Medication counselling practices amid COVID -19 pandemic and associated factors in drug retail outlets of Jimma town, Southwest Ethiopia: cross-sectional study

Background Patients' good understanding and awareness of drug information received at the drug retail outlet is paramount to gaining expected outcomes. In the COVID-19 pandemic, the routine counselling practice faced multifactorial challenges. Objectives The study aimed to assess medication counseling practice and associated factors in drug retail outlets of Jimma town, southwest Ethiopia. Methods A facility-based cross-sectional study was conducted using an interviewer administered questionnaire. The data were analysed by using SPSS version 23. A multivariable logistic regression model was used to identify factors associated with medication counselling practice. Results A total of 180 pharmacy professionals were enrolled in the study, about half (51.1%) of the participants reported good medication counselling provision for their patients. In A multivariable logistic regression analysis, reduced pharmacist's level of communication (AOR=0.008; CI: 0.001–0.292; p= 0.009) and shortage of personal protective equipment (AOR=0.021; CI: 0.002–0.226; p=0.002) due Covid-19 were factors associated with poor medication counselling practice. Conclusion Reduced level of communication and shortage of personal protective equipment due to Covid-19 were factors associated with poor medication counselling practice. In general, Jimma town health offices and Oromia Region Health bureau should struggle in association with other stakeholders to improve the identified bottleneck of pharmacist's counselling practice.


Background
Drug use counseling is an interactive approach between the patient and the pharmacist, which focuses on the patient's requirements, beliefs, and perceptions about drug treatment 1 . Pharmacists' medication counselling activities are the core part of pharmaceutical care services, which are currently getting the great focus of pharmacy professionals, and expanding rapidly to promote cost-effective patient treatment outcomes. Medication counseling during dispensing should be clear, accurate, understandable, and complete for the patients [2][3][4] .
The detail of counseling information includes the importance of taking medicine, consequences of discontinuing or using it incorrectly, the dose of the medicine, route of taking, frequency of receiving, action should be taken if a patient misses a dose, duration of treatment, storage conditions, side effects and actions to be taken, lifestyle modification during treatment, drug-drug interaction, food-medicine interaction, re-checking whether the information is understood by the patient after advising. Patients' good understanding and awareness of drugs received at the dispensary unit is vital to gain expected medication outcomes 3,5,6 . The clinical and economic burden of inappropriate medication use is growing. Patients, without adequate information about their medications they cannot be effective collaborators in managing their care. So, patients and caregivers should perceive the counselling area as comfortable and confidential to help patients easily understand and remember their medication taking procedure 7,8 . However, pharmacists' insufficient knowledge on medication treatment, lack of updated drug information, high patient load, inappropriate counselling area, undervaluing the prominence of counseling, lack of commitment and poor communication were the factors that hampered medication counseling [9][10][11] . In Ethiopian, blow 40% of pharmacists have provided an acceptable level of medication counselling, and this is due to many pharmacists viewing it as an extra activity. The outbreak of COVID-19 pandemic further complicates the problems (12,13). Community pharmacy setting is the widely accessible and major pharmaceutical care services for the community, which is largely affected by the COVID-19 pandemic. As a result, pharmacists are at risk of contracting the COVID-19 pandemic because of they are on the frontline of the fight. Many patients with mild symptoms without a confirmed diagnosis of COVID-19 will seek advice from the pharmacist; in addition, the daily interact with an expected of 500 consumers asking about cosmetics, supplementary food, minor illnesses, and filling of prescriptions. However, in a low-income country, implementing appropriate social distancing is very difficult to reduce pandemic transmission in a drug retail outlet due to the weak health care system setting. As consequence, pharmacists are prone to COVID-19 infection and these mainly reduce their effort to provide appropriate medication counselling practice [14][15][16] . Ethiopia faces a different challenge with the different waves of the Covid-19 epidemic as other low-income countries are also unable to stop their major casualties. According to a report by the Ethiopian Public Health Institute, a total of 372,334 total cases, 12,480 active cases and 6,804 died of coronavirus by the end of December, 2021. The Ethiopian Ministry of Health officially kicked off the COVID-19 vaccine at Eka Kotebe COVID-19 Hospital on March 13, 2021, by prioritizing health workers, the elderly and patients with the chronic disease over the age of 55. However, due to lack of sufficient vaccine doses, the country planed only to vaccinate 20% of its 110 million populations by the end of 2021. This implies the impact of covid-19 continues to impose its destructive effect on medication counselling practice across the country 17,18 . Even though some studies reveal that there were inadequate pharmacists' medications counselling practices globally and in Ethiopia, as far as our knowledge is concerned, during the Covid-19 pandemic there was no study conducted in the current study area other than some commentary on pharmacist's medication counseling practice. Jimma is the largest town in southwestern Ethiopia, where many pharmaceutical care services are provided, and this is why it's designated as the study area. Therefore, this study aimed to assess the pharmacist's medication counselling practice amid the COVID -19 pandemic in drug-retail outlets of Jimma town, southwest Ethiopia.

Study settings, design, and period
A facility-based cross-sectional study was undertaken in drug retail outlets of Jimma town, Southwest Ethiopia. The town is located 346 kilometers away from Addis Ababa, the capital city of Ethiopia. There was one medical center, one primary hospital, 4 health centers, 24 private pharmacies and 33 drug stores in the town. A total of 190 pharmacy professionals were working in drug retail outlets found in Jimma town. The study was conducted from June to September, 2021.

Study population
All the pharmacists working in drug retail outlets of Jimma town were the source population whereas, pharmacists who volunteered to participate in the study and found during the data collection period were the study population. All pharmacists actively working in Jimma town drug retail outlets were included in the assessment however, pharmacists with less than one month's experience at drug retail outlet, who have not volunteered to participate in the study and are not available during the data collection period were excluded from the study. Sample size and sampling technique Actively, 190 pharmacists were working in Jimma town drug retail outlets. Using the census sample method, we took all pharmacists who fulfilled eligibility criteria, 185 Data collection procedures Structured self-administered questionnaires were developed by reviewing different kinds of literature (9,11,16,19,20) which had four parts and were distributed face to face. Part I: sociodemographic characteristics (age, sex, level of education, nature of employment, monthly income, working sector, and year of experience) of study participants assessed with seven items. Part II: Patient's counselling activities of pharmacists and evaluated by 16 items on a 5-point Likert-type scale from (1, always to 5, never). Part III: the impact of COVID-19 on pharmacists' counseling practice and assessed by 9 items on a 4 Likert scale (1, not affected to 4, strongly affected). The average score is used to dichotomize the participant's responses into not affected (No) and affected (Yes). Part IV: potential barriers of pharmacist's medication counseling practice and evaluated by 9 items on the Likert scale type questioners (1, strongly agree to 5, strongly disagree). The average score was used to split the responses into two categories: factors that affect (Yes) and not affect (No) pharmacists' counseling practices.

Outcome measurement
Patient's counseling activities evaluated by 16 items through a 5-point Likert scale. The average score of the scale was used as cut point to declare the counseling practice of pharmacists as adequate (above the average) and inadequate (below the average) in the drug retail outlet during dispensing.

Data quality assurance
In order to maintain the quality of the data, the tool was pre-tested for 5% of people surveyed at Buno Badele town drug retail outlets found Oromia region, southwest Ethiopia. The necessary modifications were made including, wordings on the questionnaire before it was applied to the study population. In addition, the data was compiled, coded, and checked for internal consistency before analysis. A Cronbach alpha analysis was done for nine Likert scale items measuring the impact of COVID-19 pandemic on pharmacists' counselling practices and resulted in 0.844.

Data analysis
The data were coded and entered into Epi data 4.2 then exported to the Statistical Package for Social Science (SPSS) 23 for analysis. Frequency and percentage of data were computed and the result is presented with a table and text as desired. The chi-square test was performed to test the adequacy of the cell before using the binary input regression. Bivariate logistic regression was carried out to investigate associations between the reported level of medication counseling and independent variables. Then, a backward, stepwise multivariate logistic regression [reported with adjusted odds ratios (AOR) with 95% confidence intervals] was performed including all explanatory variables with ap-value of < 0.25 on bivariate logistic regression to evaluate factors independently associated with the reported level of medication counseling. All p-values calculated were two-sided, and the statistical significance threshold was <0.05.

Result
Sociodemographic characteristics of the study participants A total of 180 pharmacists participated in the study with the response rate of 97.3%. Of the participants, majority, 102 (56.7%), of them were males, 186(47.8%) participants were aged below 30 years, and 112(62.2%) were working in the public secto/span>r. Most of the respondents (72.8%) were degree and above. Regarding years of experience, more than half (58.3%) of the respondents had less than five years of experience (Table 1).

Potential barriers of medication counseling practice
Study participants claimed that lack of knowledge (33.9%), lack of updated drug information (39.3%), high patient load (69.7%) and absence of private counselling room (55.4%) were the main factors that prohibit pharmacists from counselling their patients. About 23% of pharmacists underestimated the benefits of counselling, while 9% of them considered medication counselling were not their professional duty (Table 4).

Perceived level of medication counseling
Ninety-two (51.1%) of the pharmacists perceived they were provided good medication counseling for their patients, while around half of the participants reported they offered inadequate medication counseling (Table 2).  (Table 5).  14 , where 82.2% and 97.1% of the study participants reported they committed a shortage of personal protection equipment to deliver pharmacy services. Additionally, these studies were reported similar findings with the current study, where the level of communication and shortage of personal protection equipment were the major predictors of inadequate pharmacist medication counseling during the COVID-19 outbreak.

Factors associated with pharmacists counselling practice
These brought a significant impact on the pharmacist's medication counseling practice where it led to poor treatment outcomes, patient dissatisfaction, and raised unnecessary health care costs.
The pharmacist's working in public drug retail outlets, 90.6% (AOR=0.094; CI: 0.013-0.663; p=0.018), were less likely to offer adequate medication counseling than private sectors. This finding was supported by the study conducted at Bahir Dar city 3 . This may be due to private drug outlets are often concerned about attracting customers to promote and improve their market value, as well as the stability of care. Pharmacists limited access to updated drug information (AOR= 8.89; CI: 1.529-51.7; p= 0.015) were associated with inadequate medication counseling in this study which supported with studies conducted in Mekele city 9 , Bahir Dar city 3 , Gondar, Ethiopia 26 , and Tikur-Anbessa specialized hospital 23 . Also, pharmacists' underestimation of the benefit of medication counseling (AOR=0.004; CI: 0.001-0.062; p=0.001) was associated with inadequate medication counseling, which was supported by the study conducted in Mekele city 9 . This may be due to the pharmacist's tendency to traditional perception and the lack of structured teaching sections so that professionals can motivate and raise awareness about practicing medication counseling. The pharmacist's underestimation of medication counseling and lack of understanding are the risk factors for inadequate medication counseling. The patient' non adherence to the treatment due to pharmacists' inadequate medication counseling is associated with morbidity, mortality rates, and rising health costs 27 .