Assessment of Knowledge, Qualification, Experience, and Medication Dispensing Practices in South Karachi, Pakistan

Background: Drug stores in Pakistan are run by dispensers with varied knowledge, qualification, and experience. The current study was sought to explore the knowledge, qualification, experience, and dispensing practices among dispensers working in drugstores in South Karachi, Pakistan. Methods: A cross-sectional survey was carried out using a structured questionnaire. Data were collected frommedical stores in South Karachi which were then categorized, coded, and analyzed using SPSS version 23. Relationship among different study variables with pharmacist’s availability and personal experience was assessed using statistical non-parametric Chi-square test. A total of 385 samples obtained using a simple random sampling method were included in the study. However, only 210 responses on questionnaire were complete which were then selected for study analysis between October and December 2018. Results: Of the 210 surveyed drugstores, 9% of their staff had studied only till primary school, 5.7% till the eighth grade, 25.2% up to secondary school level, 26.7% till higher secondary school level, 15.7% had non-professional education, and 8.1% were professional graduate. Only 9% of them had a degree in Pharm. D or B. Pharm, while 0.5% had a post-graduation qualification. Furthermore, 44.8% of pharmacies had a valid pharmacy license but the pharmacist was physically absent in 91% of the drugstores. Majority of pharmacies did not maintain appropriate temperature (refrigerator and/or room temperature). Majority of dispensers did not review prescription particulars before dispensing medications and also dispensed medications on older prescriptions as well as without prescription. Conclusion: In conclusion, the overall knowledge and practices of dispensers working in drugstores was poor. However, the presence of pharmacist was associated with good dispensing practices to a certain extent.


Introduction
Pharmacy services begin with prescription of medicines and continues till its dispensing and as medication's effect is monitored [1]. Good dispensing practices ensure that an effective form of correct drug is provided to the right patient, in correct dose and number of units, with clear instructions, and in a package that maintains the potency of drug.
Dispensing also incorporates all of actions that befall between the time prescription is dropped to pharmacy and the time when medication or other articles prescribed are delivered [2].
In Pakistan, medications-use patterns vary among gender and age groups. Selfmedication and polypharmacy are frequent amid the youth and elderly population, respectively [3][4][5][6][7]. Likewise, the self-use of analgesics and antipyretics is very common among youth [3][4][5]. Systematized dispensing practices are disregarded in community pharmacies as well as in hospitals [8]. Unfortunately, majority of the drug dispensing at pharmacies and medical stores is carried out by untrained dispensers with no proper qualification in pharmacy. In such circumstances, there is a serious need to ensure the presence of a qualified pharmacist at all retail pharmacies so that the medications are safely dispensed [9,10]. Lack of physicians in the rustic regions has created an opportunity for the dispensers and quacks to fill the gap where they are the only decision-makers of the medications for the public [11]. Furthermore, patients have to cover long distances to acquire basic medications. Additionally, most of the medications can be purchased from private pharmacies without showing a legal prescription [3,12,13]. A study carried out in Pakistan stated that numerous dispensers have irrelevant education and negligible or no competent training in managing drugstores [14]. Provided that with inadequate knowledge concerning indications, contraindications, as well as side effects, their dispensing practices might have unwanted outcomes.
Although a system of healthcare facilities exists in Pakistan's public division as well as an overabundance of private division programs, 45% of people still face paucities to approach to healthcare facilities. However, to encounter healthcare necessities and decrease personal costs, people depend on unconventional healthcare systems such as chemists, contemporary medication specialists, faith healers, and homeopaths. Huge disparities in formal healthcare division promote self-medication; therefore, knowledge as well as practices of dispensers become significantly valuable [15]. Drugstores in developing countries like Pakistan are frequently deficient of competent and trained dispensers to store, label, and handle medicines in suitable manner which may compromise drug safety and its therapeutic outcomes. Therefore, the current study was sought to explore the dispensing practices in medical stores/pharmacies in Pakistan and to investigate the implementation of laws and regulations regarding selling, storage, and dispensing of medications.

Materials and Methods
A cross-sectional survey was carried out using a structured questionnaire. The structured questionnaire was developed from the WHO surveillance form designed for perceiving medicine counselling and dispensing practices and was customized in accordance with the aims of this study [16]. Data were collected from pharmacies/medical stores of South Karachi. The city of Karachi is divided into six districts, South, Central, West, East, Korangi, and Malir. The southern district of Karachi has the distinction of being the only district in the country with a representation of all ethnic and socioeconomic groups of the country [17]. The present study was conducted between October and December 2018 and included 384 samples obtained through simple random sampling method. The accuracy and consistency of data collection form was assessed in a pilot study of 20 pharmacies. Each pharmacy was observed for one day. The response of pharmacies to participate in study was also estimated to calculate the sample size.
The standardized questionnaire was tested on 30 participants before the actual data collection and it was modified into a list of questions that were comprehensive and unambiguous. A predesigned and pretested survey in English language was utilized to collect responses. A total of 385 samples were included in the study. The sample size was obtained using a simple random sampling method, out of which 210 responses on questionnaire were complete and selected for study analysis. Conversely, those who did not understand English were questioned by researcher in local Urdu and the answers were then translated into English. We used paper-based questionnaire. The structured questionnaire consisted of 33 questions containing information on demographics, level of education, experience, temperature control information, dispensing practices, presence of pharmacist, and status of pharmacy licensing. Only participants who met the following criteria were included: male or female irrespective of age, retailers who were involved in the pharmaceutical drug sales, owner as well as employee in pharmacy, participant with any qualification and/or level of education with zero to any number of years of experience, pharmacies/medical stores in southern region of Karachi involved in drug dispensing. Conversely, participants who met the following criteria were excluded: wholesalers and distributors, retailers associated with sales other than pharmaceutical drugs, all inadequately filled questionnaires, pharmacies/medical stores located in other areas than the South of Karachi, participants working in store/stock management and administrative positions. Data collected in the form of completed questionnaires were then categorized, coded, and analyzed. They were expressed as percentages and frequencies. The relationship among different study variables with pharmacists' availability was assessed using a statistical non-parametric Chi-square test at 0.05 level of significance with the help of SPSS version 23.     Furthermore, 59.5% of the study participants did not confirm the expiry date of the medicine before dispensing while 40.5% of them did so.

Awareness of pregnancy category of medicines
Yes 9% (19) No 91% (191)  there is a significant relationship between the presence of power backup at pharmacies, refrigerator temperature maintenance, room temperature maintenance, reviewing prescription particulars before dispensing, dispensing alternative brands in case of nonavailability of prescribed brand, and expiry date confirmation before dispensing and the availability of a pharmacist at a drug store at 0.000 (two-tailed). The level of significance and variables such as dispensing without prescriptions and dispensing on P-value 0.000

Discussion
In the past century, pharmacy as a profession mostly included compounding. While the compounding roles have declined considerably in the last few decades, it has turned out primarily to be dispensing medications. Nevertheless, merely dispensing of medications does not satisfy the necessities, and not long ago, a new role had to be progressed for the profession [18,19]. The aim of the pharmacy practice is to offer medicine in addition to further healthcare products and facilities, and to benefit people and community to make the best use of them [20]. Pharmacists need to be part of clinical decision-making for sensible use of medications. The transforming position of pharmacist as patient counsellor/instructor as well as an intermediary to enhance therapy outcome is important for encouraging reasonable use of medications [21]. The system by which medications are procured, stored, distributed, as well as dispensed and information provided by pharmacist determines the quality use, consequently in terms of motivating rational practice of medications [22].
In our study, it has been observed that only 9% of the pharmacists were present in various pharmacies. Rest of the pharmacies/medical stores had unqualified personals including personals who never attended school or those who had studied only till the eighth grade or had attended secondary or higher secondary school. Others had a professional education and single study participant was a qualified postgraduate.
A study reports that generally qualification, understanding, and schooling of drug dispensers functioning at community drugstores in Pakistan is deficient. Pharmacies are mostly run by unqualified as well as inexpert personals. However, it has been noticed that they have copious years of experience [23]. Similar findings have been observed in our study that although majority of pharmacies had unqualified personals, they had plenty of experience. The existence of legitimately competent individuals is insignificant at drugstores. In majority of circumstances proprietors are operating instead of a trained individual [24]. However, in our study, it was observed that 74.3% of the participants were employee working in the pharmacy while 25.7% were the owner of the pharmacy.
According to the drug acts of Pakistan, pharmacy buildings must have suitable facilities to store drugs including refrigeration, cleanliness of outlets, hygienic and neat condition, and constant personal observation of a pharmacist [25]. However, in our study, it was revealed that majority of pharmacies did not took necessary measures for proper storage of medicines. Medicines are not stored in hygienic conditions and appropriate temperature was not maintained. Very few drugstores had power backup for refrigerator, which is a major distress as a consequence of extreme occurrence of power breakdown in city. These customs uncover that generally society is unaware or ignorant with regard to storage medications. In a related study from Karachi, greater than half of the pharmacies stored medications in compromised storage settings [14,15,26,27].
Moreover, it was found in our study that 44.8% of the pharmacies had a valid pharmacy license, while 55.2% did not. However, it has been reported in a study that while 62.4% of the participants had a license for retail sale, only 5.6% of them were license holder for wholesale. Another one-fourth of the total drug sellers (26.9%) were those having no license at all. Moreover, only 5.1% of the participants possessed license for the sale of controlled substances. But a total of 66% drug sellers were involved in selling of controlled substances [28].
About 81.9% of the study participants admitted selling medicines without prescription.

Conclusion
Medical