Current Practices and Perceived Role of Community Pharmacists in Type 2 Diabetes Services in Pakistan

Background Diabetes mellitus is a chronic illness which is becoming more prevalent in developing countries, and it is being managed mostly in hospitals or clinics in underdeveloped nations. Other strategies for treatment delivery in emerging nations must be considered as the number of diabetic patients grows. Community pharmacists are a valuable choice for diabetes care. However, only developed countries have data on community pharmacists' diabetes treatment practices. Methodology A non-probability consecutive sampling strategy was used to gather a self-administered questionnaire from 289 community pharmacists. Six points Likert scale was employed to score current practices and pharmacists' perceived role. A response rate of 55% was attained. Characteristics associated with present behaviors and perceived roles were analyzed using Chi-square and logistic regression. Results The majority of the respondents were males, 234 (81.0%). Out of 289, 229 (79.2%) were of 25-30 years of age and were pharmacists as well as qualified persons (QP) 189 (65.4%). A QP is one who has the legal authority to sell drugs to customers. The majority had <5 years of working experience as a community pharmacist, 268 (92.7%), and did not have diabetes training, 237 (82.0%). Most community pharmacies were stand-alone, 110 (38.1%), and had a single or a group of proprietors, 248 (85.8%). Open hours of most of the pharmacies were 16-20 hours per day, 202 (69.8%), and most had one pharmacist, 243 (84.1%), i.e., working as a pharmacist as well as a qualified person. Approximately 203 (70.2%) of the pharmacies had customers >2000 in a month and >100 customers purchased anti-diabetes medications per month. Only 44 (15.2%) community pharmacies had a designated room or space for patient counselling. The majority of pharmacists were also in favor of providing services other than dispensing such as counselling the patients about prescribed medicines, direction of use, use of devices for insulin administration, training on self-monitoring of glucose, and healthy lifestyle and diet practices. Pharmacy setting, ownership, patient counseling area, and the number of customers per month were key factors in the provision of diabetes services. The main obstacles identified were a lack of pharmacist availability and academic competency. Conclusion In Rawalpindi and Islamabad, most community pharmacies only provide a basic dispensing service for diabetes patients. Most of the community pharmacists agreed to extend their duties. The expansion of pharmacist professional responsibilities would help control the rising diabetes burden. The facilitators and hurdles identified would serve as a foundation for the introduction of diabetic care in community pharmacies.


Introduction
Diabetes is among the most prevalent public health issues all over the world, and its prevalence is rising, especially in developing countries. Diabetes currently affects 415 million people globally, with that number estimated to rise to 642 million by 2040 [1]. When type 2 diabetes is combined with complications, it can have a significant impact on individuals, as well as societal implications. Because of growing urbanization, changes in diet, and a more sedentary lifestyle, diabetes has expanded to middle-and low-income nations, including Pakistan [2]. The number of patients with diabetes in Pakistan was 26.3% in 2016-2017, according to the National Diabetes Survey of Pakistan (NDSP) [3]. International Diabetes Federation (IDF) currently estimates that one in every 11 people has diabetes [4]. Moreover, 33 million adults in Pakistan have diabetes as of 2021, ranking it third in terms of the disease's burden [5]. Another study published in 2018 revealed that 16.98% of Pakistanis have type 2 diabetes [2]. Pakistan is dealing with a double burden of diseases, hunger, unemployment, illiteracy, as well as social and cultural aspects, all of which have resulted in a low priority being placed on disease prevention and its repercussions.
Many factors such as ineffective communication, counseling and limited time-sparing factors of the healthcare workers have contributed to the failure of effective management of chronic illnesses such as diabetes [6]. These gaps in management bring focus towards the participation of community pharmacists, which yielded positive outcomes in many settings [7].
The public has developed a misconception over the years that community pharmacies only sell medicines; however, the community pharmacist, as a custodian of the ailing community, can play a key role in changing this impression by providing health education about self-management, prevention of adverse effects, prevention of long-term complications, the direction of medication use, adherence, and therapeutic plan management. According to a Japanese study, community pharmacists' consultations focusing on lifestyle changes helped patients with type II diabetes achieve better glycemic control. The patients' HbA1c levels were also observed to improve after 6 months of treatment, and the number of blood glucose-controlling medications was also reduced [8]. So, community pharmacists can be ideal additions to the multidisciplinary primary health care team as specialists in drug therapy, drug selection, patient education and counseling, leading to better care for the patients. Diabetes-oriented services at community pharmacies can help relieve the strain on other healthcare facilities by serving around 26% of the population. Diabetes care by community pharmacists is now confined to developed nations like the US, European countries, and the UK.
Therefore, the aim of the study is to evaluate existing practices and the community pharmacist's perceived role in type 2 diabetes care, as well as factors (pharmacist and community pharmacy) linked to the current practices.

Materials And Methods
In Rawalpindi and Islamabad, a cross-sectional (quantitative) study was undertaken to evaluate existing practices and the community pharmacist's perceived role in type 2 diabetes care, as well as factors (pharmacist and community pharmacy) linked to the current practices. These two cities were chosen as both cities' community pharmacy procedures are comparable. Rawalpindi has a population of 22.8 million people, whereas Islamabad has a population of roughly 11.6 million [9]. 289 community pharmacies were chosen at random from a list of registered pharmacies gathered from respected district health offices of Rawalpindi and Islamabad, Pakistan.

Sample size and setting
The study population was all community pharmacists working in community pharmacies of Rawalpindi and Islamabad. A non-probability consecutive sampling strategy was used to choose community pharmacies. The sample size was determined from a list of community pharmacies obtained from the respective health authorities. The total number of community pharmacies in Islamabad and Rawalpindi was 550 and 600, respectively (total 1150) [6]. A total of 289 responses were usable from the 525 questionnaires circulated as they were incomplete, producing a response rate of 55%, which was sufficient for statistical analysis. The sample size calculated using the OpenEpi version 3 sample size calculator at a 95% confidence interval was 289.

Data collection
A 33-question pre-tested six-point Likert scale (see Appendices) on community pharmacy-based services and pharmacists' perceived involvement in type 2 diabetes services was used. An in-person survey was conducted with the help of a questionnaire. There were four sections to the research questionnaire: (1) Community pharmacist and Community pharmacy characteristics; (2) Current practices in the treatment of type 2 diabetes; (3) consent form, and (4) pharmacists' perceived roles for type 2 diabetes patients. The frequency of providing the services was scored using a six-point Likert scale; 1 (never) to 6 (often). The perceived role of the pharmacist in current diabetic practice was scored using a six-point Likert scale; 1 (definitely no) to 6 (definitely yes) Details of community pharmacists such as gender, age, position, experience as a community pharmacist, registration year, and duration of diabetes training were collected. And details about community pharmacies such as setting, opening hours per week, ownership, opening days per week, presence of counselling area/ room, number of pharmacists per pharmacy, customers per month, customers purchasing oral anti-diabetic medications and insulin per month were also collected. Informed and verbal consent was obtained from the community pharmacists only, no other healthcare practitioners or support workers were involved in the study. The responders were verbally informed of the confidentiality of the information, and the principal investigator signed a confidentiality undertaking, after getting formal approval from the Ethical Review Committee of Al-Shifa Trust Eye Hospital, School of Public Health in Rawalpindi (Reference no: ERC-13/AST-21).

Data analysis
Statistical Package for Social Science (SPSS) software version 26.0 (IBM Corp., Armonk, USA) and Microsoft Excel 365 (Microsoft Corporation, Redmond, USA) were used for statistical analysis and data entry. Data entry was done according to the codes assigned to all the items in the questionnaire, while numeric variables were segregated accordingly. The characteristics of the community pharmacists and their pharmacies were summarized using descriptive statistics. Frequencies were determined for responses from Likert scales of current practice and pharmacists' perceived roles in diabetes services. Current service responses were divided into two variables indicating 'frequent service' (5-6 on the Likert scale) versus 'less frequent service' (1-4 on the Likert scale), as well as pharmacist roles, which were also divided into two variables indicating 'agreement' (5-6 on Likert scale) and 'disagreement' (1-4 on Likert scale). The frequencies of these replies were determined after coding. Chi-square test of association was used to determine the significance between independent and dependent variables. At 95% confidence intervals and p<0.05, a logistic regression model was developed to evaluate the relationship between features of community pharmacy and pharmacist with the current provision of services for diabetes and the perceived role of the community pharmacist. Tables are used to present the results.

Results
Most respondents were male, 234 (81.0%). Out of 289, 229 (79.2%) were of 25-30 years of age and 189 (65.4%) were pharmacists as well as qualified persons (QP). The majority of community pharmacists, 268 (92.7%), had less than 5 years of experience. Five (1.7%) pharmacists had more than 10 hours of training, 13 (4.5%) had 6-10 hours of training, 34 (11.8%) had 1-5 hours of training, and 237 (82%) had no training in diabetes care. The majority of them had no training; however, in recent times pharmacists have been highly encouraged to undergo training as the role of pharmacists is expanding due to the increased number of patients being diagnosed with diabetes. Being trained definitely had an edge over not being trained in a few detailed aspects such as instructing the patients about the interaction of food consumed and blood sugar levels, monthly refilling of anti-diabetic drugs, meal planning etc. The majority of pharmacies were standalone, 110 (38.1%), and were owned by a single or group of entrepreneurs, 248 (85.8%). A total of 24 (8.3%) pharmacies were owned by trained pharmacist managers. 202 (69.9%) pharmacies were open for 15-20 hours a day, and 243 (84.1%) pharmacies had only one pharmacist in each pharmacy. To evaluate pharmacist availability in each community pharmacy, a ratio of the total working hours of a pharmacist in a week to the total operating hours of a pharmacy in a week was calculated. The ratios came out were 0.0-2.0, with the majority of pharmacies having less than 1.0 (80%). Thus, most of the pharmacies did not have a pharmacist on duty during the week while they were open. As the pharmacies hired only one pharmacist and they work for approximately 40 hours a week, most of them have their day off on weekdays. Approximately 203 (70.2%) pharmacies had >2000 monthly consumers, and 218 (75.4%) had >100 diabetic patients per month. Only 44 (15.2%) pharmacies had a separate room or area dedicated to counseling. Table 1 summarizes the characteristics of respondent pharmacists and their pharmacies in terms of frequencies and percentages.  Community pharmacists reported dispensing was a prominent service, but the additional diabetic services were minimal. Patient education on pharmaceuticals, notably directions for use 221 (76.5%), directions for use of insulin devices, and storage requirements 234 (81.0%) were the only services indicated by the majority of respondents.

Characteristics of Community Pharmacist Frequency Percent
All the community pharmacists were in favor of providing services other than dispensing and in expanding their staff. Counselling on prescribed medications like directions for use (99.7%) and use of devices for insulin administration (99.7%), training on self-monitoring of blood glucose (SMBG) (93.1%), education on healthy eating and exercise (91.3%), and strategy for prevention/treatment of long-term complications (91.3%) were the prime considerations for services other than dispensing (77.2%).  The association of pharmacists' characteristics and the perceived role of community pharmacists in type 2 diabetes care are shown in Table 3

community pharmacists for type 2 diabetes services
To find characteristics of community pharmacist and community pharmacy linked with current practice, logistic regression models were used. Community pharmacists who thought providing a service was part of their job were more inclined to do so. Community pharmacies with more than 50 diabetes patients purchasing insulin and diabetes medicine in a month (for education on diet) and engagement in the training of diabetes were also recognized as facilitators (for compliance monitoring services). The lack of pharmacist availability was highlighted as a barrier to efficiently providing diabetes and compliance monitoring services. Table 4 summarizes the odds ratios of the significant characteristics.

Discussion
For the management of diabetic patients, proper pharmaceutical treatment is crucial to achieving the desired outcome. Community pharmacists help in controlling blood sugar levels and enhance the quality of life by providing pharmaceutical care and prescription management services [10].
This study highlights the community pharmacist's existing practices and their role in type 2 diabetes care. As the survey requested input about future services, respondents are likely more enthused about them than they are about their implementation.
Although dispensing was firmly established in Rawalpindi and Islamabad community pharmacies, services besides dispensing were only given to a limited level. The most regular practice here was providing basic medication information on how to use them. Also, at community pharmacies in Pakistan, prescription handling and patient management are rarely seen [11].
Most of the research conducted in developed countries reported pharmacists were consistently counseling patients about their prescription drugs, including usage and adverse effects [12]. However, pharmacists have been shown to play a significant role in delivering lifestyle modification and smoking cessation education [13], assisting patients with self-monitoring blood glucose (SMBG) [12], and supervising medication adherence [3]. Less common practices have been documented, such as tracking treatment progress and engaging in treatment strategies. Despite their limited ability to provide services other than dispensing, the most of community pharmacists of Rawalpindi and Islamabad believed that their services should be expanded. Studies conducted in developed countries reflected similar results for, the preferences of pharmacists in education and monitoring services, like training about medicines, healthy lifestyles, and SMBG; monitoring of medication compliance, carrying out a test for the monitoring of blood glucose, and providing feedback on glycemic control [14]. Pharmacists can fill the vacuum left by most Pakistani physicians who do not commit enough time to counsel and educate their patients properly.
Community pharmacists are underutilized in contrast to the situation in developed countries since they are not seen as healthcare professionals and as a result, their contribution to the healthcare system is not acknowledged [15] When a pharmacist's responsibility included services, the regression models demonstrated that this perspective acted as a catalyst for the provision of a wide range of services for patients. Indonesian research found that pharmacists who worked in pharmacies that provided diabetes care had a much greater agreement with the service than those who worked in pharmacies that did not [16].
The availability of pharmacists for various patients' education and monitoring activities was associated with their degree of availability. It is required by law that a pharmacist must be there throughout the operational hours of a community pharmacy [17]. More than 80% of pharmacies in Rawalpindi and Islamabad, on the other hand, may have had no pharmacists throughout their business hours.
Administrative barriers, insufficient implementation of rules and regulations, an insufficient number of pharmacy personnel (0.06 pharmacists for 10,000 people -6/1,000,000), a pharmacist's academic expertise in terms of clinical services revolving around a patient, a deficiency of collaboration with other healthcare personnel, and a lack of knowledge about the existence and role of pharmacists are all obstacles to the expansion of pharmacy services in community settings [13].
Weak monitoring mechanisms and law enforcement may contribute to this, making implementation dependent on the pharmacist's dedication. Because proprietors (non-pharmacist managers' owners) own the majority of pharmacies, their dedication is likely to affect this practice. According to this study, pharmacies managed by pharmacist managers had pharmacists present throughout business hours than pharmacies owned by non-pharmacist owners. Low pharmacist availability might indicate that owners are more focused on business, selling drugs in less expensive methods without the use of pharmacists. Many pharmacists would be employed only for legal reasons, which would result in reduced salaries. Pharmacists may take on other jobs due to low pay and shorter hours, causing them to be unavailable at pharmacies.
Despite continuous government initiatives, and literature and policy that demand pharmacy services to be implemented, deficiency of acknowledgment of the entire breadth of pharmacy services has limited pharmacists' ability to establish themselves as skilled and acknowledged healthcare providers in Pakistan [10]. Along with a few exceptions, advanced patient-centered pharmacy services are not being provided in Pakistani hospitals and private-sector pharmacies [18].
The general public underutilizes community pharmacies, which may make it difficult for pharmacy owners to provide services like pharmacist availability. Each month, the majority of local pharmacies claimed to serve over 2000 people. Pharmacist involvement in diabetes education was found to be a useful tool for delivering teaching and monitoring duties. Pharmacists who have received diabetes training execute more diabetesrelated activities than pharmacists who have not received diabetes training, according to studies conducted in Australia and Canada [12,19]. As a result, Pakistani pharmacy councils may consider offering formal diabetes training to improve the skills of pharmacy graduates. Pharmacies with the designated counseling area, those in clinics, and those with more diabetes patients were all more likely to engage in various teaching and monitoring activities. Despite this, only 15.2% of pharmacies have a counseling space or room. Pharmacies within clinics, according to the findings, may create chances for pharmacists to develop professional relations with physicians, hence increasing the establishment of additional diabetes services. The vicinity of practice places was one of the facilitators for forming solid cooperation. Furthermore, increased customers may be associated with higher revenue and, as a result, the drugstore's ability to offer additional services along with the availability of pharmacists, employment of adequate staff, and training of diabetes-related services. More turnover is one of the factors in administering diabetes therapy, according to an Australian study [1].

Strengths
The research would provide information to enable the government and pharmacy authorities to construct community pharmacy-centered diabetes care in a developing country like Pakistan.

Limitations
The limitations include the availability of community pharmacists and a lack of published data on type 2 diabetes service coverage, use, or quality in Rawalpindi and Islamabad

Conclusions
In Rawalpindi and Islamabad, most community pharmacies only provide a basic dispensing service for diabetes patients. Most of the community pharmacists agreed to extend their duties. The expansion of pharmacist professional responsibilities would help control the rising diabetes burden. The facilitators and hurdles identified would serve as a foundation for the introduction of diabetic care in community pharmacies.