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Fulltext Snapshot of antimicrobial stewardship programs in the hospitals of Pakistan: findings and implications

Saleem Z, Hassali MA, Hashmi FK, Godman B, Ahmed Z

Heliyon, 2019 Jul;5(7):e02159.
PMID: 31384689 DOI: 10.1016/j.heliyon.2019.e02159

Objective: We are unaware of the extent of antimicrobial stewardship programs (ASPs) among hospitals in Pakistan, which is a concern given the population size, high use of antibiotics across sectors and increasing antimicrobial resistance (AMR) rates. Consequently, we sought to address this by undertaking a comprehensive survey.
Method: In this cross-sectional observational study in Punjab, an instrument of the measure was developed based on health care facility characteristics and ASPs after an extensive literature review. The questionnaire was circulated by mail or through drop off surveys to medical superintendents or directors/heads of pharmacy departments of hospitals.
Results: Out of 254, a total of 137 hospitals fully completed the questionnaire - 11 primary, 65 secondary, 46 tertiary and 15 specialized hospitals. The use of antimicrobial prescribing guidelines (68.7%), provision of infectious diseases consultation services (66.4%), clinical pharmacy service (65.7%), use of drug and therapeutics committees to approve antimicrobial prescribing (65.5%), regular audit by doctors on antimicrobial prescribing (54.1%) and use of a restricted formulary for antimicrobial (50.4%) were the most common ASPs. However, most of these activities were only somewhat or moderately successful. Whereas, electronic antimicrobial prescribing approval systems (15.3%), using a sticker to notify prescribers regarding the need to obtain approval for the antimicrobial prescribed (16.1%) and participation in the national antimicrobial utilization surveillance program (19.7%) were only seen in a few hospitals.
Conclusion: Study inferred that there are inadequate ASPs in the hospitals of Pakistan. A multidisciplinary approach, clinical leadership and availability of motivated and trained individuals are essential elements for the success of future ASPs.
Knowledge and Barriers Among Physicians Toward Adverse Drug Reaction Reporting at a Tertiary Care Hospital in Saudi Arabia

Al-Abdulkarim DA, Aljadhey HS, Mahmoud MA, Poff GA, Hassali MA, Ali S

Hosp Pharm, 2021 Aug;56(4):368-373.
PMID: 34381276 DOI: 10.1177/0018578720910385

Background: Spontaneous reporting systems are essential as they help detect serious unknown adverse drug reaction (ADR). However, underreporting of ADR is a commonly associated problem. This research work aims to assess knowledge, barriers, and factors that encourage the reporting of ADR among physicians.
Methods: A total of 600 physicians working at a tertiary referral hospital in Riyadh, Saudi Arabia, were included in this cross-sectional study. A pretested questionnaire was used.
Results: Out of the 600 physicians, 240 (40%) completed the questionnaire. Most of the participants (85.4%) could correctly define ADR; nearly 75% physicians were unaware of the spontaneous reporting of ADR in Saudi Arabia. A total of 175 (72.9%) physicians had not reported any ADR among their patients in the last year; 40% of the physicians said that they did not report ADR because they were unaware of the online reporting of ADR. Providing guidelines and regular bulletins on the reporting of ADR is a critical aspect that encourages physicians to report ADR (51%). Education and training are the most recognized measures for improving the reporting of ADR.
Conclusion: Physicians were adequately aware of ADR but inadequately aware of the reporting system and reporting authorities. Continuing medical education, training, and integration of the reporting of ADR into physicians' various clinical activities may improve ADR reporting.
Fulltext Medication Safety at Home: A Qualitative Study on Caregivers of Chronically Ill Children in Malaysia

Chew CC, Hss AS, Chan HK, Hassali MA

Hosp Pharm, 2020 Dec;55(6):405-411.
PMID: 33245714 DOI: 10.1177/0018578719851719

Introduction: Medication errors are more likely to occur in chronically ill children, who are highly dependent on caregivers for medication administration. This study aimed to explore the issues related to medication safety among pediatric outpatients in Malaysia from the caregivers' perspective. Methods: This was a qualitative study conducted between May and June 2018 at a pediatric clinic of a regional referral hospital. Caregivers of children who (1) were under 6 years of age and (2) had hypothyroidism, epilepsy, thalassemia, asthma, or other chronic diseases were recruited via purposive sampling. Each selected disease was represented by at least 3 caregivers, who were identified from the medical records of their children. Face-to-face interviews were conducted with each of them, facilitated by a semi-structured interview guide. All the interviews were audio-recorded, transcribed verbatim, and analyzed using the thematic analysis approach. Results: A total of 15 mothers with a median age of 34 years were interviewed. Three themes emerged from the interviews: (I) actual experiences with medication errors, (II) underlying risk factors for medication errors, and (III) recommendations to improve medication safety. Several cases of administration errors, including missed doses and self-decided dose adjustment, were detected. Furthermore, the caregivers were found to have inadequate understanding of the medications in general. Conclusions: While children were shown to be consistently exposed to medication errors at home in Malaysia, the recommendations of the caregivers, including the use of written instructions and a diary, could be effective strategies to improve the out-of-hospital medication safety in children.
Frequency and evaluation of the perceptions towards caesarean section among pregnant women attending public hospitals in Pakistan and the implications

Ishaq R, Baloch NS, Iqbal Q, Saleem F, Hassali MA, Iqbal J, et al.

Hosp Pract (1995), 2017 Aug;45(3):104-110.
PMID: 28490205 DOI: 10.1080/21548331.2017.1328250

OBJECTIVES: There is increasing prevalence of caesarean sections (CS) worldwide; however, there are concerns about their rates in some countries, including potential fears among mothers. Consequently, we aimed to determine the frequency of CS, and explore patient's perception towards CS attending public hospitals in Pakistan, to provide future guidance.
METHODS: A two-phased study design (retrospective and cross sectional) was adopted. A retrospective study was conducted to assess the frequency of CS over one year among four public hospitals. A cross sectional study was subsequently conducted to determine patients' perception towards CS attending the four tertiary care public hospitals in Quetta city, Pakistan, which is where most births take place.
RESULTS: Overall prevalence of CS was 13.1% across the four hospitals. 728 patients were approached and 717 responded to the survey. Although 78.8% perceived CS as dangerous, influenced by education (p = 0.004), locality (p = 0.001) and employment status (p = 0.001), 74.5% of patients were in agreement that this is the best approach to save mother's and baby's lives if needed. 62% of respondents reported they would like to avoid CS if they could due to post-operative pain, and 58.9% preferred a normal delivery. There was also a significant association with education (p = 0.001) and locality (p = 0.001) where respondents considered normal vaginal delivery as painful.
CONCLUSION: The overall frequency of CS approximates to WHO recommendations, although there is appreciable variation among the four hospitals. When it comes to perception towards CS, women had limited information. There is a need to provide mothers with education during the antenatal period, especially those with limited education, to accept CS where needed.
A repeated point prevalence survey of antimicrobial use in specialized cancer care hospital of Pakistan: findings and implications

Saleem Z, Hassali MA, Hashmi FK, Godman B, Bhutta OA

Hosp Pract (1995), 2019 Aug;47(3):149-154.
PMID: 31180791 DOI: 10.1080/21548331.2019.1628614

Background: The extensive use of broad-spectrum antimicrobials in immunocompromised patients is inevitable in situations where culture and sensitivity testing is challenging. However, their overuse leads to an increase in antimicrobial resistance (AMR), which is a growing concern. Method: A repeated point prevalence survey (PPS) was conducted to assess the pattern of antimicrobial prescribing in a specialized cancer care hospital in Pakistan using the methodology employed by the European Centre of Disease Prevention and Control. Results: Out of 313 hospitalized patients, 156 (49.8%) were prescribed one or more antimicrobials, 82 (50.9) in 2017 and 74 (48.7) in 2018. The average bed occupancy in the hospital was 80.3%. Fever in neutropenic patients (20.2%), lower respiratory tract infections (17.8%), and sepsis (14.9%) were the three most common clinical indications. The total number of prescribed antimicrobials was 242, of whom, 41 (16.9%) were given orally and 201 (83.1%) were given parenterally. The most commonly used antimicrobials were piperacillin plus enzyme inhibitor (31.8%), meropenem (7.9%), ceftriaxone (6.2%) and vancomycin (6.2%). Of the total prescribed antimicrobials, 42 (17.3%) antimicrobials were used in surgical departments, 89 (36.8) in adult medical departments, 73 (30.1%) in pediatric medical departments and 38 (15.7) in the intensive care unit (ICU). In addition to these antibacterials, there was relatively high use of antivirals (acyclovir; 4.1%) and antifungals (fluconazole; 3.7%, amphotericin B; 2.9%). Conclusion: The study concluded that broad-spectrum antimicrobial usage in cancer hospitals in Pakistan is high, which can be a risk factor for the emergence of AMR. Repeated PPS is a fruitful way to maintain a focus on inappropriate antimicrobial use and develop pertinent intervention programs targeteing specific issues to improve future use.
Fulltext The role of pharmacists in developing countries: the current scenario in Pakistan

Azhar S, Hassali MA, Ibrahim MI, Ahmad M, Masood I, Shafie AA

Hum Resour Health, 2009;7:54.
PMID: 19594916 DOI: 10.1186/1478-4491-7-54

During the past few years, the pharmacy profession has expanded significantly in terms of professional services delivery and now has been recognized as an important profession in the multidisciplinary provision of health care. In contrast to the situation in developed countries, pharmacists in developing countries are still underutilized and their role as health care professionals is not deemed important by either the community or other health care providers. The aim of this paper is to highlight the role of pharmacists in developing countries, particularly in Pakistan. The paper draws on the literature related to the socioeconomic and health status of Pakistan's population, along with background on the pharmacy profession in the country in the context of the current directions of health care. The paper highlights the current scenario and portrays the pharmacy profession in Pakistan. It concludes that although the pharmacy profession in Pakistan is continuously evolving, the health care system of Pakistan has yet to recognize the pharmacist's role. This lack of recognition is due to the limited interaction of pharmacists with the public. Pharmacists in Pakistan are concerned about their present professional role in the health care system. The main problem they are facing is the shortage of pharmacists in pharmacies. Moreover, their services are focused towards management more than towards customers. For these reasons, the pharmacist's role as a health care professional is not familiar to the public.
Fulltext Assessment of knowledge and perceptions toward generic medicines among basic science undergraduate medical students at Aruba

Shankar PR, Herz BL, Dubey AK, Hassali MA

Indian J Pharmacol, 2016 Oct;48(Suppl 1):S29-S32.
PMID: 28031604 DOI: 10.4103/0253-7613.193309

OBJECTIVE: Use of generic medicines is important to reduce rising health-care costs. Proper knowledge and perception of medical students and doctors toward generic medicines are important. Xavier University School of Medicine in Aruba admits students from the United States, Canada, and other countries to the undergraduate medical (MD) program. The present study was conducted to study the knowledge and perception about generic medicines among basic science MD students.
MATERIALS AND METHODS: The cross-sectional study was conducted among first to fifth semester students during February 2015. A previously developed instrument was used. Basic demographic information was collected. Respondent's agreement with a set of statements was noted using a Likert-type scale. The calculated total score was compared among subgroups of respondents. One sample Kolmogorov-Smirnov test was used to study the normality of distribution, Independent samples t-test to compare the total score for dichotomous variables, and analysis of variance for others were used for statistical analysis.
RESULTS: Fifty-six of the 85 students (65.8%) participated. Around 55% of respondents were between 20 and 25 years of age and of American nationality. Only three respondents (5.3%) provided the correct value of the regulatory bioequivalence limits. The mean total score was 43.41 (maximum 60). There was no significant difference in scores among subgroups.
CONCLUSIONS: There was a significant knowledge gap with regard to the regulatory bioequivalence limits for generic medicines. Respondents' level of knowledge about other aspects of generic medicines was good but could be improved. Studies among clinical students in the institution and in other Caribbean medical schools are required. Deficiencies were noted and we have strengthened learning about generic medicines during the basic science years.
Fulltext Use of drug information resources by the community pharmacist in Penang, Malaysia

Hassali MA, Khan TM, Shafie AA

Inform Prim Care, 2010;18(3):213-6.
PMID: 21396245

This study aimed to identify the types of drug information resources used by community pharmacists in daily practice in Penang, Malaysia.
Modified labels for long-term medications: influences on adherence, comprehension and preferences in Malaysia

Chan HK, Hassali MA

Int J Clin Pharm, 2014 Oct;36(5):904-13.
PMID: 25135804 DOI: 10.1007/s11096-014-0003-1

BACKGROUND: Inability to read instructions on drug labels has been identified among the Malaysian population since 1990's.
OBJECTIVE: To assess the impact of font-enlarged and pictogram-incorporated labels used for long-term medications on patients' adherence, comprehension and preferences.
SETTING: Outpatient pharmacy in one of the major general hospitals across Northern Malaysia.
METHOD: This was a three-arm, randomized controlled trial. Outpatients with refill prescriptions of selected oral antihypertensive or antidiabetic medications were screened for eligibility. They were randomly allocated with standard (n = 35), font-enlarged (n = 40) or pictogram-incorporated (n = 35) labels. Assessment of baseline adherence scores using the 8-item Morisky Medication Adherence Scale, comprehension scores using a structured questionnaire and preferences was conducted upon recruitment. Follow-up telephone interviews were conducted after 4 weeks.
MAIN OUTCOME MEASURE: The changes of patients' adherence and comprehension scores and their preferences.
RESULTS: Within-group comparisons demonstrated an increase of total adherence scores after 4 weeks in all three groups (mean changes 0.35, 0.58 and 0.67; p = 0.029, 0.013 and 0.011, respectively). The repeatedly measured total comprehension score of pictogram-incorporated label group was significantly higher than baseline (mean change 0.37, p = 0.010). Two intervention groups obtained significantly higher scores for few items in both adherence and comprehension measurements after 4 weeks as compared with baselines. As indicated by F tests, three groups did not significantly differ in the changes of both total adherence and comprehension scores (p = 0.573 and 0.069, respectively) with the subjects' age adjusted. Elderlies and those with a higher number of morbidity preferred pictogram-incorporated label over font-enlarged label.
CONCLUSION: We did not find a significant change of both adherence and comprehension levels after the introduction of modified medication labels. However, on the basis of within-group comparisons, they may have positive influences on certain aspects of patients' adherence and comprehension. Variations in preferences may reflect the unique need of different subgroups in receiving written medication instructions.
Study site: Outpatient pharmacy, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
Comparing effectiveness of two anticoagulation management models in a Malaysian tertiary hospital

Thanimalai S, Shafie AA, Hassali MA, Sinnadurai J

Int J Clin Pharm, 2013 Oct;35(5):736-43.
PMID: 23715759 DOI: 10.1007/s11096-013-9796-6

BACKGROUNDS: Limited evidence is available regarding pharmacist managed anticoagulation clinic in the Southeast Asian region where there is marked difference in terms of care model, genetic composition and patient demographics.

OBJECTIVES: This study aimed at comparing the anticoagulation clinic managed by the pharmacist with physician advisory and the usual medical care provided in Kuala Lumpur Hospital (KLH) in terms of anticoagulation control and adverse outcomes.

SETTING: A 2,302 bedded government tertiary referral hospital in Malaysia.

METHODS: A 6-month retrospective cohort study of the effectiveness of two models of anticoagulation care, the pharmacist managed anticoagulation clinic which is known as warfarin medication therapy adherence clinic (WMTAC) and usual medical clinic (UMC) in KLH was conducted, where a random number generator was used to recruit patients. The UMC patients received standard medical care where they are managed by rotational medical officers in the physicians' clinic. As for the WMTAC with physician advisory, the pharmacist will counsel and review the patients internationalised normalization ratio at each clinic visit and also adjust the patients' warfarin dose accordingly. Patients are referred to physicians if immediate attention is required.

MAIN OUTCOME MEASURE: The main therapeutic outcome is time in therapeutic range (TTR) both actual and expanded TTR and thromboembolic and bleeding complications.

RESULTS: Each of the WMTAC and usual medical care recruited 92 patients, which totals to 184 patients. The patient demographics in terms of age, race and indication of treatment were comparable. At the end of the 6 months follow-up, patients in the WMTAC group had significantly higher actual-TTR (65.1 vs. 48.3 %; p < 0.05) compared to those in usual medical care group. Rates of admission were 6.5 versus 28.2 events per 100 person-years for the WMTAC and UMC groups, respectively. Though the bleeding incidences were not significantly different, it was reduced.

CONCLUSIONS: These findings will impact local warfarin patient management services and policies because there was no available evidence supporting the role of pharmacists in the management of warfarin patients prior to this study.
Evaluation of potentially inappropriate medications among older residents of Malaysian nursing homes

Chen LL, Tangiisuran B, Shafie AA, Hassali MA

Int J Clin Pharm, 2012 Aug;34(4):596-603.
PMID: 22622593 DOI: 10.1007/s11096-012-9651-1

BACKGROUND: There is an increasing evidence of medicines related issues such as inappropriate prescribing among older people. Inappropriate prescribing is an important risk factor for adverse drug reactions and hospitalizations in the older people.
OBJECTIVE: To assess and characterize the prevalence of Potentially Inappropriate Medications (PIMs) in nursing home care in Malaysia as defined by Screening Tool of Older Peoples Prescriptions (STOPP) and Beers criteria.
SETTING: Four Nursing Homes situated in Penang, Malaysia.
METHODS: A multicenter and cross-sectional study was conducted over 2 months period at four large non-governmental organizations nursing homes in Penang, Malaysia. The study population included older residents (≥65 years old) taking at least one medication. Residents who had been diagnosed with dementia or taking anti dementia drugs, delirium, too frail or refused to give consent were excluded. Demographic, clinical data and concurrent medications were collected through direct interview and also by reviewing medical records. STOPP and Beers criteria were applied in the medical review to screen for PIMs.
MAIN OUTCOME MEASURE: Potentially Inappropriate Medication using STOPP and Beers criteria.
RESULTS: Two hundred eleven residents were included in the study with the median age of 77 (inter quartile range (IQR) 72-82) years. Median number of prescription medicines was 4 (IQR 1-14). STOPP identified less residents (50 residents, 23.7 %) being prescribed on PIMs compared with Beers criteria (69 residents, 32.7 %) (p < 0.001). There was a significant difference in the number of residents with PIMs detected by STOPP (23.7 %) and by Beers criteria (32.7 %), p < 0.001. The common identified PIMs by Beers criteria included nifedipine short acting, chlorpheniramine and diphenhydramine. The STOPP identified first generation antihistamines, duplication of drug classes, glibenclamide and anticholinergic agents. Higher number of medications (OR = 1.405 [1.193-1.654]; OR = 1.447 [1.215-1.723]) and longer stay at nursing home (OR = 1.132 [1.045-1.226]; OR = 1.133 [1.034-1.241]) were identified as predictors for both Beers and STOPP PIMs.
CONCLUSION: Potentially inappropriate medications are highly prevalent among older residents living in the nursing homes and are associated with number of medications and longer nursing home stay. Further research is warranted to study the impact of PIMs towards health related outcomes in these elderly.
WHO guidelines for treatment of tuberculosis: the missing links

Atif M, Sulaiman SA, Shafie AA, Ali I, Hassali MA, Saleem F

Int J Clin Pharm, 2012 Aug;34(4):506-9.
PMID: 22706597 DOI: 10.1007/s11096-012-9657-8

Worldwide, the treatment of tuberculosis is based on evidence-based guidelines developed by the World Health Organization (WHO) for national tuberculosis programs. However, the importance of health related quality of life, the adequate management of side effects associated with antituberculosis drugs and the elaboration of tuberculosis treatment outcome categories are a few issues that need to be addressed in forthcoming WHO guidelines for the treatment of tuberculosis.
Self-medication practices among adult population attending community pharmacies in Malaysia: an exploratory study

Hassali MA, Shafie AA, Al-Qazaz H, Tambyappa J, Palaian S, Hariraj V

Int J Clin Pharm, 2011 Oct;33(5):794-9.
PMID: 21811832 DOI: 10.1007/s11096-011-9539-5

OBJECTIVE: To assess the prevalence of self-medication among adults in an urban setting and to identify any factors contributing to self-medication in relation to consumer characteristics.
SETTING: The study was carried out in Kuala Lumpur, the capital of Malaysia.
METHODS: A cross-sectional study using a self administered questionnaire including adults above 21 years old as an exit survey was conducted in Kuala Lumpur.
MAIN OUTCOME MEASURES: Number of medications taken in a day by participants, source of medication for the treatment of minor illnesses among participants, common illnesses chosen for self-medication by participants, and the sources of information of participants.
RESULTS: Of 314 participants, 62.7% had taken at least one medication in the past week without prescription and 62.7% believed that over the counter medicines were just as effective as those prescribed by doctors. 69.4% would seek a healthcare professional's advice before purchasing any medication and 86.9% would consult a pharmacist prior to buying medication from the pharmacy. Only 86% checked the expiry dates on medications and 54.5% reported keeping leftover medication.
CONCLUSIONS: Self-medication practice is prevalent in Kuala Lumpur but some practice might be harmful. Education on appropriate use of self-medication need to be emphasized in order to ensure quality use of medicines.
Exploring community pharmacists' views on generic medicines: a nationwide study from Malaysia

Chong CP, Hassali MA, Bahari MB, Shafie AA

Int J Clin Pharm, 2011 Feb;33(1):124-31.
PMID: 21365404 DOI: 10.1007/s11096-010-9470-1

OBJECTIVE: To evaluate the Malaysian community pharmacists' views on generic medicines.
SETTING: A sample of 1419 Malaysian community pharmacies with resident pharmacists.
METHOD: A cross-sectional nationwide survey using a self-completed mailing questionnaire.
MAIN OUTCOME MEASURE: Pharmacists' views on generic medicines including issues surrounding efficacy, safety, quality and bioequivalence.
RESULTS: Responses were received from 219 pharmacies (response rate 15.4%). Only 50.2% of the surveyed pharmacists agreed that all products that are approved as generic equivalents can be considered therapeutically equivalent with the innovator medicines. Around 76% of respondents indicated that generic substitution of narrow therapeutic index medicines is inappropriate. The majority of the pharmacists understood that a generic medicine must contain the same amount of active ingredient (84.5%) and must be in the same dosage form as the innovator brand (71.7%). About 21% of respondents though that generic medicines are of inferior quality compared to innovator medicines. Most of the pharmacists (61.6%) disagreed that generic medicines produce more side-effects than innovator brand. Pharmacists graduated from Malaysian universities, twinning program and overseas universities were not differed significantly in their views on generic medicines. Additionally, the respondents appeared to have difficulty in ascertaining the bioequivalent status of the marketed generic products in Malaysia.
CONCLUSION: The Malaysian pharmacists' have lack of information and/or trust in the generic manufacturing and/or approval system in Malaysia. This issue should be addressed by pharmacy educators and relevant government agencies.
Attitudes, knowledge and views on off-label prescribing in children among healthcare professionals in Malaysia

Balan S, Ahmad Hassali MA, Mak VSL

Int J Clin Pharm, 2019 Aug;41(4):1074-1084.
PMID: 31197546 DOI: 10.1007/s11096-019-00862-y

Background Off-label prescribing in children is associated with several prerequisites such as ensuring sound and scientific evidence and obtaining written consent prior to use of off-label drugs to ensure that protection is provided to patients and healthcare professionals. Adherence to the pre-requisites depends on the attitude, views and knowledge of the pharmacists and doctors involved in this practice. Objective To explore the attitudes, knowledge and views on off-label prescribing in children among hospital-based pharmacists and paediatric doctors. Setting The study was conducted in a 620-bedded general hospital located in the urban area of central Peninsular Malaysia. Method Face to face, semi-structured interviews with 12 pharmacists and 12 paediatric doctors. Interviews were audio-recorded, transcribed and analysed using constant comparison method. Main outcome measure Themes surrounding hospital-based pharmacists' and paediatric doctors' attitude, knowledge and views on off-label prescribing in children. Results Four themes were derived: knowledge on off-label prescribing in children, views on off-label prescribing in children, attitude towards off-label prescribing in children and guidance on off-label prescribing in children. Conclusion There is a need to increase the knowledge of hospital-based pharmacists and paediatric doctors and address several concerns on off-label prescribing in children. The decision to prescribe or dispense off-label drugs involved collective decision-making mechanisms and guidance is required with regards to offlabel prescribing in children.
Perspectives of community pharmacists in Pakistan about practice change and implementation of extended pharmacy services: a mixed method study

Hashmi F, Hassali MA, Saleem F, Saeed H, Islam M, Malik UR, et al.

Int J Clin Pharm, 2021 Aug;43(4):1090-1100.
PMID: 33411180 DOI: 10.1007/s11096-020-01221-y

Background Community pharmacists' role in the primary health care, patient-centered services, beyond traditional dispensing services is well established in the developed world. However, this role is not fully established in low-middle-income countries including Pakistan. Objective To explore community pharmacists' perspectives and preparedness about practice change and associated facilitators and barriers to extended services. Setting A study was conducted involving community pharmacists of Lahore, Pakistan. Method Two phased studies were conducted using mixed-method sequential design. The first phase involved qualitative semi-structured face-to-face interviews with the community pharmacists, while the second phase constituted a questionnaire-based cross-sectional study. Main outcome measure Pharmacists' perspectives about extended pharmacy services, facilitators, barriers and preparedness for the practice change. Results For the first phase, pharmacists were purposively sampled and the saturation yielded a final sample size of fifteen pharmacists (N = 15). The thematic content analysis yielded four distinct themes; (1) current practices and familiarity with extended pharmacy services (2) practice gap between Pakistan and the developed countries (3) facilitators and the preparedness, and (4) barriers towards its implementation and provision. The second part was a questionnaire-based cross-sectional phase, where a total of 348 community pharmacists were approached, while only 242 responded, yielding a response rate of 69.5%. The triangulation of qualitative and quantitative data identified several barriers such as; shortage of pharmacists, lack of knowledge and skills, poor collaboration with general practitioners, failure of customers to pay for extended services. Facilitators and preparedness for the provision of extended pharmacy services were; access to patient notes, follow-up, separate counselling areas, accreditation of specific services and sufficient resources. Conclusion This study's findings call for the implementation and enforcement of Punjab Drug Sale Rules 2007 to facilitate the practice change and provision of comprehensive pharmacy services in Punjab, Pakistan. There is a need for additional laws to define community pharmacists' roles, uniform job description, training, new funding model, separate area, and accreditation of extended pharmacy services in Pakistan.
Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics

Samsiah A, Othman N, Jamshed S, Hassali MA

Int J Clin Pharm, 2020 Aug;42(4):1118-1127.
PMID: 32494990 DOI: 10.1007/s11096-020-01041-0

Background Medication errors are the most common types of medical errors that occur in health care organisations; however, these errors are largely underreported. Objective This study assessed knowledge on medication error reporting, perceived barriers to reporting medication errors, motivations for reporting medication errors and medication error reporting practices among various health care practitioners working at primary care clinics. Setting This study was conducted in 27 primary care clinics in Malaysia. Methods A self-administered survey was distributed to family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. Main outcome measures Health care practitioners' knowledge, perceived barriers and motivations for reporting medication errors. Results Of all respondents (N = 376), nurses represented 31.9% (n = 120), followed by doctors (n = 87, 23.1%), pharmacists (n = 63, 16.8%), assistant medical officers (n = 53, 14.1%), pharmacist assistants (n = 46, 12.2%) and family medicine specialists (n = 7, 1.9%). Of the survey respondents who had experience reporting medication errors, 56% (n = 62) had submitted medication error reports in the preceding 12 months. Results showed that 41.2% (n = 155) of respondents were classified as having good knowledge on medication error and medication error reporting. The mean score of knowledge was significantly higher among prescribers and pharmacists than nurses, pharmacist assistants and assistant medical officers (p
A cross-sectional survey on the attitudes and interests of rural population towards expanded pharmacist prescribing in India

Khan MU, Arief M, Ahmad A, Malik S, Gogoi LJ, Kalita M, et al.

Int J Clin Pharm, 2017 Apr;39(2):473-477.
PMID: 28260131 DOI: 10.1007/s11096-017-0443-5

Background Shortage of qualified medical doctors and little or no access to basic medicines and medical facilities are the major rural health concerns in India. Expanding the role of pharmacists to provide prescribing services could improve rural health outcomes. Objective To assess the attitudes of rural population towards pharmacist prescribing and their interest in using expanded pharmacist prescribing services. Setting Rural population of Assam, India. Methods A descriptive, cross-sectional survey was conducted for a period of 2 months from March to April 2016 in the State of Assam, India. A multi-stage sampling was used to recruit (n = 410) eligible participants. Main outcome measure Rural population attitudes towards, and interests in using, pharmacist prescribing services. Results The attitudes of participants were generally positive towards pharmacist prescribing. A large proportion of participants (81.5%) agreed that pharmacists should have a prescribing role in rural India. Participants indicated their interest in using expanded pharmacist prescribing services, with greater interests in receiving medications in emergency situations (79.7%) and getting a treatment plan for their medical problem (75.6%). Participants with low income and tertiary education had better attitudes and showed more interest towards expanded pharmacist prescribing services (p
Antimicrobial prescribing and determinants of antimicrobial resistance: a qualitative study among physicians in Pakistan

Saleem Z, Hassali MA, Godman B, Hashmi FK, Saleem F

Int J Clin Pharm, 2019 Oct;41(5):1348-1358.
PMID: 31273588 DOI: 10.1007/s11096-019-00875-7

Background Understanding physicians' perception about antimicrobial use and resistance is essential to ensure that the objectives of the Pakistan national action plan on antimicrobial resistance are met. Little is currently known about physicians' perceptions in Pakistan. Objective Assess physicians' perception surrounding antibiotic use and resistance, factors influencing antibiotic prescribing and potential interventions to improve future antibiotic prescribing. Settings The study was conducted in Lahore, the capital of the province of Punjab, which is the second largest and most populous city of Pakistan. Method Qualitative study was conducted with a semi-structured interview guide involving in-depth face-to-face interviews with purposively selected physicians. Audiorecorded interviews were transcribed verbatim and transcripts analyzed by thematic content analysis. Main outcome measures Themes surrounding the perspectives of physicians on issues of antimicrobial use and resistance. Results Five major themes emerged: (1) knowledge and perception of physicians about antimicrobials, (2) antimicrobial prescribing behaviors of physicians, (3) factors influencing prescribing, (4) determinants of antimicrobial resistance, (5) and potential interventions to reduce antimicrobial resistance. The main challenges and issues associated with antibiotic prescribing were the improvement of knowledge, implementation of hygienic measures, access to and clarity of treatment recommendations and minimizing external factors influencing prescribing including pharmaceutical company activities. Suggestions for the future included stricter regulations for prescribing, improved diagnosis, availability of local guidelines and monitoring of prescribing and resistance patterns. Conclusion Identification of concerns regarding inappropriate antimicrobial prescribing will enable specific initiatives and approaches to improve future antimicrobial use and reduce antimicrobial resistance in Pakistan.
Diabetes knowledge, medication adherence and glycemic control among patients with type 2 diabetes

Al-Qazaz HKh, Sulaiman SA, Hassali MA, Shafie AA, Sundram S, Al-Nuri R, et al.

Int J Clin Pharm, 2011 Dec;33(6):1028-35.
PMID: 22083724 DOI: 10.1007/s11096-011-9582-2

BACKGROUND: Most of interventions that have attempted to improve medication adherence in type 2 diabetes have been educational; on the assumption that knowledge regarding diabetes might affect patients' adherence to their treatment regimen.
OBJECTIVES: The purpose of the study was to investigate any association of knowledge and medication adherence with glycemic control in patients with type 2 diabetes mellitus. Setting The study was conducted at the Diabetes Outpatients Clinic, Hospital Pulau Pinang.
METHODS: A cross-sectional study was conducted with a convenience sample of 540 adult patients with type 2 diabetes attending the clinic. A questionnaire including previously validated Michigan Diabetes Knowledge Test and Morisky Medication Adherence Scale was used and the patients' medical records were reviewed for haemoglobin A1C (HbA1C) levels and other disease-related information. A total of 35 (6.48%) patients were excluded after data collection due to lack of HbA1C results.
RESULTS: Five hundred and five patients were included in the final analysis, with a mean age of 58.15 years (SD = 9.16), 50.7% males and median HbA1C of 7.6 (IQR was 6.7-8.9). The median total knowledge score was 7.0 (IQR was 5.0-10.0) while the median adherence score was 6.5 (IQR was 4.75-7.75). Significant correlations were found between the three variables (HbA1C, knowledge and adherence). A significantly higher score for knowledge and adherence (P < 0.05) was found in those patients with lower HbA1C. Higher diabetes knowledge, higher medication adherence and using mono-therapy were significant predictors of good glycemic control in the multivariate analysis.
CONCLUSION: Patients' knowledge about diabetes is associated with better medication adherence and better glycemic control. In addition to other factors affecting medication adherence and glycemic control, healthcare providers should pay attention to knowledge about diabetes that the patients carry towards medication adherence.

Study site: Diabetes Outpatients Clinic, Hospital Pulau Pinang, Pulau Pinang, Malaysia

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