A review of the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries

Research in Social and Administrative Pharmacy 9 (2013) 370–383

Review Article

A review of the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries Cecilia Brata, M.Pharm., Ph.D. Candidatea,*, Sajni Gudka, B.Pharm., Ph.D. Candidatea, Carl R. Schneider, Ph.D.b, Alan Everett, Ph.D.a, Colleen Fisher, Ph.D.c, Rhonda M. Clifford, Ph.D.a a

Pharmacy, School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia b Pharmacy, School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, UK c School of Population Health, The University of Western Australia, Perth, Western Australia, Australia

Abstract Background: Currently, no review has been completed regarding the information-gathering process for the provision of medicines for self-medication in community pharmacies in developing countries. Objective: To review the rate of information gathering and the types of information gathered when patients present for self-medication requests. Methods: Six databases were searched for studies that described the rate of information gathering and/or the types of information gathered in the provision of medicines for self-medication in community pharmacies in developing countries. The types of information reported were classified as: signs and symptoms, patient identity, action taken, medications, medical history, and others. Results: Twenty-two studies met the inclusion criteria. Variations in the study populations, types of scenarios, research methods, and data reporting were observed. The reported rate of information gathering varied from 18% to 97%, depending on the research methods used. Information on signs and symptoms and patient identity was more frequently reported to be gathered compared with information on action taken, medications, and medical history. Conclusion: Evidence showed that the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries is inconsistent. There is a need to determine the barriers to appropriate information-gathering practice as well as to develop strategies to implement effective information-gathering processes. It is also recommended that international and national pharmacy organizations, including pharmacy academics and pharmacy researchers, develop a consensus on the types of information that should be reported in the original studies. This will facilitate comparison across studies so that areas that need improvement can be identified. Ó 2013 Elsevier Inc. All rights reserved. Keywords: Information gathering; Community pharmacy; Developing countries; Self-medication

* Corresponding author. School of Medicine and Pharmacology, The University of Western Australia, M315 Pharmacy, 35 Stirling Highway, Crawley 6009, Western Australia, Australia. Tel.: þ61 8 6488 2444; fax: þ61 8 6488 7532. E-mail address: [email protected] (C. Brata). 1551-7411/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2012.08.001

Brata et al. / Research in Social and Administrative Pharmacy 9 (2013) 370–383

Introduction Self-medication is defined by the World Health Organization as “the selection and use of medicines by individuals to treat self-recognized illness or symptoms”.1 A growing body of literature shows that many people in developing countries treat their episode of illness by purchasing either a nonprescription product or a prescription product without a prescription from the doctor.2–5 A patient in a developing country can access a range of medicine outlets spanning the formal and informal sectors, such as community pharmacies, drug stores, grocery stores, kiosks, market stalls, and through itinerant hawkers.6,7 By doing so, the patient can obtain advice from professional and nonprofessional as well as trained and untrained personnel. Such use of medicines has been identified by the World Health Organization as one form of irrational use of medicines, which hinders safe and effective health care in developing countries.8 The level of patients’ understanding about their medications is highly variable.9 In addition, the wide array of product choices and often overstated, vague, and misleading marketing messages can confuse the patients.9 This situation highlights the importance of the role of community pharmacists. As health care professionals, they are ideally positioned in the community to help facilitate safe and effective use of medicines for patients who self-medicate.1,10–12 The provision of medicines for self-medication in community pharmacies should consist of 2 important stages.13–15 The initial stage is that of patient assessment, which includes a process in which the pharmacist gathers information from the patient about their illness, analyses the information gathered, and makes a decision on the best outcome for the patient. The second stage relates to how the pharmacist provides the advice, be it about the illness, a product to alleviate the signs and symptoms of the illness, and/or nonpharmacological advice. During the process, the pharmacist needs to differentiate between serious symptoms that require referral to a doctor and self-limiting conditions that can be self-treated with medications and/or nonpharmacology therapy.14 This article focuses on the first part of the initial stage, that is, the information-gathering process in community pharmacies in developing countries. There are many different ways in which information can be gathered from the patient. Although there is no standardized protocol used by pharmacists around the world, there are

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common themes that can be observed in the literature and protocols published by various pharmacy academics and professional pharmacy bodies.12,14,16–22 The most common themes of what should be included in the informationgathering process are presented in Table 1. There are no published reviews of the literature regarding this information-gathering process. Therefore, the aim of this review was to examine studies on the information-gathering process in the provision of medicines for self-medication in community pharmacies in developing countries. Methods Search strategy and screening of the literature A literature search was undertaken on MEDLINE, EMBASE, Cochrane Library, CINAHL Plus, Web of Science, and International Pharmaceutical Abstracts from 1990 to December 2011. The search terms for each database are presented in Appendix 1. The search was limited to English language and studies conducted on humans. Additional articles were also searched from citations in relevant articles and the author’s personal collection. The screening of studies consisted of 2 stages. The first stage was to apply 3 inclusion criteria, which were (1) studies that reported on the provision of medicines for self-medication in Table 1 Common themes of the types of information that should be included in the information-gathering process according to the literature

During the information-gathering process, a pharmacists or pharmacy staff member should gather information on:  All the signs and symptoms of the presenting complaint.  The patient’s identity, such as age, sex, and race.  What actions the patient has taken to alleviate any of the signs and symptoms to date. This includes, but is not limited to, any medications attempted to alleviate the symptoms and/or any prior visit to a doctor.  Any other medications the patient uses for any health issue, including prescription medications, over-thecounter pharmacy products, and complementary medications.  The patient’s medical history.  Any other information deemed to be relevant to the patient assessment, such as allergies, history of adverse drug reactions, confirmation of pregnancy and breastfeeding, and dietary restrictions.

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community pharmacies, (2) studies that were conducted in developing countries as listed by the World Bank,23 and (3) studies that were original research. The second stage was to screen the results from the first stage for all cross-sectional studies that reported on the rate of information gathering and/or the types of information gathered when patients presented with self-medication requests. Studies that met these inclusion criteria were reviewed. Operational definitions For the purposes of this review, a community pharmacy was defined as a medicine outlet that is authorized to sell prescription and nonprescription medicines and is registered by the national authority as having a qualified pharmacist responsible for the provision of these services. The term “the provision of medicines for self medication” referred to services provided by pharmacists or pharmacy staff to assist people who would like to self-medicate without prescription. Moreover, the term “information gathering” referred to a process of collecting information regarding the patient’s symptoms and patient’s history by pharmacists or pharmacy staff. The rate of information gathering in patient simulation and observational studies was defined as: Number of encounters in which gathering information was performed  100% Number of total encounters For the purpose of this article, patientsimulation studies involve using a person who is trained to pose as a patient and act out a scenario for testing the professional practice of pharmacy staff.24 Meanwhile, observational studies involve researchers who observe and record the interaction between pharmacy staff and patients. The rate of information gathering in pharmacy staff face-to-face interviews was defined as: Number of pharmacy staff who reported that they gathered information  100% Number of pharmacy staff who were interviewed Finally, the types of information gathered referred to the types of information that were reported by the authors in the original studies. Data extraction and analysis A data extraction sheet was developed, pilot tested, and refined via a discussion and consensus

between 3 authors (CB, SG, RMC). First author’s name, year of publication, country where the study was conducted, types of research methods, sampling and participant, the reported rate of information gathering, and the reported types of information gathered were extracted. The reported types of information gathered were categorized according to the 6 categories presented in Table 1. Ambiguous terms such as “drug consumed” or “medicines taken” were categorized under the “uncertain” category. This was because these terms could be interpreted as medications attempted to alleviate the presenting symptoms or as medications used to treat medical conditions other than the presenting symptoms, or both. The first author (CB) performed the analysis and the second author (SG) subsequently checked 20% of the articles randomly for the consistency of coding. Because of great variations between study populations, types of scenarios, types of methods, and data reporting, the data could not be combined statistically and risk of bias were not undertaken. Results Study selection The search described in Appendix 1 identified 1350 articles. After eliminating duplication, screening the titles and abstracts, reviewing the full text articles, and retrieving additional articles from reference lists and the author’s personal collection, 53 studies met the first stage inclusion criteria. Of these 53 studies, 22 met the second stage inclusion criteria and were reviewed (Fig. 1). Study characteristics The 22 included studies are presented in Table 2. These 22 studies spanned all regions of the developing world. Twelve studies came from the Asian regions: Thailand,25,26 Vietnam,27–30 Indonesia,31 Malaysia,32 Turkey,33 Nepal,34,35 and India.36 Another 8 studies were conducted in 6 countries in the African regions: Kenya,37 Gambia,38 Zimbabwe,39 Egypt,40,41 Tanzania,42 and South Africa.43,44 Lastly, 2 studies were undertaken in Central and South American regions: Mexico,45 and both Guatemala and Mexico.46 A wide variety of scenarios were covered by these 22 studies. Eighteen studies described the information-gathering process for a specific scenario, namely sexually transmitted infections

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Fig. 1. Literature search and study selection process.

(STIs),27,37–39 acute respiratory infections (ARIs),25,28,46 diarrhea,26,29,33,34,40,46 requests for oral contraceptives,45 pregnancy related anemia,35 hypertension,46 steroid requests,30 antibiotic requests,31 malaria chemoprophylaxis,43 asthma,36 and cystitis.34 The other 4 studies described the information-gathering process in relation to

nonprescription product consultation process32,44 or the overall provision of medicines for selfmedication.41,42 A variety of methods were used to conduct the 22 studies. Fourteen studies used the patientsimulation method,25,26,29–31,33–37,39,40,43,46 2 studies used the observational method,41,42 1 study used

Author (year)

Country

Kwena et al37 (2008)

Kenya

Leiva et al38 (2001)

Gambia

Nyazema et al39 (2007)

Zimbabwe

Chuc et al

28

(2001)

Vietnam

Saengcharoen et al25 (2008)

Thailand

Kroeger et al46 (2001)

Guatemala

Sampling type and participants

Case

Simple random sampling. 60 pharmacies, 297 encounters. Convenience. 50 pharmacies, 100 encounters (50 encounters for each case). Simple random sampling. 24 pharmacies, 24 encounters. Stratified proportionate random sampling, then systematic sampling. 87 pharmacies, 57 encounters. Stratified proportionate random sampling, then systematic sampling. 87 pharmacies, 63 encounters. Simple random sampling. 60 pharmacies, 297 encounters. Simple random sampling. 32 pharmacies, 128 encounters. All pharmacies in zone 19 Guatemala city and Chimaltenango. 67 pharmacies, 368 encounters.

STI (urethral discharge)

The rate of information gathering

Types of information reported Signs and symptoms

Patient identity

Action taken

Other medication

Medical history

Other

“Uncertain”

45% (134/297)

U

U{

U

N/R

N/R

Allergy, history of symptoms, STI risk factors.

“Drugs consumed”

STIs (gonorrhea and genital ulcer disease)

97% (97/100)

U

U{

N/R

N/R

N/R

Allergy, STI risk factors.

“Previous medications taken”

STI (urethral discharge)

N/A

U

U{

N/R

N/R

N/R

STI risk factors.

No

STI (vaginal discharge)

N/A

U

N/R

N/R

U

N/R

STI risk factors, pregnancy.

No

STI (urethral discharge)

N/A

U

N/R

U

N/R

N/R

STI risk factors.

No

ARI (cough)

90% (267/297)

U

U{

N/R

N/R

N/R

N/R

“Drugs consumed”

ARI (sore throat)

N/A

U

U

N/R

N/R

U

Allergy.

“Medication currently taking”

ARI Hypertension

N/A N/A

U U

U U

N/R N/R

N/R N/R

N/R N/R

No No

Diarrhea

N/A

U

U

N/R

N/R

N/R

N/R Possession of a prescription. Possession of a prescription.

No

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Patient-simulation studies Vietnam Chalker et al27 (2000)

374

Table 2 Characteristics of included studies

Mexico

Turkey

Duong et al29 (1997)

Vietnam

Saengcharoen and Lerkiatbundit26 (2010)

Thailand

Sokar-Todd and Smith40 (2003)

Egypt

Wachter et al34 (1999)

Nepal

Van Sickle36 (2006)

India

Kafle et al35 (1996)

Nepal

All pharmacies in Antalya. 214 pharmacies, 214 encounters. Stratified random sampling. 30 pharmacies, 29 encounters. Simple random sampling. 96 pharmacies, 96 encounters. Stratified random sampling. 30 pharmacies, 25 visited in person or telephoned.

Stratified random sampling. 30 pharmacies, 24 visited in person or telephoned. Simple random sampling. 100 pharmacies. Simple random sampling. 100 pharmacies. Quota sampling. 52 pharmacies, 56 encounters. 54 encounters were analyzed. Stratified random sampling. 112 drug shops/pharmacies. 112 encounters.

ARI

N/A

U

U

N/R

N/R

N/R

Hypertension

N/A

U

U

N/R

N/R

N/R

Diarrhea Infant diarrhea

N/A 43% (91/214)

U U

U U{

N/R N/R

N/R N/R

N/R N/R

Infant diarrhea

90% (26/29)

U

U

N/R

N/R

4-y-old child diarrhea

N/A

U

U

U

Infant diarrhea

96% (24/25)

U

U

Elderly diarrhea

63% (15/24)

U

5-y-old child diarrhea

N/A

Cystitis

Possession of a prescription. Possession of a prescription. N/R Causative factors, mother’s medication

No

N/R

N/R

“Medicines taken”

N/R

U

Allergy, causative factors.

No

N/R

N/R

N/R

No

U

U

U

U

Causative factors, medicine available at home, whether the baby was alright the day before. Causative factors, medicine available at home.

U

U{

N/R

N/R

N/R

N/R

“Medications taken”

N/A

U

U{

N/R

N/R

N/R

N/R

No

Asthma

N/A

U

U

U

N/R

N/R

Possession of a prescription.

No

Anemia in pregnancy

N/A

U

U{

N/R

N/R

N/R

Pregnancy.

“Any medicines taken”

No No No

No

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Aktekin et al33 (1998)

Simple random sampling. 124 pharmacies, 601 encounters.

(continued)

375

Author (year)

376

Table 2 (continued ) Country

South Africa

Larsson et al30 (2006)

Vietnam

Puspitasari et al31 (2011)

Indonesia

Observational studies Kagashe et al42 (2011)

Tanzania

Sallam et al41 (2009)

Egypt

Pharmacy staff face-to face-interviews Chalker et al27 (2000) Vietnam

Leiva et al38 (2001)

Gambia

Case

Sampling type was not stated. 43 encounters for malarious destination, and 25 encounters for nonmalarious destination. Simple random sampling. 60 pharmacies, 295 encounters.

Malaria Chemoprophylaxis

Purposive sampling. 105 pharmacies, 88 encounters. Purposive sampling. 105 pharmacies, 88 encounters.

The rate of information gathering

Types of information reported Signs and symptoms

Patient identity

Action taken

Other medication

Medical history

Other

“Uncertain”

N/A

N/R

U{

N/R

N/R

U

Activities in the destination country (Diving).

No

Steroid requests

41% (121/295)

U

U{

N/R

U

N/R

Possession of a prescription, other information.

No

Ciprofloxacin requests

N/A

U

U

U

N/R

N/R

N/R

No

Tetracycline requests

N/A

U

U

U

N/R

N/R

N/R

No

100 pharmacies were randomly selected. 70 pharmacies agreed to participate, 628 encounters of specific medicines requested without prescription were observed. 35 pharmacies were randomly selected. A total of 1050 encounters were observed.

Product based requests

29% (182/628)

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Self-medication

18% (184/1050)

N/A

N/A

N/A

N/A

N/A

N/A

N/A

60 pharmacies were randomly selected, 69 pharmacy staff were interviewed. 24 pharmacies were randomly selected, 24 pharmacy staff were interviewed.

STI (urethral discharge)

39% (27/69)

N/R

N/R

N/R

N/R

N/R

STI risk factors

No

STI (urethral discharge)

N/A

U

N/R

N/R

N/R

N/R

STI risk factors

No

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Toovey43 (2006)

Sampling type and participants

Chuc et al28 (2001)

Vietnam

Becker et al45 (2004)

Mexico

Structured patient telephone interviews Bornman et al44 (2006) South Africa

N/A

U

N/R

N/R

N/R

N/R

Allergy

“Whether any drugs had been used”

Oral contraceptives

31% (33/108)

N/R

U

U

U

U

History of adverse drug reaction, life style, pregnancy.

No

Type of sampling was not stated. The questionnaire was sent to 85 pharmacies. Only 30 questionnaires were analysed.

Over-the-counter consultation process

N/A

N/A

N/A

N/A

U

U

N/A

No

300 patients were selected using stratified random sampling from telephone directories.

Over-the-counter consultation process

N/A

N/A

N/A

N/A

U

U

Allergy

No

N/A ¼ not applicable; N/R ¼ not reported; { ¼ the information was voluntarily provided by the simulated patient; U ¼ the information was reported to be gathered by pharmacy staff.

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Pharmacist-mailed questionnaire studies Sarriff32 (1994) Malaysia

ARI (cough)

60 pharmacies were randomly selected, 70 pharmacy staff were interviewed. 10% of total population of pharmacies in Mexico city were randomly selected, 109 pharmacy staff were interviewed, 108 interviews were analyzed

377

378

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pharmacy staff face-to-face interviews,45 3 studies used both patient simulation and pharmacy staff face-to-face interviews,27,28,38 1 study used pharmacist-mailed questionnaire,32 and 1 study used structured patient telephone interviews.44 Data reporting also varied. In the 17 patientsimulation studies, 2 studies stated that they only reported the most common types of information gathered,28,30 whereas others reported all types of information that were recorded.25–27,29,31,33–40,43,46 In the 2 observational studies,41,42 the form on which the data was written were not clearly reported. In 4 studies that used pharmacy staff face-to-face interviews, 2 of them27,28 reported that the interview used open-ended questions. Meanwhile, the other 2 pharmacy staff face-toface interview studies did not provide any detail regarding the extent of the interviews (i.e., whether the interview used open-ended or closeended questions).38,45 The reported rate of information gathering Of the 22 studies included, 10 studies provided data on the rate of information gathering with 3 different types of methods, namely patient simulation,27–30,33,37,40 observation,41,42 and pharmacy staff face-to-face interview.27,45 These studies covered different types of scenarios and they were carried out in different countries. The reported rate of information gathering in these 10 studies varied widely. It ranged from 18% to 97%, depending on the methods used. Patientsimulation studies reported the highest rate of information gathering, ranging from 41% to 97% of the total encounters.27–30,33,37,40 This was followed by 2 pharmacy staff face-to-face interview studies, which stated that 31% and 39% of pharmacy staff reported that they gathered information from patients.27,45 Lastly, 2 observational studies reported the lowest rate of information gathering, which were 18% and 29% of the total encounters.41,42 There were 12 scenarios involved in these 10 studies that reported the rate of information gathering. Of these 12 scenarios, 4 scenarios reported a high rate of information gathering, which ranged from 90% to 97% of the total encounters 28,29,37,40 and 1 scenario reported the rate of information gathering as 63% of the total encounters.40 The other 7 scenarios reported the rate of information gathering as less than 50% of the total encounters or the total number of pharmacy staff who were interviewed.27,30,33,41,42,45

The reported types of information gathered Of the 22 studies included, 20 studies25–40,43–46 reported the types of information gathered with 4 different types of methods, namely patient simulation,25–31,33–40,43,46 pharmacy staff face-to-face interview,27,28,38,45 pharmacist mailed questionnaire,32 and structured patient telephone interview.44 The types of information reported were not as thorough as stated in the pharmacy literature (Table 1).14,16–22 In the 17 patient-simulation studies, signs and symptoms followed by patient identity were the most common types of information reported in the 26 scenarios performed.25–31,33–40,43,46 These types of information were reported in 25 and 24 scenarios respectively. Other information, however, was seldom reported. Of the 26 scenarios, information on action taken, medication, and medical history were only reported in 7, 3 and 4 scenarios, respectively. Similarly, the types of information reported in the 4 pharmacy staff face-to-face interview studies were not as thorough as stated in the pharmacy literature (Table 1).27,28,38,45 However, no patterns can be concluded with regard to which types of information were commonly reported and which types of information were not because of the small number of studies. In the pharmacist-mailed questionnaire study as well as in the structured patient telephone interview study,32,44 the types of information reported were preselected by the authors. In the pharmacist-mailed questionnaire study, the author only selected information on medication and medical history to be put on the questionnaire.32 Approximately 30% of the pharmacists reported that they gathered these types of information when serving their self-medicating patients.32 Meanwhile, in the structured patient telephone interview study, the authors selected information on medication, medical history, and allergy to be put in the interview guide.44 Approximately 80% of the patients agreed that pharmacy staff asked for these types of information.44 There were 7 studies that used ambiguous terms, such as “drugs consumed” or “medicines taken”.26–29,34,35,37 These terms were categorized under the “uncertain” category.

Discussion This article has documented the rate of information gathering and types of information gathered in the provision of medicines for

Brata et al. / Research in Social and Administrative Pharmacy 9 (2013) 370–383

self-medication in community pharmacies in developing countries. A variety of study populations, types of scenarios, research methods, and data reporting were found. The rate of information-gathering and the types of information gathered varied across studies. Signs and symptoms, followed by patient identity were the types of information commonly reported. Information such as action taken, medications, medical history, and other forms of information was seldom reported. This review found that the reported rate of information gathering varied widely.27–30,33,37, 40–42,45 Several reasons may explain these findings. Firstly, differences in the countries where the study was conducted, including the pace of development, health care systems, pharmacy education systems, and pharmacy staff training, may affect the knowledge and ability of pharmacy staff to gather information when consulted by self-medicating patients. Secondly, the pharmacy staff may respond differently to different types of requests, resulting in differences in the rate of information gathering. Three patient-simulation studies conducted from the same study population in Vietnam showed that while the rate of information gathering in the STI scenario was 45%, it was 90% for ARI and 41% for steroid requests, confirming these opinions.27,28,30 Finally, differences in types of methods can produce different results in the rate of information gathering. We found that the lowest, moderate, and highest rate of information gathering were reported from observational, pharmacy staff faceto-face interview, and patient-simulation method, respectively.27–30,33,37,40–42,45 However, whether there was any significant difference on the reported rate of information gathering between these 3 types of methods could not be firmly concluded because of the small number of studies as well as variations in the types of scenarios and study populations. Indeed, despite the broad search strategy used and high number of countries categorized as developing countries in the world, only 10 studies that reported on the rate of information gathering were identified.27–30,33,37,40–42,45 Therefore, more research with sound methodology on the provision of medicines for self-medication in developing countries is needed. Only information on signs and symptoms and patient identity were frequently reported.22–38,41,44,45 Other information such as action taken, medications, and medical history were seldom reported.22–38, 41,44,45 The lack of information gathered by pharmacy staff may lead to inappropriate advice being

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provided. This reported deficit in the types of information gathered has been confirmed in the discussion section of most of the currently reviewed studies.25–27, 29,31,33–35,40,45 Accordingly, inappropriateness of advice provided by pharmacy staff to patients has also been reported in these studies.25–27,29–31,33–40,46 For example, inappropriate recommendation in 5 STI scenarios ranged from 67% to 100% of the total encounters.27,37–39 A similar figure has been found in diarrhea,26,46 asthma,36 ARI,28,46 and antibiotic requests scenarios.31 It is also important to note that the staff member involved in the provision of medicines for selfmedication reported in these original studies might not be a pharmacist. In fact, a study from Indonesia by Puspitasari et al found that although they purposively chose community pharmacies where the pharmacist was considered to be present during business hours as their sample, they found that in less than 20% of pharmacies that the provision of services was delivered by a pharmacist.31 In some developing countries, such as Indonesia, although a medicine outlet was registered by the national authority as having a pharmacist responsible for the provision of services, most pharmacists may not be physically present in the community pharmacies during business hours.47 Thus, most of the pharmacist’s role was undertaken by nonpharmacists. This situation may also contribute to the deficit in the information-gathering process that was reported by most authors of the currently reviewed studies. Although inadequacy in the informationgathering process was reported in developing countries, some studies in developed countries have also found a similar situation.48–51 Two Australian studies in the provision of emergency contraceptive and salbutamol requests indicated poor compliance with the Pharmaceutical Society of Australia recommendations.48,49 Similarly, a study in Scotland also showed low compliance with each component in the accepted information-gathering practice guideline.50 Furthermore, a study in the management of acute childhood diarrhea in Belgium also found that pharmacists did not ask appropriate questions, which limited proper evaluation of the scenario.51 Clearly, inadequacy in the information-gathering process for the provision of medicines for selfmedication in community pharmacies has been reported as a worldwide problem. The International Pharmaceutical Federation has published a statement related to the types of information that should be gathered in the provision of medicines for self-medication.12 Similarly, several pharmacy textbooks and national

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standards have also mentioned the types of information that should be gathered during the information-gathering process.14,16–22 However, there is no consensus on the types of information that should be reported by the authors in original studies. International and national pharmacy organizations including pharmacy academics and pharmacy researchers need to standardize the types of information that should be reported in the original studies. Standardizing data reporting will facilitate comparisons across studies so that reviewers can draw inferences of the comprehensiveness of the information-gathering process and accurately identify deficient areas that need improvement. Furthermore, because most authors of the currently reviewed studies stated that information gathering was inadequate, there is a need to do further research to find the barriers of appropriate information-gathering practice as well as to develop strategies to improve these practices. Limitations The search strategy that we used did not include the gray literature, so it is possible that some studies, which may be relevant in the information-gathering process in the provision of medicines for self-medication in developing countries, were not identified. Additionally, these findings were limited to studies published in the English language over the last 20 years. Other non-English publications which may be relevant within the context of developing countries, as well as older studies, were omitted. Only 20% of the original studies were checked by the second author for coding consistency. We acknowledge that it would have been better to have 2 authors categorizing each study. However, because no inconsistencies were found, this was deemed sufficient. Regarding the measurement for the rate of information gathering, we acknowledge that gathering one type of information was given the same weight as gathering extensive information. However, using this type of measurement, we found that a considerable number of pharmacy staff in developing countries did not gather information when serving self-medicating patients. In 7 of the 12 scenarios, the rate of information gathering was less than 50% of the total encounters or the total number of pharmacy staff who were interviewed.27,30,33,41,42,45 The way we analyzed our data could lead to an overestimation of the comprehensiveness of the types of information that were reported to be

gathered by pharmacy staff. We did not consider the amount reported from each type of information. Small and large amounts of each type of information reported were regarded as having an equal weight. However, despite the possibility of overestimating the comprehensiveness of the types of information reported, we still found that the types of information reported to be gathered by the pharmacy staff were not thorough. In contrast, inconsistent data reporting in the original studies regarding the types of information gathered can also lead to underestimation of the comprehensiveness of the types of information reported. Two patient-simulation studies that only reported the most common types of information gathered would lead to a lesser number of the types of information reported.28,30 Furthermore, 2 questionnaire studies did not include information on signs and symptoms, patient identity, and action taken in their questionnaire.32,44 Thus, these circumstances would lead to under reporting these particular types of information. However, if we removed these studies,28,30,32,44 we still found that the cumulative types of information reported were not thorough. Variations in the data recording and reporting were identified across the currently reviewed studies. Due to these variations, we were uncertain of the extent of the types of information that were not reported. It cannot be assumed that the types of information not reported meant that they were not actually gathered by the pharmacy staff. Because most of the authors of the currently reviewed studies had discussed and concluded in their original studies that the information-gathering process was inadequate, it is possible the findings from what were reported about deficit in the reported types of information gathered also showed deficit in the actual process of information gathering. In the future, it is essential to standardize data reporting in the original studies, so that a strong inference of what was reported, to what actually happened in practice, can be made.

Conclusion The evidence shows that the informationgathering process for the provision of selfmedication services via community pharmacies in developing countries is inconsistent. The reported rate of information gathering varied widely, and the reported types of information gathered were not thorough. There is a need to

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find the barriers of appropriate informationgathering practice as well as to develop strategies to improve practices. It is also recommended that international and national pharmacy organizations, including pharmacy academia and pharmacy researchers develop a consensus on the types of information that should be reported in the original studies. This will help to standardize data reporting and facilitate comparisons across studies, so that deficient areas that need improvement can be identified.

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Acknowledgments This study is supported by the Australian Development Scholarship as part of the first author’s doctoral research.

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Appendix 1 Search terms used in the review MEDLINE & Cochranea Self medication Self treatment Self care Non prescription medic*

Pharmacy Pharmacist

Developing Countries [MeSH] Asia [MeSH] Africa [MeSH] Caribbean region OR Central America OR Latin America OR Mexico OR South America [MeSH] Melanesia OR Micronesia OR Polynesia [MeSH] Indonesia

Pharmacy Pharmacist

Developing country [MeSH] Africa [MeSH] Asia [MeSH] South and Central America [MeSH] Mexico [MeSH] Caribbean islands [MeSH] Pacific islands [MeSH] Indonesia

Pharmacy Pharmacist

Developing Countries [MeSH] Asia [MeSH] Africa [MeSH] Central America OR South America OR Mexico OR Latin America [MeSH] Melanesia OR Micronesia OR Polynesia [MeSH] Indonesia

Non prescription drug* Practice* Pharmacy service* EMBASEa Self medication Self treatment Self care Non prescription medic* Non prescription drug* Practice* Pharmacy service* CINAHL Plusa Self medication Self treatment Self care Non prescription medic* Non prescription drug* Practice* Pharmacy service*

Web of Science and International Pharmaceutical Abstracts (self medication OR self treatment OR self care OR non prescription medic* OR non prescription drug* OR practice* OR pharmacy service*) AND (pharmacy OR pharmacist) AND (Indonesia OR developing countr* OR less developed countr* OR least developed countr* OR third world countr* OR low income countr* OR middle income countr* OR low economic countr* OR middle economic countr*) a

The search term within each column were combined with “OR” and between columns were combined with “AND.”