Knowledge, Attitudes and Practice of Physicians towards Clinical Pharmacy Services in Ten Public Hospitals in Oromia Regional State, Ethiopia

Objective: The purpose of this study was to assess knowledge, attitudes and practice of medical doctors in some selected public hospitals towards Clinical Pharmacy Services in Ethiopia. Methodology: Cross sectional study design was employed to assess knowledge, attitude and practices of medical doctors towards clinical pharmacy services. The study population was selected using simple random sampling technique. Self-administered questionnaires were used to extract relevant information from the study subjects. The data was entered, cleaned and analyzed by using SPSS version-20. Results: The mean age of the study participants was 28.2 ± 5.2 years with a range between 20-53 years and 87.1% were males. 89.6% of the respondents are general practitioner and 8(8.6%) with different specialization with year of experience 2.94 + 3(0.5-22 year). Majority of respondents are knowledgeable regarding to clinical pharmacists as a member of medical teams and their services in reducing medication related errors and health related costs. More than 74% of the respondents were highly satisfied by the role of clinical pharmacists in counseling of patients regarding to safe and appropriate use of medications, prevention, detection and management adverse drug reactions. The present study depicted that lack of support from administration (70%); shortage of staff (63.4%) and lack of adequate support by the health care team (62.4%) were the major limitations to practice clinical pharmacy service in the hospitals. Conclusions: Physicians undoubtedly considered that pharmacists are drug information experts. Nevertheless, their anticipation of pharmacists as providers of quality clinically-focused pharmacy services was little. Physicians were willing to collaborate with clinical pharmacists in monitoring drug therapy and improving patient care by identifying medication errors.


Introduction Background information
Managing medicines safely, effectively and efficiently is central to the delivery of high-quality care that is focused on the patient and gives value for money. Clinical pharmacy is a health science discipline whereby pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention [1]. The practice of clinical pharmacy embraces the philosophy of pharmaceutical care; it blends a caring orientation with specialized therapeutic knowledge, experience, and judgment for the purpose of ensuring optimal patient outcomes. This field of pharmacy practice focuses on patient-oriented rather than drug product-oriented service [2]. The discipline arose out of dissatisfaction with old practice norms and the pressing need for a competent health professional with a comprehensive knowledge in the therapeutic use of drugs. Clinical pharmacists are a primary source of scientifically valid information and advice regarding the safe, appropriate, and cost-effective use of medications [1,3]. In the developed countries, rational use of drugs is a habitual practice due to the high level of interaction between physicians and pharmacists [3].

How does clinical pharmacy differ from pharmacy?
The discipline of pharmacy embraces the knowledge on synthesis, chemistry and preparation of drugs. But Clinical pharmacy is more oriented to the analysis of population needs with regards to medicines, ways of administration, patterns of use and drugs effects on the patients. Clinical pharmacy is a relatively new discipline in the pharmacy profession which is patient rather than drug oriented and aims to improve the quality of drug therapy [4].
The focus clinical pharmacy moves from the drug to the single patient or population receiving drugs. The goal of clinical pharmacy activities is to promote the correct and appropriate use of medicinal products and devices [5].
Pharmacists in Ethiopia practice in various settings, including community pharmacy, hospital pharmacy, drug information service, pharmaceutical industry, marketing, sales, regulatory agencies, academia, and drug distribution. There are few clinical pharmacists working in the public sector in Ethiopia and virtually none in the private sector. Thus, clinical pharmacy is in its infancy stage of development in Ethiopia and hence it requires greater attention to achieve the objective of pharmaceutical care [6].

Statement of the problem
Many studies have shown that physicians are receptive to several clinical services provided by pharmacists if these services were provided in the form of consultation or in a supportive role [7]. However, the relationship between the physician and community pharmacist has been described as a 'complex one' [8][9][10] and few studies have reported the existence of communication gap between pharmacists and medical doctors [11][12][13].
A study conducted in some Arabian countries revealed that patient care was exclusively delivered by physicians and nurses. Nevertheless, the input of pharmacists in managing drug therapy depends on the physician's willingness [13]. In Sudan, physicians were not interested with pharmacists about their recommendation regarding to prescription medications [14]. However, in Jordan 63% of physicians anticipate the pharmacist to educate their patients with regard to the safe and appropriate use of drugs. In addition, approximately half of the physicians agreed that pharmacists were always a reliable source of drug information [15]. In contrast, although the role of the community pharmacist seems to be changing in many countries, 48.2% of physicians in Kuwait are still uncomfortable with pharmacists' suggestion about the use of prescription medications to patients. Furthermore, one third of physicians do not expect the pharmacist to be available for consultation during rounds [16,17]. Doctors and community pharmacists have little interaction in Libya and UAE, based on the findings of one particular study [18] which showed that almost 70 and 60% of doctors in Libya and UAE, respectively, either 'rarely' or 'never' discussed patients' drug therapy with a pharmacist. Furthermore, it would appear that there is some skepticism about the appropriateness of pharmacists being involved in monitoring blood pressure and providing a therapeutic substitute. In Ethiopia, despite their increasing demand for clinical pharmacy professionals, there was no study about the satisfaction level of physicians about the patient oriented pharmacy service. This triggered an immense interest to do further assessment in this area.

Objective
General objective: To evaluate the knowledge, attitude and practices (KAP) of the medical doctors towards clinical pharmacy in Oromia regional state, Ethiopia.

Description of the study area and period
The study was conducted in Oromia Regional State, one of the largest regional states in Ethiopia. It is the homeland of 35 million populations, in which the number of males and females are almost proportional. In 2014, there are 67 functional hospitals in Oromia regien. Most of them are general hospitals. The study facilities were ten public hospitals found in Oromia regional state, Ethiopia. The study was conducted from May 01-30/2015.

Population
Source population: All medical doctors working in the selected hospitals Study population: Medical doctors working in the selected hospitals during the study period.

Inclusion and exclusion criteria
Inclusion criteria: All medical doctors working in ten public hospitals and consented to participate in the study during the study period were included.
Exclusion criteria: Jimma University specialized hospital physicians.

Study variables
Independent variables: Sex, Age, Educational Level, Religion.

Study design
A cross sectional study was conducted to assess knowledge, attitude and satisfaction of medical doctors towards clinical pharmacy services using interview.

Sample size and sampling technique
Ten public hospitals which offer clinical pharmacy services were selected by simple random sampling.

Data collection procedures
Data was collected using self-administered structured questionnaire. The questionnaire includes both closed and open ended questions, and consists of a series of questions prepared by the researchers with one version targeted at medical doctors. It was prepared in English. The questionnaire includes information on sociodemographic characteristics, knowledge, attitude and practice towards clinical pharmacy service. and standard deviation were used to summarize patients' baseline socio-demographic data and evaluate distribution of responses. Odds ratio and 95% confidence interval was used to check significant association between dependent & independent variables using univariate and multivariate analysis by logistic regression model. In all cases, P-value<0.05 were considered to be statistically significant.

Data quality management
Semi-structured questionnaire was pretested in 5% of the participants, and then the input was used to prepare the final questionnaire. Training was given for the data collectors and the quality of each data was checked by the principal investigators.

Ethical consideration
Ethical approval of the research proposal was obtained from the ethical review committee of Ambo University. Then the letter written from the college of medicine and health science coordinator was given to the CEO of the selected public hospitals to solicit their collaboration. In addition, data collection supervisors clarified the objectives of the study to the hospitals, verbal consent was obtained from the study participants and those voluntary to participate provided the questionnaire to fill. The confidentiality was assured by excluding their names and the right not to participate in the study was respected.

Result
Out of 101 questionnaires administered, 93 were completed and retrieved thereby giving response rates of 92.1%. The mean age of the study participants is 28.2 ± 5.2 years (20-53 years). Majority of the respondents were (83, 89.6%) general practitioner. They do have an average of 2.94 + 3 year (0.5-22 yr) of experience (Table 1).   Most of the physicians (>50%) have good attitude on clinical pharmacists' service in monitoring patient response to drug therapy from toxicity, roles in patient education and counseling and provide relevant drug information to health care professionals. However, less than half of the respondents said the current set up (infrastructure and environment) of their hospital is appropriate for the provision of clinical pharmacy services (Table 3).  Greater than half of the participants are satisfied with pharmacists' role as counselor of patients regarding to safe and appropriate use of medication, involvement in side effect prevention and management, and preventing, detecting and resolving adverse drug reactions. But they were poorly satisfied with participation of pharmacists in round, patient counseling during discharge, and documenting their services (

Factors affecting KA of physicians
From logistic regression, it is found that level education (p=0.996) and length of service year (p=1.000) are not determinant factor for physicians' knowledge regarding to current clinical pharmacy service.
From logistic regression, it is also found that level education (p=0.994) and length of service year (p=1.000) are not determinant factor for physicians' attitude regarding to current clinical pharmacy service. Moreover, the correlation between physicians' knowledge and attitude is insignificant.

Discussion
Globally, World Health Organization (WHO) is making attempts to deliver cost-effective quality health care globally [19]. The involvement of pharmacist in health care team has been proved cost-effective rather than an extra cost added to the treatment cost, which is evident because of treatment success, avoidance of adverse drug events, optimization of complex regimens, designing of adherence programs, and recommendation for cost-effective therapies. The health care team members need synchronization and alliance in order to fulfill their responsibilities. Patient care can be improved by coordinated work between physicians and pharmacists. Due to varying side effects of numerous medications, it is imperative that the pharmacist and physicians work together to reduce health care cost as well as provide the best available care to patients. Medication related health problem requires close interaction between physicians and pharmacist to be avoided and resolved [20]. This interaction demands an expanding role for the pharmacist to ensure cost effective and potential patient cares. As a result, it is very important for the physicians to be willing to accept clinical pharmacy services.
The practice of pharmacy has changed significantly in recent years. This, invariably, will necessitate changes in procedures and training, and may require more resources, imaginative use of pharmacy skills, and involvement of clinical pharmacists at prescribing and dispensing stages [21].
Interestingly, the present study revealed that there was a strong belief among medical doctors that clinical pharmacists were an important part of the clinical team to minimize medication errors, improve the patient's quality of life, offer primary care to the patients, and reduce adverse drug event and health care costs in a hospital setting. Another study done in United Arab Emirates reported that 75% medical students perceived that the clinical pharmacists are important part of the healthcare team. On the other hand, 82% believed that clinical pharmacists can help improve the quality of medical care in hospitals [22]. Furthermore, a study done by Bleiker & Lewis revealed that general practitioners have a positive attitude towards pharmacists about their insertion into the primary health care panel and an expansion of their role in relation to medicines; however, there was small support for the thought of pharmacists undertaking screening and running therapeutic monitoring clinics [23].
The finding was also comparable in study done in Pakistan and Jordan, which demonstrated that majority of general practitioners (>90%) thought that clinical pharmacist should be a source of clinical medicines information to general practitioners such as adverse effects of medicines and selection of a medicine for a particular disease state [24]. But in a study done in Sudan and Kuwait, physicians were found to be 'uncomfortable' with pharmacists' suggestion or recommendation on prescription medications to their patients, even if they are involved in the treatment of minor illnesses [25]. This might be due to lack of awareness on pharmaceutical care service.
In this study, participants had poor awareness on clinical pharmacist role in ambulatory and intensive care unit. However, other studies showed that clinical pharmacists started contributing to patient care in the hospitals by conducting ward rounds, monitor drug therapies and most importantly educate patient by the bedside. Moreover, they also perform a major role in provision of ambulatory clinical setups by providing intensive patient education and consultation to the prescribers [26]. This may be due to, in the developed countries, the improved interaction among physicians and pharmacist has resulted in a more cost effective and safe drug therapy [27].
Participated physicians agreed on clinical pharmacists' service on monitoring toxicity of medications (94.6%), patient education and counseling (93.5%) and provision of relevant drug information to health care professionals (87%). This is in line with studies done in United Arab Emirates, in which 75% medical personnel perceived that the clinical pharmacist is an important part of the healthcare team while 82% believed that clinical pharmacists can help to improve the quality of medical care in hospitals [28]. Furthermore, a study done in Pakistan showed that most physicians (70.8%) consider that involvement of clinical pharmacist in medication management is undoubtedly good [29].
In this study most of the respondents replied that there was no organized clinical pharmacy service in their setups. Interestingly, this study was in line with the study done in UAE in which 53% of the respondents reported that they did not have better setup for clinical pharmacy services in their institutions. Nevertheless, there was substantial willingness among physicians and nurses to cooperate with clinical pharmacists [30].
The study revealed that 95.5% of the medical doctors knew about the clinical pharmacy services in their institutions. This may be attributed to the presence of patient-oriented services by pharmacists. Although the findings demonstrated that physicians generally have good attitude towards clinical pharmacy service, such practice was relatively common only in public health care facilities. This is due to the virtual lack of clinical pharmacists in private hospitals in Ethiopia.
Findings from this study also further support the need for clinical pharmacists to perform specific duties that have been suggested in previous studies, e.g., patient education and minimizing medication errors [30,20]. Another study in Pakistan showed that physicians were ambivalent about the government policies and did not believe that the current policies give sufficient recognition to patient care approach. The government should develop strategies to strengthen doctorspharmacists relation, thereby enhancing the role of pharmacists in clinical care.
Regarding to the level of satisfaction in clinical pharmacy service, (%) physicians were satisfied role played by pharmacists with patients counseling concerning to safe and appropriate use of medication, involvement in side effect prevention and management, and preventing, detecting and resolving adverse drug reactions. Nevertheless, they were poorly satisfied with pharmacists' participation in ward rounds with other health care team, patient counseling during discharge, and documenting their services.
The present study depicted that lack of support from administration (70%); shortage of staff (63.4%) and lack of adequate support by the health care team (62.4%) were the major limitations to practice clinical pharmacy service in the hospitals.
The present study revealed that level education (p>0.05) and length of service year (p>0.05) were not determinant factors for physicians' knowledge and attitude regarding to current clinical pharmacy service. Moreover, there was no correlation between physicians' attitude and knowledge regarding to clinical pharmacy service [29,30].

Conclusion
Physicians undoubtedly considered that pharmacists are drug information experts. Nevertheless, their anticipation of pharmacists as providers of quality clinically-focused pharmacy services was little. Physicians were willing to collaborate with clinical pharmacists in monitoring drug therapy and improving patient care by identifying medication errors. However, Year of service and level of education were not significant predictors of physicians' knowledge and attitude towards the service.
In order to strengthen pharmaceutical care service the following concerned bodies ought to do the following major tasks:

Ministry of health
• To create new measures to promote and extend clinical pharmacy services in both government and private health care facilities. • To formulate doctors-pharmacists partnership programs, thereby enhancing health care. • To prepare some facilities and benefits for clinical pharmacy service.

Ministry of education
• To formulate inter-professional relationships between physicians and pharmacists in medical and pharmaceutical education curricula is also needed to enhance collaboration between physicians and pharmacists in patient care.

Pharmacy schools and associations
• To modify clinical curriculum for pharmacy students.

Physicians and other health care professionals
• To advocate team work in health care delivery