A review of the provision of appropriate advice by pharmacy staff for self-medication in developing countries

Research in Social and Administrative Pharmacy j (2014) j–j

Review Article

A review of the provision of appropriate advice by pharmacy staff for self-medication in developing countries Cecilia Brata, M.Pharm.a,b,*, Sajni Gudka, Ph.D.a, Carl R. Schneider, Ph.D.c, Rhonda M. Clifford, Ph.D.a a Pharmacy, School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia Centre of Medicine Information and Pharmaceutical Care, The University of Surabaya, Surabaya, Indonesia c Faculty of Pharmacy, The University of Sydney, Sydney, Australia

b

Abstract Background: Patients in developing countries often prefer to self-medicate via community pharmacies. Pharmacy staff are therefore in a strategic position to optimize the health of the public by providing appropriate advice to patients who self-medicate. Objective: To determine the proportion of pharmacy staff who provide appropriate advice when handling self-medication requests in developing countries. Method: A literature search was undertaken via MEDLINE, EMBASE, CINAHL Plus, Web of Science and International Pharmaceutical Abstracts. Studies that reported on the proportion of pharmacy staff providing appropriate advice when handling self-medication requests in developing countries were included. The appropriateness of advice was determined by each author’s definition in the original studies. Results: Twenty-eight studies met the inclusion criteria. There were variations in methods, scenarios, how the authors reported and defined appropriate advice, and study populations. The proportion of pharmacy staff providing appropriate advice varied widely from 0% to 96%, with a minority providing appropriate advice in 83% of the scenarios performed. Conclusion: There was considerable variation in results, with the majority of studies reporting that inappropriate advice was provided by pharmacy staff when handling self-medication requests in developing countries. Consistent and robust methods are required to provide comparisons across practice settings. There is also a need to identify contributing factors to poor provision of advice for developing intervention strategies for practice improvement. Ó 2014 Elsevier Inc. All rights reserved. Keywords: Self-medication; Developing country; Community pharmacy; Appropriate advice

* Corresponding author. School of Medicine and Pharmacology, The University of Western Australia, M315 Pharmacy, 35 Stirling Highway, Crawley, Western Australia 6009, Australia. Tel.: þ61 8 6488 3324; fax: þ61 8 6488 7532. E-mail address: [email protected] (C. Brata). 1551-7411/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.07.003

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Introduction Self-medication, defined as “the selection and use of medicines by individuals to treat selfrecognized illnesses or symptoms,”1 is considered a core activity conducted by community pharmacies internationally. Providing pharmacy-based advice for self-medication requests is particularly important in developing countries for several reasons. First, due to poor economic situations and lack of universal health coverage, low income patients may not be able to afford professional medical consultations.2,3 Second, public health care facilities in developing countries are usually overburdened with patients resulting in prolonged waiting times to see a doctor.4 Third, poor resourcing of public health care facilities can result in short supply of medications for patients.4–6 As a consequence, many patients in developing countries opt to self-medicate. They obtain their medication from community pharmacies because pharmacy staff provide free advice in addition to medicine supply.4,6 The process of self-medication consultation in community pharmacies includes 2 main stages: patient assessment and the provision of advice.7–10 During patient assessment, pharmacy staff need to gather and analyze patient information in order to choose the best treatment option for the patient.8 Next, based on the assessment, the pharmacy staff need to provide advice on their treatment option. The treatment option may include providing medicines along with the associated medicine information, referring the patients to a doctor, providing non-pharmacological advice, or providing other advice that is relevant to patient’s needs.11 In 2013, an in-depth literature review was conducted to determine the rate of informationgathering and to understand the types of information that were gathered by community pharmacy staff in developing countries.12 This review found that the rate of information-gathering varied widely from 18% to 97% across studies. Furthermore, the majority of studies showed that pharmacy staff did not gather an appropriate range of information that is in accordance with international standards.12 The authors concluded that the information-gathering process for the provision of self-medication consultation via community pharmacies in developing countries was inconsistent and the majority of studies reported that the types of information gathered were not comprehensive. The authors recommended that there is

a need to standardize the types of information reported in the original studies and to determine the barriers to appropriate information-gathering practice. There is very little published evidence on the provision of advice for self-medication from community pharmacies. One review, which focused on the quality of pharmacy services in developing countries, indicated that there were shortcomings in professional practices for advicegiving.13 However, the review did not particularly focus on self-medication requests. Nor did it provide quantitative data to sufficiently understand the scale of the problem. Therefore, to complete a picture of self-medication consultation in community pharmacies in developing countries, this review aims to determine the proportion of pharmacy staff who provide appropriate advice. Methods Search strategy and screening of the literature A literature search was undertaken via MEDLINE, EMBASE, CINAHL Plus, Web of Science and International Pharmaceutical Abstracts from 1990 to December 2013. The search terms for each database are presented in Appendix 1.12 The search was limited to the English language and studies conducted on humans. Additional articles were also searched from citations in relevant papers and the lead 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 advice for self-medication in community pharmacies, (2) studies that were conducted in developing countries as listed by the World Bank14 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 proportion of pharmacy staff providing appropriate advice when handling selfmedication requests. Studies that met these inclusion criteria were reviewed (Fig. 1). Operational definitions For the purposes of our review, a community pharmacy was defined as “a medicine outlet that is authorized to sell prescription and nonprescription medicines and is registered by the relevant national authority as having a qualified

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Fig. 1. Literature searches and study selection.

pharmacist responsible for the provision of these services.”12 The appropriateness of advice was based on each author’s definition in the original

studies and no further steps were undertaken to check whether the authors’ definition was consistent with the latest guideline.

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Data extraction and analysis A data extraction sheet was developed, pilot tested and refined via a consensus between 2 authors (CB, SG). First author’s name, year of publication, the country where the study was conducted, types of research methods, types of sampling and participants, the authors’ definition of appropriate advice, and the proportion of pharmacy staff providing appropriate advice were extracted. The first author extracted the data, and the second author randomly checked 25% of the included papers for consistency in data extraction. If there were any disagreements, it would be resolved by discussion between both authors (CB, SG). Because of variations between study populations, types of scenarios, types of methods, and the authors’ definition of appropriate advice, the data could not be combined statistically. The risk of bias was assessed according to the adapted criteria from Crombie.15 The criteria used to appraise the included studies were presented in Table 1. Results Study selection The search described in Appendix 1 identified 2710 articles (Fig. 1) (Table 2). After eliminating Table 1 The criteria to appraise the included studies (1) Did the study address a focused issue? (2) Was the research method appropriate to answer the aim? (3) Was the sample representative of its target population? (in terms of the selection of participants, including the types of sampling used.) (4) Any justification of sample size? (5) Whether a valid and reliable measure was used. For patient simulation method, 3 criteria to enhance validity and reliability were assessed, namely: the training of simulated patients, the use of formal scenarios, and the use of a standardized data collection form or audio-recording.16 For structured questionnaires used in pharmacy staff interviews, the types of reliability and validity used by the authors were assessed. There are many types of reliability tests that can be used, including: test-retest reliability, internal consistency, alternate-form reliability, or inter/intra-rater reliability.17 Meanwhile, the types of validity can include content validity, face validity, construct validity, or criterion validity. (6) Response rate (7) Whether appropriate data analysis used.

duplicates, screening the titles and abstracts, reviewing the full text articles, and retrieving additional articles from reference lists and the author’s personal collection, 83 studies met the first stage inclusion criteria. Of these 83 studies, 28 met the second stage inclusion criteria and were reviewed. Study characteristics Data extracted from the 28 included studies are presented in Table 1. Eleven studies were conducted in Asian regions: India,44 Indonesia,37 Pakistan,26,27 Thailand,19,39,40 Turkey,18 and Vietnam.22,24,32 Six studies came from African regions: Gambia,33 Kenya,29 South Africa,41,45 Sudan,36 and Zimbabwe,35 Lastly, 11 studies were undertaken in Latin American and Caribbean regions: Bolivia,25 Brazil,34,38 Colombia,43 Mexico,20,21,31,42 Jamaica,23 Latin American,30 and both Guatemala and Mexico.28 A wide variety of scenarios (n ¼ 64) were covered. This included abortifacients and/or misoprostol requests,21,30,31 acute respiratory infections,24,27,28 antimicrobials dispensing,19,37 asthma and the devices,36,44 carbamazepine substitution without medical authorization,43 diarrhea,25,26,28,34,39 34 28 headache, hypertension, influenza remedies in hypertension,43 malaria chemoprophylaxis,41 metronidazole use in pregnancy,43 migraine,40 oral and/or emergency contraceptives,20,23 sexually transmitted infections,22,29,33,35,38,42,45 steroid requests,32 and supplying dipyrone or misoprostol without prescription.43 Several methods were used to conduct these 28 studies. The patient simulation method was employed in 20 studies,19,21–29,31,34–39,41,43,44 pharmacy staff interview was performed in 4 studies,20,30,42,45 and a combination of patient simulation with pharmacy staff interview was employed in 4 studies.18,32,33,40 The provision of appropriate advice Of the 64 scenarios used in the 28 studies, the proportion of pharmacy staff providing appropriate advice ranged from 0% to 96%.18–45 However, in 53 of these 64 scenarios (83%), appropriate advice was provided to a minority of patients (range 0%–47%).18–33,35–40,42–45 The definition of appropriate advice varied across studies (Table 1). In 19 of the 28 included studies, authors used their own definition to decide whether the advice provided was considered appropriate.18–21,23,25–28,30,31,35–37,39–43 In 8 studies, authors used a national or international

Table 2 Summary of studies Country

Scenario

Methods

Sampling

Participants

The definition used to decide on the appropriateness of the advice

The proportion of pharmacy staff providing appropriate advice

Aktekin et al18 1998

Turkey

Infant diarrhea

PS

All population All population

214 214 214 208

Authors’ own definition  Appropriate advice was defined as medical referral.

21%

PS-Int

pharmacies, encounters. pharmacies interviews.

47%

All 315 pharmacies, population 280 encounters.

20% Authors’ own definition  The types and regime of antibiotic supplied must be appropriate for the scenario presented.

PS-Int OC supplied for 4 scenarios: a breastfeeding woman, a woman with breast cancer, a woman with irregular menstrual cycle, and a woman with a gastric ulcer

Random

108 interviews.

Authors’ own definition  Appropriate advice was defined as not supplying OC for breastfeeding woman and woman with breast cancer and supplying OC for woman with irregular menstrual cycle and woman with a gastric ulcer.

Misoprostol dosing regimen

Random

169 pharmacies, 153 encounters recommended products.

Authors’ own 16% of 106 encounters definition which provided  Potentially effective information about dosing for abortion. misoprostol.

Apisarnthanarak et al19 2008

Thailand

Antibiotic dispensing

Becker et al20 2004

Mexico

Billings et al21 2009

Mexico

PS

PS

 A breastfeeding woman (74%)  A woman with breast cancer (70%)  A woman with irregular menstrual cycle (37%)  A woman with a gastric ulcer (38%)

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Author, year

(continued) 5

Author, year

6

Table 2(continued ) Country

Scenario

Methods

Sampling

Participants

The proportion of pharmacy staff providing appropriate advice

Chalker et al22 2000

Vietnam

STI

Chin-Quee et al23 2006

Jamaica

OC supplied in an PS adolescent, a smoker patient, and a hypertensive patient

Purposive

15 pharmacies, 15 encounters.

Authors’ own definition  An adolescent patient scenario (40%)  Appropriate advice  A smoker patient was defined as scenario (73%) supplying OC for an  A hypertensive adolescent and not patient scenario supplying OC for a (93%) smoker and a hypertensive patient.

Chuc et al24 2001

Vietnam

ARI

PS

Random

60 pharmacies, 297 encounters.

The national guideline 36%  The management must meet the requirement of the guideline.

Gutierrez et al25 1995

Bolivia

Diarrhea

PS

All 498 pharmacies, population 596 encounters.

PS

Random

The national guideline. 0%  The type and regime of product supplied must meet the requirement of the guideline.

Authors’ own definition  Appropriate advice on the overall  Appropriate advice management of was defined as diarrhea (2%) increasing fluid  Appropriate advice intake, administer on fluid intake (8%) rehydration salts, or refer the patient to a health service.

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106 encounters provided medicine information about misoprostol. 60 pharmacies, 297 encounters.

The definition used to decide on the appropriateness of the advice

Pakistan

Diarrhea

PS

Convenience 371 pharmacies, 371 encounters.

Authors’ own definition 0%  The types and regime of product supplied must meet standard prescription or standard therapy.

Hussain et al27 2012

Pakistan

ARI

PS

Convenience 371 pharmacies, 371 encounters.

Authors’ own definition  The types and regime of product supplied must meet standard rational prescription by a doctor.

0%

Kroeger et al28 2001

Guatemala

ARI, hypertension, and diarrhea

PS

All 67 pharmacies, population 368 encounters.

 ARI (0%)  Hypertension (55%)  Diarrhea (3%)

Mexico

ARI, hypertension, and diarrhea

PS

Random

Authors’ own definition  Appropriate advice was defined as: B ARI: no antibiotics, emphasizing on liquid intake and continuing normal nutrition. B Hypertension: medical referral. B Diarrhea: only oral rehydration, no antibiotics, absorbents or antimotility.

Kenya

STIs

PS

Convenience 50 pharmacies, 100 encounters

Kwena et al29 2008

124 pharmacies, 601 encounters.

 ARI (2%)  Hypertension (40%)  Diarrhea (1%)

National guideline 10%  The types and regime of product supplied must meet the requirement of the guideline.

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Hussain et al26 2012

(continued) 7

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Table 2(continued ) Country

Lara et al30 2006

Methods

Sampling

Participants

The definition used to decide on the appropriateness of the advice

Latin American cities Misoprostol as abortifacients

PS-Int

Random

Authors’ own definition 6% of 29 interviews  Effective dose of which provided misoprostol for information about abortion. misoprostol

Lara et al31 2011

Mexico

Cytotec medicine information

PS

Random

Larrson et al32 2006

Vietnam

Steroid requests

PS

Random Random

The national regulation  Appropriate advice was defined as not supplying steroid without prescription.

24%

PS-Int

102 pharmacies. 97 interviews. 29 interviews provided information about misoprostol. 192 pharmacies, 576 encounters. 434 encounters provided information about misoprostol. 60 pharmacies, 295 encounters. 60 pharmacies, 70 interviews.

PS

Random Random

The national and/or WHO guidelines and CDC guidelines.  The types and regime of product supplied must meet the requirement of the guideline.

4%

PS-Int

24 24 24 24

PS

Convenience 25 pharmacies, 24 encounters

Leiva et al33 2001

Mesquita et al34 2013

Gambia

Brazil

Scenario

STI (Urethral discharge) STIs (Urethral discharge, pelvic inflammatory disease, and genital ulcer disease)

Headache

pharmacies, encounters. pharmacies, interviews.

The proportion of pharmacy staff providing appropriate advice

Authors’ own definition 15% of 434 encounters  Effective dose of which provided misoprostol for information about abortion. misoprostol.

Expert panel consensus

60%

 Urethral discharge (8%)  Pelvic inflammatory disease (0%)  Genital ulcer disease (0%) 96%

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Author, year

Osman et al36 2012

Puspitasari et al37 2011

Zimbabwe

Sudan

Indonesia

PS

Convenience 25 pharmacies, 25 encounters

 The product supplied must meet the expert panel consensus definition.

STI (Vaginal discharge) STI (Urethral discharge) Childhood diarrhea

PS

Random

PS

Random

PS

Random

Authors’ own definition 33%  The advice provided 8% must meet the requirement of the 22% step model management. The step model was developed based on the data collected and several guidelines.

Metered dose inhaler technique

PS

Metered dose inhaler þ spacer technique

PS

Turbuhaler technique

PS

Diskus

PS

Ciprofloxacin request

PS

Convenience 105 pharmacies, 105 encounters responded to the inquiry. Convenience 83 pharmacies, 83 encounters responded to the inquiry. Convenience 61 pharmacies, 61 encounters responded to the inquiry. Convenience 51 pharmacies, 51 encounters responded to the inquiry. Purposive 105 pharmacies, 88 encounters.

87 57 87 63 87 68

pharmacies, encounters pharmacies, encounters pharmacies, encounters

84%

Authors’ own definition Adequate or optimal technique (5%)  The instruction provided must meet with the recommended steps of asthma Adequate or optimal technique (7%) inhaler techniques required by the author. Adequate or optimal technique (5%)

Adequate or optimal technique (16%)

Authors’ own definition  Appropriate advice was defined as not supplying antibiotics, BUT medical referral.

0%

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(continued)

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Nyazema et al35 2007

Childhood diarrhea

Author, year

10

Table 2(continued ) Country

Methods

Sampling

Participants

The definition used to decide on the appropriateness of the advice

The proportion of pharmacy staff providing appropriate advice

Tetracycline request

PS

Purposive

105 pharmacies, 88 encounters

Authors’ own definition 4%  Appropriate advice was defined as not supplying antibiotics, BUT medical referral or providing topical antibiotics under pharmacist-onlymedicine group.

Ramos et al38 2004

Brazil

STI

PS

Random

63 pharmacies, 62 encounters.

The national guideline 0%  The types of product supplied must meet the requirement of the guideline.

Saeng-charoen et al39 2010

Thailand

Childhood diarrhea

PS

Random

96 pharmacies, 96 encounters.

Authors’ own definition  Appropriate product supplied was oral rehydration salts.  Appropriate advice regarding nonpharmacological therapy was on continuing giving food and milk.

Saeng-charoen et al40 2013

Thailand

Mild and moderate migraine

PS

Random

142 pharmacies 142 encounters.

Authors’ own  Mild migraine definition based on (33%) The WHO guideline  Moderate migraine and a pharmacy text (54%) book

 Appropriate product supplied (4%)  Appropriate advice on food (14%)  Appropriate advice on milk feeding (7%)

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Scenario

Random

142 pharmacies, 135 interviews.

 Appropriate prod-  Mild migraine (29%) uct supplied was:  Moderate migraine B Mild migraine – (30%) NSAIDs without ergotamine, triptans and prophylactic medications. B Moderate migraine: ergotamine without prophylactic medications.

Toovey et al41 2006

South Africa

Malaria chemoprophylaxis for malarious and non-malarious destination area

PS

N/R

68 encounters.

79% Authors’ own definition  Appropriate advice was defined as supplying malaria chemoprophylaxis for malarious destination area and not supplying malaria chemoprophylaxis for non-malarious destination area.

Turner et al42 2003

Mexico

STIs

PS-Int

Random

57 pharmacies, 57 interviews.

 Urethral discharge Authors’ own (16%) definition  The types of product  Genital ulcer (12%) recommended were  Vaginal discharge (16%) assessed according to the WHO guideline, literature, and medical doctor practices.

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PS-Int

(continued) 11

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Table 2(continued ) The proportion of pharmacy staff providing appropriate advice

Country

Scenario

Methods

Sampling

Participants

The definition used to decide on the appropriateness of the advice

Vacca et al43 2005

Colombia

 Substituting carbamazepine without authorization.

PS

Random

119 encounters.

Authors’ own definition 6%  Appropriate advice was defined as not substituting carbamazepine without the doctor’s authorization.

PS

Random

120 encounters.

Authors’ own definition 16%  Appropriate advice was defined as not supplying dipyrone without prescription.

 Dispensing misoprostol without prescription

PS

Random

119 encounters.

Authors’ own definition 28%  Appropriate advice was defined as not supplying misoprostol without prescription.

 Metronidazole request for a pregnant woman

PS-(telephone) Random

101 telephone encounters

Authors’ own definition 74%  Appropriate advice was defined as not recommending metronidazole.

 Acute respiratory infection

PS-(telephone) Random

88 telephone encounters

Authors’ own definition 3%  Appropriate advice was defined as not recommending antibiotics, but medical referral.

 Dispensing dipyrone without prescription

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Author, year

89 telephone encounters

Authors’ own criteria  Appropriate advice was defined as not recommending influenza remedies for these hypertensive patients.

29%

Van Sickle et al44 2006

India

Asthma

PS

Quota

52 pharmacies, 54 encounters.

The international 0% asthma guideline  The type of product supplied must meet the requirement of the guideline.

Ward et al45 2003

South Africa

STIs

PS-Int

Random

90 pharmacies, 85 interviews

The STI standard  Urethral discharge  The type of product (7%) supplied must meet  Genital ulcer (2%) the requirement of  Vaginal discharge the standard. (0%)

STI ¼ sexually transmitted infection; ARI ¼ acute respiratory infections; OC ¼ oral contraceptives; WHO ¼ World Health Organization; NSAID ¼ non-steroidal antiinflammatory drug; PS ¼ patient simulation; PS-Int ¼ pharmacy staff interview; N/R ¼ not reported.

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 Influenza remedies PS-(telephone) Random for an elderly hypertensive patient

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guideline to decide on the appropriateness of the product recommended or supplied.22,24,29,32,33,38,44,45 One study used expert panel consensus to decide on the appropriateness of the advice provided by pharmacy staff.34 Risk of biases Of the 7 criteria stated in Table 1, all 28 studies met the requirements for the first 2 criteria, which were addressing a focused issue and using an appropriate research method. Regarding sampling representativeness; 8 studies used non-random sampling, including: convenience sampling (5 studies),26,27,29,34,36 purposive sampling (2 studies),23,37 and quota sampling (1 study).44 One study, however, did not report the type of sampling used.41 Regarding sample size, the justification of sample size used was provided in 7 studies.21,27,30,31,37,39,40 The other 17 studies did not report on sample size calculation20,22–24,26,29,32–36,38,41–45 and 4 studies did not need sample size justification as the whole population was measured.18,19,25,28 With regard to the use of valid and reliable measures, 7 pharmacy staff interview studies did not report on the validity and reliability of the measurements used.18,20,30,32,33,42,45 Nine patient simulation studies did not provide a complete report on the 3 criteria used to enhance the validity and reliability (Table 1).18,19,22,24,25,28,29,32,43 Therefore, the validity and reliability of the measurements could not be fully assessed. Regarding the response rate or visit completion rate, the majority of studies (24 studies) achieved a response rate and/or visit completion rate of over 80%,18–27,29–34,36–40,42,44,45 2 patient simulation studies achieved a visit completion rate between 66% and 78%,35,43 and 2 patient simulation studies did not provide data on visit completion rate.28,41 Regarding data analysis, descriptive data analysis was provided in all 28 included studies. Of studies using pharmacy staff interviews, 2 studies stated to have open-ended questions in the questionnaire but did not report on the coding analysis process. Thus the consistency of coding could not be assessed.32,40 Another 4 studies did not report on the types of questions used in the questionnaire so the data analysis process could not be completely assessed.18,30,42,45

Discussion This review has described the provision of appropriate advice for self-medication via community

pharmacies in developing countries. A variety of methods, scenarios, how the authors report and define appropriate advice, and study populations was found. In total, there were 64 scenarios used in 28 studies to assess the provision of appropriate advice. The proportion of pharmacy staff providing appropriate advice varied from 0% to 96%, and the majority of scenarios (83%) had a percentage below 50%.18–33,35–40,42–45 This indicates that first, there are wide variations in the proportion of pharmacy staff who provided appropriate advice, and second, only a minority of pharmacy staff provided appropriate advice. There are a number of factors that could contribute to the wide variation in the proportion of appropriate advice being provided. First, there were differences in the type of method used by the various authors, leading to different results. Four studies that used 2 different methods (that is, patient simulation and pharmacy staff interviews) in the same study population and scenarios showed differences in the proportion of pharmacy staff providing appropriate advice between these 2 methods.18,32,33,40 For example, a study conducted in Vietnam found that while appropriate advice was provided in 25% of the oral steroid patient simulation scenarios, pharmacy staff interview identified that proportion to be 60%.32 Patient simulation measures the actual practice of the pharmacy staff whereas pharmacy staff interview relates to self-reported practice. Therefore, if future authors want to measure actual practice, this review highlights that the patient simulation method is more robust and accurate compared to pharmacy staff interviews. Second, the variation in the proportion of appropriate advice being provided by pharmacy staff could be due to the different types of scenarios used. Several studies that used the same method and conducted in the same study population have confirmed this statement.20,23,28,40,43 For example, a study in Guatemala showed that while appropriate advice was provided in 55% of encounters in the hypertension scenario, it was 0% for acute respiratory infection and 3% for diarrhea.28 The reasons why pharmacy staff respond differently to different type of scenarios have not been the focus of prior research. It could be that pharmacy staff have different levels of knowledge for different scenarios, thereby resulting in the variation in the proportion of appropriate advice found in this review. Third, there was variation in how the authors reported and defined appropriate advice. For example, for scenarios concerning sexually

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transmitted infections, appropriate advice was reported by some authors based on the type of product recommended. In this case, advice was considered appropriate if the product recommended was consistent with a particular guideline.22,38 In another study, the definition of appropriate advice was based on the overall management of the scenario, in which advice was considered appropriate if pharmacy staff recommended medical referral and provided non-pharmacological advice during the encounters.35 Thus, differences in how appropriateness is defined would automatically lead to variation in the proportion of pharmacy staff providing appropriate advice. Finally, contextual factors such as differences in the legislation, health care resources, and sociocultural factors could also cause variation in the management by pharmacy staff of self-medication requests across countries. In fact, practice can vary not only across countries but also within a country.46 This could be due to differences in the health care resources and socio-economic status between rural and urban areas, and between metropolitan cities and villages within a country.47,48 Also, within a culturally diverse country, there could be variations in health care perceptions and cultural characteristics among different ethnic groups.49 The International Pharmaceutical Federations (FIP) in particular reports that in developing countries, health care resources such as the number of pharmacists could be significantly different between urban and rural areas.46 As a result, the benefit of having pharmacists available to provide quality services is not obtained in an area where there is a lack of pharmacists,46 thus leading to differences in how pharmacy staff respond to a selfmedication request. Of the 28 studies reviewed, none explored the effect of contextual factors on how pharmacy staff responded to self-medication requests. It is essential for such research to use consistent and robust methods for each scenario as well as consistent measurement of appropriate advice in order to determine the influence of the contextual factors across practice settings. Community pharmacies have the potential to contribute to the health care of the public.13,50 However, this review showed that the majority of pharmacy staff did not provide appropriate advice when handling self-medication requests in developing countries. The pharmacy profession needs to find strategies to manage these shortcomings.13 It has been reported that the reasons for inappropriate practice in developing countries are usually complex and contextual factors may play an

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important role.51 As contextual factors are specific for each setting,50 researchers should determine the scale of the problem by identifying the baseline levels of pharmacy practice for each unique setting. This would enable an accurate assessment of the effect of interventions to improve the practice of pharmacy staff in developing countries when responding to self-medication requests. Strengths and limitations This is the first review that quantitatively examined the provision of appropriate advice for self-medication in community pharmacies in developing countries. The results were not combined statistically because of differences in the methodology, the types of scenarios, the definition of appropriate advice, and the contextual factors. As a result, this review can only provide a descriptive analysis about the baseline levels of appropriate advice being provided in community pharmacies in developing countries. The literature search did not include the gray literature, and therefore it is possible that all the research relevant to the provision of advice in community pharmacies in developing countries may not have been identified. Furthermore, the search strategy only included studies published in the English language, and therefore non-English publications which may be relevant to developing countries, were omitted. However, additional studies are unlikely to change the findings of wide variations in the proportion of appropriate advice being provided by pharmacy staff when handling self-medication requests in developing countries. There were some factors that may cause bias within the included studies. Eight studies used non-random sampling, and therefore may affect the representativeness of the sample and limit the generalizability of the finding. While the majority of studies had a response rate of over 80%, there could be a possibility of 20% non-response bias. However, although 20% of the results from nonrespondents was positive, this was unlikely to change the conclusion that a small proportion of pharmacy staff providing appropriate advice was found in the included studies.

Conclusion The evidence showed a wide variation in the proportion of pharmacy staff providing appropriate advice when handling self-medication requests in developing countries. This variation may

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be due to differences in the methods, scenarios, how the authors defined appropriate advice, as well as varying contextual factors across settings. The use of consistent and robust methods for each scenario is important to enable comparisons across practice settings. Furthermore, this review also found that the majority of pharmacy staff did not provide appropriate advice when handling self-medication requests in developing countries. The contributing factors to the current situation must be identified to allow the development of strategies to improve pharmacy practice for selfmedication requests. Acknowledgment This study is supported by the DFAT Australia Awards as part of the first author’s doctoral research.

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Appendix 1

MEDLINEa Self-medication Pharmacy Self treatment Pharmacist Self Care Non prescription medic* Non prescription drug* Practice* Pharmacy service* EMBASEa Self-medication Pharmacy Self treatment Pharmacist Self care Non prescription medic* Non prescription drug* Practice* Pharmacy service*

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

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

CINAHL Plusa Self-medication Pharmacy Developing Countries [MeSH] Self treatment Pharmacist Asia [MeSH] Self care Africa [MeSH] Non prescription medic* Central America OR South America OR Mexico OR Latin America [MeSH] Non prescription drug* Melanesia OR Micronesia OR Polynesia [MeSH] Practice* Indonesia 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 terms within each column were combined with “OR” and between columns were combined with “AND.”