. The overall impression as reported by the two pseudo-customer of the perceived care service (later confirmed by the investigator) was either highly satisfied (75, 37.5%) or satisfied (63, 31.5%). On feed-back eye contact during consultation was ranked very highly satisfied for almost a quarter of the participating pharmacists (47, 23.5%). Attention of the community pharmacist was ranked at very highly satisfied and highly satisfied categories (54, 27.0% and 83, 41.5% respectively) (Table 4).
Table 4.
Overall satisfaction of the pseudo-customer about the pharmacist (n =200)
| Variables | Frequency (%) | P-value |
|---|---|---|
| Overall satisfaction | ||
| Very highly satisfied | 0.484 | |
| Highly satisfied | 75 (37.5) | 0.446 |
| Satisfied | 63 (31.5) | 0.414 |
| Less satisfied | 31 (15.5) | 0.468 |
| Not satisfied | 14 (7.0) | 0.436 |
| The eye contact of the pharmacist with the pseudo-customer | ||
| Very highly satisfied | 47 (23.5) | 0.447 |
| Highly satisfied | 88 (44.0) | 0.468 |
| Satisfied | 46 (23.0) | 0.459 |
| Less satisfied | 15 (7.5) | 0.468 |
| Not satisfied | 4 (2.0) | |
| The attention of the community pharmacist with the pseudo-customer | ||
| Very highly satisfied | 54 (27.0) | 0.410 |
| Highly satisfied | 83 (41.5) | 0.412 |
| Satisfied | 45 (22.5) | 0.466 |
| Less satisfied | 15 (7.5) | 0.489 |
| Not satisfied | 3(1.5) | |
%: percent
The information provided during the counselling process enquires if the community pharmacist utilized other source of information than his/her knowledge, such as computer/data base, reference books, package insert and others. The majority of the community pharmacists were not using any source of information during the counseling process other than their own knowledge (165, 82.5%). Sources of information used during the counseling process were the internet, package insert and calling the physician [14, (10.5%), 15 (8.5%) and 3, (2.0%)]. Putting a sticker/remark/label on the insert-package of the medication was the most used approach to educate the pseudo-customer by the community pharmacists (37, 36.5%), (Table 5).
Table 5.
The source and type of information offered by the community pharmacist to the pseudo-customer
| Parameter measured | Frequency (%) | P-value |
|---|---|---|
| Has the community pharmacist utilized other source of information during counselling process? | 0.447 | |
| Yes | 35 (17.5) | |
| No | 165 (82.5) | |
| Has the community pharmacist offered any written information to the pseudo-customer? | 0.447 | |
| Yes | 39 (19.5) | |
| No | 161 (80.5) | |
| Community pharmacist utilized package insert (patient information/brochures) | 16 (9.0) | 0.586 |
| Community pharmacist utilized the internet | 14 (10.5) | 0.680 |
| Individual customer-information (computer printout) | 2 (1.0) | |
| Other ways used to respond to provision of information (call the doctor) | 3 (2.0) |
%: percent
There was no enough evidence to suggest an association between being in-charge community pharmacist or not in-charge community pharmacist (P =.0399) against the ability to be proactive to ask the patient about the description of the symptoms. We did not observe any association between the gender of pharmacists against the ability to be proactive to ask the patient about the description of the symptoms (P =0.5). Furthermore, there is no relationship between the pharmacist’s nationalities and the capability to be a proactive to ask the pseudo-customer about the description of the symptoms (P =0.568). There is no enough evidence to suggest an association between the utilization of source of information and gender (P =0.31). The proportions of community pharmacists utilizing other source of information was not significantly associated with their nationality (P =0.162). There was no relationship between job titles of the community pharmacists and the capability of utilizing other sources of information, (P =0.236). The ability of prescribing community pharmacists without probing or only after a probe was independent of job title (P =0.310); gender (P =0.44) and nationality (P =0.128).
The community pharmacists who have being reported to offer written information have had significantly 45 times higher odds to dispense medication compared to those who have not (OR =45.547, 95% CI: 2.653 - 782.088, P =0.008). Furthermore, the pharmacists who have being reported to ask for precipitating factors of migraine had significantly 11.955 times higher odds to dispense medication compared to those pharmacists who have not (OR =11.955, 95% CI: 1.083-131.948, P =0.043), (Table 6).
Table 6.
Multivariate model for associations with being proactive and ask the pseudo-customer for the description of her symptoms (n=200)
| Variables | Response | OR | 95% CI | P-value |
|---|---|---|---|---|
| Gender (ref-male) | Female | 1.155 | 0.596 – 2.239 | 0.669 |
| Nationality (ref-Arab) | Non-Arab | 0.939 | 0.475 – 1.859 | 0.858 |
| Job-title (ref-in charge Pharmacist) | Not –in charge Pharmacist | 0.631 | 0.296 – 1.345 | 0.233 |
| Utilization of other source of information (ref-yes) | No | 3.514 | 1.533 – 8.054 | 0.003* |
CI: confidence interval, OR: odds-ratio
DISCUSSION
The main objective of the current study was to evaluate, the effectiveness of the pseudo-customer model on the care services (management, counseling and advice) provided by the community pharmacists in UAE for migraine during pregnancy. The main finding of the current study was the effective applicability of the pseudo-customer model in our population. The second finding was relevant to the community pharmacist involved in the care model concerning their proactive role to ask the pseudo-customer about the description of the migraine symptoms, other conditions that might co-exist with the migraine, the potential factors that could trigger the attack of migraine and respective management to resolve the pain.
The current study has evaluated the headache management practices of community pharmacists in the UAE. The results obtained from the pseudo-customer visits have revealed important discrepancies regarding the frequency of information provided to the pseudo-customer. Furthermore, the pseudo-customer method that was used to assess the effectiveness of community pharmacist counselling procedures was a viable tool. This approach has focused on assessing the interaction between the pharmacist and the pseudo-customer, and the counselling process from management perspective. In our study, more than half of responded community pharmacists hold bachelor of pharmacy (B. Pharm). This was contrary to other study carried out in Saudia Arabia,19 which has shown that over three quarters of participated pharmacists have had B. Pharm. Although not tested precisely, but it might have indicated that more community pharmacists with Pharm-D were represented in our sample which might have improved the care services offered to the pseudo-customer. In the current study, less than half of the community pharmacists have had guidelines for migraine management. This was encouraging as compared to earlier study,20 which has reported that the vast majority of community pharmacists have not had such guidelines.
Our study shares several similarities with the study conducted by Netere and associates,20 comprising questions and pseudo-customer histories required by the community pharmacist during the encounter. For instance, our results have showed that half of pharmacists asked about the symptoms described by the pseudo-customer. These results build on existing evidence by Netere who found that below half of community pharmacist ask about types of typical signs/symptoms of headache. Additionally, Netere has shown that almost three quarters of the pharmacists asked about the duration of headache. Our results support and augment these findings by showing less than three quarters of the community pharmacists asked about duration of symptoms without a probe. In line with our finding that the majority of community pharmacists did not enquired but only after have been probed about the potential factors that could trigger the attack of migraine. Similarly, Netere reported that the vast majority of participated pharmacists did not enquire about exacerbating or relieving factors of headache. Conversely, our results contradict with the findings of Netere that the vast majority of participated pharmacists neither enquired about previous or current medical condition nor enquired about the type of past medication history.
In our study, patient education about the dose and frequency of the prescribed medication were offered to the pseudo-customer without any probe by more than half of the community pharmacists. The results do not fit much with that of Alfadl,21 who found that below third of community pharmacist provided information about dose, frequency and the duration. Nevertheless, both studies revealed that none of the community pharmacists informed the patient about potential drug-drug and drug-food interaction of prescribed medication. Recent research conducted in UAE found that almost one third of participated pharmacists refer the pseudo-customer to the physician,22 however; our current study reported higher rate.
Our results have indicated that the overall impression as reported by the two pseudo-customers of the perceived care services was either highly satisfied or satisfied. This was positive result as compared with one previous study.23 Communication was found to be a barrier to patient counselling in various studies.24-26 This imbeds the care services, even if the reported patient’s satisfaction was high with management of disease. The studies reporting poor communication skills as a barrier to effective patient counselling also urge for improvement of communications skills of pharmacists. In our study, the majority of community pharmacists were not using any source of information during the counseling process other than their own knowledge. Boardman and Heeley27 have noted that when pharmacists do not have sufficient knowledge of symptomatology and drug side-effects, this subsequently impacts on the counselling process.
In the current study, when community pharmacists actively sought out other sources of information, they were also 3.5 times more likely to enquire about symptomatology. This may indicate that when community pharmacists are aware of a lack of knowledge in a certain area, they seek out the information needed and corroborate it with patient symptomatology, which may result in an improved of the counselling. Nonetheless, pharmacist’s lack of awareness over knowledge gaps may impact the likelihood of seeking information and subsequently the rate of proactive behaviour. Some studies carried in the Arab nations,28-30 have reported that a portion of pharmacists do not feel confident in their knowledge. Hence, it is unclear to what extent community pharmacists in this situation would seek out additional information.
As argued by these authors, the vast majority of studies carried out in Arab nations used male samples. Hence, it cannot be determined if these results can be generalized to the female population. In the present study, although the majority of the community pharmacist sample were males (139), there was no differences reported based on gender in terms of being proactive, utilizing other sources of information or prescribing medication. However, although the results did not reach the threshold for statistical significance, males were more likely to seek information from other sources. This type of behavior was a statistically significant predictor (3.5 times more likely) of proactive behavior.
Limitations of the current study
The main two limitations in the current study, firstly, this study used a sample of pseudo-customers who had previous health science knowledge. The pseudo-customers trained in the use of the assessment tool may provide more objective evaluations and eliminate professional subjective bias. Another limitation of the current study is the number of scenarios used. The data resulted from this study indicated that a significant portion of pharmacists did not ask about symptom duration or coexisting conditions, which may have revealed underlying conditions or potential drug-drug interactions.
CONCLUSION
The study has revealed that the community pharmacist’s care services (counseling, advice, and management) offered to the pseudo-customer visits was effective for dealing with migraine during pregnancy. The findings of this study support the development of pharmacy guidelines for patient counselling. We highly recommended future research to be carried out in order to assess the evidence-based for developing such a guide. Further, other investigations using the pseudo-customer method can be applied in the UAE to assess the community pharmacist’s management of migraine during pregnancy in people with complex conditions and poly-pharmacy. Additional differences between the results in this study and previous literature noted an increased rate of proactive behavior by the community pharmacists.
What is already known on this subject?
Pseudo-customer is well known model for improvement of quality of patient’s care.
The use of pseudo-customer in community pharmacy is not well defined particularly in pregnant women with migraine.
What our article adds to the literature?
The pseudo-customer method to assess the effectiveness of management, counseling and advice provided by community pharmacists is a viable tool that improves current practice.
The findings of this study support the development of community pharmacy guidelines for the care of pregnant women with migraine.
Providing educational interventions and continuous clinical training about migraine management in pregnancy may improve the community pharmacy practice.
ACKNOWLEDGMENTS
We would like to thank all the participated community pharmacists in the three Emirates (Ajman, Dubai and Sharjah - UAE) and the research assistants for their assistance in conducting the study.
Contributor Information
Khalid Al Kubaisi, PhD, MSc. Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, Sharjah University, Sharjah, Ajman university, clinical pharmacy, master program, College of Pharmacy and Health Sciences, Ajman University, Ajman-United Arab Emirates. kalkubaissi@sharjah.ac.ae.
Sanah Hasan, Associate Professor, Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates. s.hasan@Ajman.ac.ae.
Nageeb AbdulGalil Hassan, Professor, Dean of college of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates. n.hassan@ajman.ac.ae; namhassan@yahoo.com.
Asim Ahmed elnour, PhD, MSc, Program of Clinical Pharmacy, College of Pharmacy, Al Ain University, Abu Dhabi campus, Abu Dhabi-United Arab Emirates (UAE). AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates. asim.ahmed@aau.ac.ae.
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
FUNDING
The authors declare that no funding was received in full or partly towards this study. No funding or financial support was obtained to conduct this study.
AVAILABILITY OF DATA AND MATERIAL (DATA TRANSPARENCY)
No data available.
CODE AVAILABILITY (SOFTWARE APPLICATION OR CUSTOM CODE)
Not applicable.
CONSENT TO PARTICIPATE
Not applicable.
CONSENT FOR PUBLICATION (INCLUDE APPROPRIATE STATEMENTS)
All author consented for publication of this manuscript.
AUTHOR’S CONTRIBUTIONS
K Alk, SH, NAH and A A Elnour, were responsible for the study concept, design, data analysis, have contributed equally to the preparation of the whole manuscript, literature review, developing and proof reading. The authors have not published or submitted any related papers from the same study. This article is not under consideration or submission for any other journals.
ABBREVIATIONS
CI confidence interval
NSAIDs non-steroidal anti-inflammatory drugs
OR odds ratio
Pharm-D Doctor of Pharmacy
SD standard deviation
SPSS statistical package for social science software
UAE United Arab Emirates
References
- 1.1. Stovner LJ, Zwart JA, Hagen K, et al. Epidemiology of headache in Europe. Eur J Neurol. 2006;13(4):333-345. https://doi.org/10.1111/j.1468-1331.2006.01184.x [DOI] [PubMed]; Stovner LJ, Zwart JA, Hagen K, et al. Epidemiology of headache in Europe. Eur J Neurol. 2006;13(4):333–345. doi: 10.1111/j.1468-1331.2006.01184.x. [DOI] [PubMed] [Google Scholar]
- 2.2. Allais G, Rolando S, De Lorenzo C, et al. Migraine and pregnancy:an internet survey. Neurol Sci. 2013;34(Suppl 1):S93-99. https://doi.org/10.1007/s10072-013-1394-9 [DOI] [PubMed]; Allais G, Rolando S, De Lorenzo C, et al. Migraine and pregnancy:an internet survey. Neurol Sci. 2013;34(1):S93–99. doi: 10.1007/s10072-013-1394-9. [DOI] [PubMed] [Google Scholar]
- 3.3. Kvisvik EV, Stovner LJ, Helde G, et al. Headache and migraine during pregnancy and puerperium:the MIGRA-study. J Headache Pain. 2011;12(4):443-451. https://doi.org/10.1007/s10194-011-0329-1 [DOI] [PMC free article] [PubMed]; Kvisvik EV, Stovner LJ, Helde G, et al. Headache and migraine during pregnancy and puerperium:the MIGRA-study. J Headache Pain. 2011;12(4):443–451. doi: 10.1007/s10194-011-0329-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.4. Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018;38(2):182-190. https://doi.org/10.1055/s-0038-1646946 [DOI] [PubMed]; Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018;38(2):182–190. doi: 10.1055/s-0038-1646946. [DOI] [PubMed] [Google Scholar]
- 5.5. Chen WT, Chou KH, Lee PL, et al. Comparison of gray matter volume between migraine and “strict-criteria”tension-type headache. J Headache Pain. 2018;19(1):1. https://doi.org/10.1186/s10194-018-0834-6 [DOI] [PMC free article] [PubMed]; Chen WT, Chou KH, Lee PL, et al. Comparison of gray matter volume between migraine and “strict-criteria”tension-type headache. J Headache Pain. 2018;19(1):1. doi: 10.1186/s10194-018-0834-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.6. Anarte E, Carvalho GF, Schwarz A, et al. Can physical testing be used to distinguish between migraine and cervicogenic headache sufferers?A protocol for a systematic review. BMJ open. 2019;9(11):e031587. https://doi.org/10.1136/bmjopen-2019-031587 [DOI] [PMC free article] [PubMed]; Anarte E, Carvalho GF, Schwarz A, et al. Can physical testing be used to distinguish between migraine and cervicogenic headache sufferers?A protocol for a systematic review. BMJ open. 2019;9(11):e031587. doi: 10.1136/bmjopen-2019-031587. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.7. Gfrerer L, Austen Jr WG. Patient Evaluation and Diagnosis. Surgical Treatment of Chronic Headaches and Migraines. 2020;27.; Gfrerer L, Austen WG., Jr Patient Evaluation and Diagnosis. Surgical Treatment of Chronic Headaches and Migraines. 2020;27 [Google Scholar]
- 8.8. Lapucci C, Saitta L, Bommarito G, et al. How much do periventricular lesions assist in distinguishing migraine with aura from CIS?Neurology. 2019;92(15):1739-1744. https://doi.org/10.1212/WNL.0000000000007266 [DOI] [PubMed]; Lapucci C, Saitta L, Bommarito G, et al. How much do periventricular lesions assist in distinguishing migraine with aura from CIS? Neurology. 2019;92(15):1739–1744. doi: 10.1212/WNL.0000000000007266. [DOI] [PubMed] [Google Scholar]
- 9.9. Brune K, Patrignani P. New insights into the use of currently available non-steroidal anti-inflammatory drugs. J Pain Res. 2015;8:105-108. https://doi.org/10.2147/JPR.S75160 [DOI] [PMC free article] [PubMed]; Brune K, Patrignani P. New insights into the use of currently available non-steroidal anti-inflammatory drugs. J Pain Res. 2015;8:105–108. doi: 10.2147/JPR.S75160. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.10. Fanelli A, Ghisi D, Aprile PL, et al. Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors:latest evidence and clinical implications. Ther Adv Drug Saf. 2017;8(6):173-182. https://doi.org/10.1177/204209↩690485 [DOI] [PMC free article] [PubMed]; Fanelli A, Ghisi D, Aprile PL, et al. Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors:latest evidence and clinical implications. Ther Adv Drug Saf. 2017;8(6):173–182. doi: 10.1177/204209↩690485. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.11. Åström K, Carlsson J, Bates I, et al. Desire for information about drugs A multi-method study in general medical inpatients. Pharm World Sci. 2000;22(4):159-164. https://doi.org/10.1023/a:1008783115420 [DOI] [PubMed]; Åström K, Carlsson J, Bates I, et al. Desire for information about drugs A multi-method study in general medical inpatients. Pharm World Sci. 2000;22(4):159–164. doi: 10.1023/a:1008783115420. [DOI] [PubMed] [Google Scholar]
- 12.12. Alhomoud FK, Kunbus A, Ameer A, et al. Quality Assessment of community pharmacy services provided in the United Arab Emirates:patient experience and satisfaction. J Appl Pharm Sci. 2016;6(3):17-23.; Alhomoud FK, Kunbus A, Ameer A, et al. Quality Assessment of community pharmacy services provided in the United Arab Emirates:patient experience and satisfaction. J Appl Pharm Sci. 2016;6(3):17–23. [Google Scholar]
- 13.13. Saramunee K, Krska J, Mackridge A, et al. How to enhance public health service utilization in community pharmacy?general public and health providers'perspectives. Res Social Adm Pharm. 2014;10(2):272-284. https://doi.org/10.1016/j.sapharm.2012.05.006 [DOI] [PubMed]; Saramunee K, Krska J, Mackridge A, et al. How to enhance public health service utilization in community pharmacy?general public and health providers'perspectives. Res Social Adm Pharm. 2014;10(2):272–284. doi: 10.1016/j.sapharm.2012.05.006. [DOI] [PubMed] [Google Scholar]
- 14.14. Puspitasari HP, Aslani P, Krass I. A review of counseling practices on prescription medicines in community pharmacies. Res Social Adm Pharm. 2009;5(3):197-210. https://doi.org/10.1016/j.sapharm.2008.08.006 [DOI] [PubMed]; Puspitasari HP, Aslani P, Krass I. A review of counseling practices on prescription medicines in community pharmacies. Res Social Adm Pharm. 2009;5(3):197–210. doi: 10.1016/j.sapharm.2008.08.006. [DOI] [PubMed] [Google Scholar]
- 15.15. Blom L, Krass I. Introduction:the role of pharmacy in patient education and counseling. Patient Educ Couns. 2011;83(3):285-287. https://doi.org/10.1016/j.pec.2011.05.021 [DOI] [PubMed]; Blom L, Krass I. Introduction:the role of pharmacy in patient education and counseling. Patient Educ Couns. 2011;83(3):285–287. doi: 10.1016/j.pec.2011.05.021. [DOI] [PubMed] [Google Scholar]
- 16.16. Mendys P, Zullig LL, Burkholder R, et al. Medication adherence:process for implementation. Patient Prefer Adherence. 2014;8:1025. https://doi.org/10.2147/PPA.S65041 [DOI] [PMC free article] [PubMed]; Mendys P, Zullig LL, Burkholder R, et al. Medication adherence:process for implementation. Patient Prefer Adherence. 2014;8:1025. doi: 10.2147/PPA.S65041. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.17. Van de Steeg-van CH, Wensing M, De Smet PA. Implementation of patient education at first and second dispensing of statins in Dutch community pharmacies:the sequel of a cluster randomized trial. BMC Health Serv Res. 2011;11(1):1. [DOI] [PMC free article] [PubMed]; Van de Steeg-van CH, Wensing M, De Smet PA. Implementation of patient education at first and second dispensing of statins in Dutch community pharmacies:the sequel of a cluster randomized trial. BMC Health Serv Res. 2011;11(1):1. doi: 10.1186/1472-6963-11-313. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.18. Koster ES, van Meeteren MM, van Dijk M, et al. Patient–provider interaction during medication encounters:A study in outpatient pharmacies in the Netherlands. Patient Educ Couns. 2015;98(7):843-848. https://doi.org/10.1016/j.pec.2015.03.007 [DOI] [PubMed]; Koster ES, van Meeteren MM, van Dijk M, et al. Patient–provider interaction during medication encounters:A study in outpatient pharmacies in the Netherlands. Patient Educ Couns. 2015;98(7):843–848. doi: 10.1016/j.pec.2015.03.007. [DOI] [PubMed] [Google Scholar]
- 19.19. Alaqeel S, Abanmy N. Counselling practices in community pharmacies in Riyadh, Saudi Arabia:a cross-sectional study. BMC Health Serv Res. 2015;15(1):1-10. https://doi.org/10.1186/s12913-015-1220-6 [DOI] [PMC free article] [PubMed]; Alaqeel S, Abanmy N. Counselling practices in community pharmacies in Riyadh, Saudi Arabia:a cross-sectional study. BMC Health Serv Res. 2015;15(1):1–10. doi: 10.1186/s12913-015-1220-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.20. Netere AK, Erku DA, Sendekie AK, et al. Assessment of community pharmacy professionals'knowledge and counseling skills achievement towards headache management:a cross-sectional and simulated-client based mixed study. J Headache Pain. 2018;19(1):1-9. https://doi.org/10.1186/s10194-018-0930-7 [DOI] [PMC free article] [PubMed]; Netere AK, Erku DA, Sendekie AK, et al. Assessment of community pharmacy professionals'knowledge and counseling skills achievement towards headache management:a cross-sectional and simulated-client based mixed study. J Headache Pain. 2018;19(1):1–9. doi: 10.1186/s10194-018-0930-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.21. Alfadl AA, Alrasheedy AA, Alhassun MS. Evaluation of medication counseling practice at community pharmacies in Qassim region, Saudi Arabia. Saudi Pharm J. 2018;26(2):258-262. https://doi.org/10.1016/j.jsps.2017.12.002 [DOI] [PMC free article] [PubMed]; Alfadl AA, Alrasheedy AA, Alhassun MS. Evaluation of medication counseling practice at community pharmacies in Qassim region, Saudi Arabia. Saudi Pharm J. 2018;26(2):258–262. doi: 10.1016/j.jsps.2017.12.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.22. Hasan S, Al Oum L, Hassan NA. A simulated patient study to evaluate community pharmacist assessment, management and advice giving to patients with asthma. J Pharm Policy Pract. 2021;14(1):1-0. https://doi.org/10.1186/s40545-020-00294-4 [DOI] [PMC free article] [PubMed]; Hasan S, Al Oum L, Hassan NA. A simulated patient study to evaluate community pharmacist assessment, management and advice giving to patients with asthma. J Pharm Policy Pract. 2021;14(1):1–0. doi: 10.1186/s40545-020-00294-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.23. Alfadl AA, Alrasheedy AA, Alhassun MS. Evaluation of medication counseling practice at community pharmacies in Qassim region, Saudi Arabia. Saudi Pharm J. 2018;26(2):258-262. https://doi.org/10.1016/j.jsps.2017.12.002 [DOI] [PMC free article] [PubMed]; Alfadl AA, Alrasheedy AA, Alhassun MS. Evaluation of medication counseling practice at community pharmacies in Qassim region, Saudi Arabia. Saudi Pharm J. 2018;26(2):258–262. doi: 10.1016/j.jsps.2017.12.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.24. MinárikováD, FazekašT, Minárik P, et al. Assessment of patient counselling on the common cold treatment at Slovak community pharmacies using mystery shopping. Saudi Pharm J. 2019;27(4):574-583. https://doi.org/10.1016/j.jsps.2019.02.005 [DOI] [PMC free article] [PubMed]; Mináriková D, Fazekaš T, Minárik P, et al. Assessment of patient counselling on the common cold treatment at Slovak community pharmacies using mystery shopping. Saudi Pharm J. 2019;27(4):574–583. doi: 10.1016/j.jsps.2019.02.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.25. Layqah LA, Alakeel YS, Shamou JZ. The practice of counseling in Pharmacy:patients'perspectives. Int J Hosp Pharm. 2018;3(17):10-5958. https://doi.org/10.15406/japlr.2018.07.00269; Layqah LA, Alakeel YS, Shamou JZ. The practice of counseling in Pharmacy:patients'perspectives. Int J Hosp Pharm. 2018;3(17):10–5958. doi: 10.15406/japlr.2018.07.00269. [DOI] [Google Scholar]
- 26.26. Seubert LJ, Whitelaw K, Boeni F, et al. Barriers and facilitators for information exchange during over-the-counter consultations in community pharmacy:A focus group study. Pharmacy. 2017;5(4):65. https://doi.org/10.3390/pharmacy5040065 [DOI] [PMC free article] [PubMed]; Seubert LJ, Whitelaw K, Boeni F, et al. Barriers and facilitators for information exchange during over-the-counter consultations in community pharmacy:A focus group study. Pharmacy. 2017;5(4):65. doi: 10.3390/pharmacy5040065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.27. Boardman HF, Heeley G. The role of the pharmacist in the selection and use of over-the-counter proton-pump inhibitors. Int J Clin Pharm. 2015;37(5):709-716. https://doi.org/10.1007/s11096-015-0150-z [DOI] [PMC free article] [PubMed]; Boardman HF, Heeley G. The role of the pharmacist in the selection and use of over-the-counter proton-pump inhibitors. Int J Clin Pharm. 2015;37(5):709–716. doi: 10.1007/s11096-015-0150-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.28. Rayes IK, Hassali MA, Abduelkarem AR. Perception of community pharmacists toward their current professional role in the healthcare system of Dubai, United Arab Emirates. Saudi Pharm J. 2015;23(3):235-240. https://doi.org/10.1016/j.jsps.2014.11.016 [DOI] [PMC free article] [PubMed]; Rayes IK, Hassali MA, Abduelkarem AR. Perception of community pharmacists toward their current professional role in the healthcare system of Dubai, United Arab Emirates. Saudi Pharm J. 2015;23(3):235–240. doi: 10.1016/j.jsps.2014.11.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.29. Alhomoud FK, Kunbus A, Ameer A, et al. Quality Assessment of community pharmacy services provided in the United Arab Emirates:patient experience and satisfaction. J Appl Pharm Sci. 2016;6(3):17-23.; Alhomoud FK, Kunbus A, Ameer A, et al. Quality Assessment of community pharmacy services provided in the United Arab Emirates:patient experience and satisfaction. J Appl Pharm Sci. 2016;6(3):17–23. [Google Scholar]
- 30.30. Van Dijk M, Blom L, Koopman L, et al. Patient–provider communication about medication use at the community pharmacy counter. Int J Pharm Pract. 2016;24(1):13-21. https://doi.org/10.1111/ijpp.12198 [DOI] [PubMed]; Van Dijk M, Blom L, Koopman L, et al. Patient–provider communication about medication use at the community pharmacy counter. Int J Pharm Pract. 2016;24(1):13–21. doi: 10.1111/ijpp.12198. [DOI] [PubMed] [Google Scholar]