Background
The provision of quality healthcare services requires the participation of all healthcare professionals in teamwork to benefit the patient [
1]. Traditionally, medical doctors and nurses have directly provided care and treatment services to patients. Unfortunately, the traditional approach no longer fits the six healthcare quality improvement goals developed by the Institute of Medicine (IOM) [
2]. The IOM advocates a team-based approach which is associated with several benefits to patients, HCPs, and the health system. The reported benefits are shortened average hospital stay, reduced chances of readmission, increased community trust in the healthcare system, improved service quality, and reduced morbidity and mortality [
3,
4]. Pharmacist integration into the team is a relatively new concept, however when done it seems to benefit patient care [
4].
Integrating pharmacists into the provision of healthcare services in developed countries commenced some years ago when the focus of the pharmacy profession shifted from drug product to the patient [
5‐
7]. Among the benefits of involving pharmacists include detecting drug therapy problems and developing various chronic disease indicators (CDIs) (example of the CDI are glycosylated hemoglobin and dilated eye examination for diabetes) [
8,
9]. However, even in these developed countries where CPS is well established, studies have outlined several barriers and facilitators to providing the services [
1,
10]. Lack of pharmacist role definition, absence of an established relationship of trust and respect with existing team members, inadequate pharmacist training, a need for mentorship or peer support, pharmacist personality, resources and funding, and a lack of adequate space were reported to affect provision of CPS [
1,
8,
11].
In Africa and Asia, the barriers to the provision of CPS may be grouped as external, financial, and individual-related factors [
12]. External factors include lack of policies, poor leadership support, and shortage of staff. Financial factors are associated with a lack of monetary incentives and in-job training, while individual-related factors include inadequate clinical and communication skills, medical doctors’ dominance and opposition, lack of confidence, assertiveness, negative attitude, and mindset among pharmacists towards CPS provision [
12‐
14].
To ensure multidisciplinary provision of healthcare in Tanzania. In 2018, Ministry of Health, through the Pharmacy Council, has revised pharmacists’ professional regulations requiring all pharmacists to participate in the provision of CPS. To be in line with the government directives, the medical universities in Tanzania amended their curriculum to include the participation of bachelor of pharmacy students in the provision of CPS with other medical professions, especially during major and service ward rounds. In addition, the Muhimbili University of Health and Allied Sciences (MUHAS) has established a Master of Pharmacy degree in Hospital and Clinical pharmacy to equip pharmacists with more knowledge and skills in CPS provision.
Despite the efforts mentioned above to ensure the integration of pharmacists into the provision of CPS in Tanzania, the participation of pharmacists is still suboptimal. Therefore, this study was conducted to explore the barriers and facilitators towards the integration of pharmacists into the provision of CPS in Tanzania.
Methods
Study designs
This was a qualitative study designed to explore the barriers and facilitators to the provision of CPS in Tanzania. The study was conducted between August and September 2021. In-depth interviews (IDIs) and focus group discussions (FGDs) with hospital administrations and HCPs were conducted to explore their perspectives on CPS provision in Tanzania.
Study settings
The study was conducted in 4 zonal referrals and 1 national hospital, which are Bugando Medical Center (BMC), Mbeya Zonal Referral Hospital (MZRH), Kilimanjaro Christian Medical Center (KCMC), Benjamini Mkapa Hospital (BMH), and Muhimbili National Hospital (MNH). The hospitals were selected because they serve as tertiary hospitals in Tanzania and have a relatively adequate number of staff, including pharmacists. Besides, these hospitals serve the majority of Tanzanians and nearby countries; in average each hospital serve around 1,000 outpatients and 700 inpatients.
Sampling technique, sample size, and study population
A purposeful sampling technique was used to select the participants based on their administrative position, level of education, clinical involvement in the direct provision of care and treatment to patients, and years of experience. In each hospital, the Executive Director, Director of Medical Services, and the Heads of the Department of Pharmacy were subjected to IDIs totaling 15 IDIs in 5 hospitals. We also conducted two FGDs, one with pharmacists only and another with nurses and medical doctors per hospital making 10 FGDs for all sites.
Data collection procedure
The semi-structured interview guides for IDIs and FGDs were developed in English and then translated into Swahili. These interview guides were developed based on the objectives, a good literature review, and the researchers’ experience. The guides were improved based on emerging issues as we moved on with interviews. The guides were composed of open-ended questions and probes that explored information on the barriers and facilitators toward the provision of CPS in the respective hospitals. The probes explored individual-related, health facility-related, and health system-related barriers and facilitators toward the integration of pharmacists in the provision of primary healthcare services.
All IDIs and FGDs were conducted by four researchers (two per interview) with experience in qualitative data collection. Among the researchers involved in data collection; two have master of philosophy in pharmacology and therapeutics, one have master of pharmacy in hospital and clinical pharmacy and the last have master of nursing in midwives. During the interview, one interviewer moderated the discussion, and another one was responsible for taking notes on key issues, including non-verbal communication. Before the beginning of the interview, the important demographic information of the study participants was collected (age, gender, cadre, highest professional education level, and working experience). Hospital administrators were visited in their offices within the hospital for the interviews based on the prior set of appointment. FGDs with pharmacists, nurses, and medical doctors were conducted in a quiet designated room at the respective health facility at their convenient time. All interviews and discussions were audio-recorded. Before each IDI and FGD, written informed consent was provided by participants after explaining the purpose of the study and that the session would be audio-recorded. Each FGD consisted of 6 to 12 participants. FGDs and IDIs lasted between 60 to 120 and 30 to 60 min, respectively. Moreover, similar information started to reappear after visiting 4 hospitals, however, data saturation was not formally addressed.
Data analysis
The audio-recorded interviews and discussions were first transcribed verbatim in the Swahili language. Six researchers were given transcripts and field notes to read and re-read to be familiar with the data and context and get a general understanding of the participants’ accounts before the analysis. The data were analyzed using a hybrid thematic analysis approach using inductive and deductive reasoning. The research team was composed of members with various health and social sciences backgrounds. These were midwifery specialists, qualitative researchers, sociologists, and public relations experts, while the rest were pharmacists with specializations in clinical pharmacy, pharmacology, and therapeutics. Then, the codebook with initial codes was developed deductively from existing domains and inductively from emergent ideas noted during familiarization with data. The open coding was done in pairs to ensure inter-code reliability allowing the discussion of discrepancies and disagreements that were then resolved. Agreements were reached with the team. The codebook was revised as we moved on with the analysis process. The identified codes list was then observed for commonalities and differences and put into sub-themes. Subthemes were collated, and repeated patterns identified across the data set were identified as themes. Themes were refined and finalized by reviewing and discussing them with the entire team of researchers. Lastly, the generated sub-themes and themes were presented with quotes describing each theme's meaning.
Discussion
The study aimed to assess the barriers and facilitators towards the integration of the pharmacist in the provision of CPS in Tanzania. The study explored the perspectives of medical doctors, nurses, and pharmacists. Five themes emerged from this study: three for barriers (individual-related, health facility-related, and health system-related) and two for facilitators (individual and health system efforts).
The current study found that limited skills for the provision of CPS, lack of confidence among pharmacists, and poor communication skills among pharmacists affect their involvement in provision of CPS. Similarly a study done in Brazil reported that the fear and frustration of pharmacists due to their lack of clinical and communication skills interfere with their participation in the provision of CPS [
15]. In Kuwait it is reported that the pharmacists’ lack of proper clinical training and poor appreciation of pharmacy services by the physician were among the barriers to adequate provision of CPS [
16]. In Nigeria, it was reported that medical doctors’ dominance and resistance to pharmacists’ intervention were among the reasons for pharmacists not providing CPS [
17].
In this study, the factors influencing the effective implementation of CPS were superiority and inferiority behavior of HCPs, shortage of pharmacists in health facilities, lack of guidelines, SOPs and capacity building for in-job pharmacists on how to offer CPS. These factors fit well in the reported categories of factors that influence provision of CPS, namely attitudinal, political, administrative, and technical [
18]. Furthermore, Jonathan and colleagues studied factors influencing the implementation of CPS in China and reported thematically related barriers and facilitators as reported in this study [
13].
To address the barriers to the effective provision of CPS, studies recommend improvement of the training of pharmacists by exposing pharmacy students to patients and working with other HCPs during pre-service training. Several studies that have been conducted in developing countries have recommended introduction of a Doctor of Pharmacy (PharmD) degree, which exposes the trainees to healthcare life and builds their knowledge and skills for the provision of CPS [
12,
16,
19,
20]. To increase assertiveness and confidence and to build inter-professional relationships among HCPs, the use of tools for communication is recommended [
7]. The recommended tools include Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis which explains to doctors and nurses the aim of the intervention, and Specific, Measurable, Achievable, Realistic, and Timely (SMART) goals which breakdown the aim of the intervention to HCPs which later increases their awareness. Thirdly, the Interest, Desire, Action (AIDA) model, which shares the intervention results and helps build the trust of medical doctors and nurses towards the intervention can be used [
7].
This study demonstrated a shortage of pharmacists, lack of in-job training for pharmacists, SOPs and guidelines for the provision of CPS, schedules for pharmacists to attend ward-rounds and limited physical space for pharmacists to offer pharmaceutical interventions while dispensing affect the provision of CPS. The findings are similar to what is reported in Ethiopia and United Arab Emirates (UAE) in which shortage of skilled pharmacists, high workload, shortage of staff, and lack of time and motivation were reported as impediments to the effective provision of health care services [
14,
21]. Elsewhere, lack of clear career path and poor financial and leadership support are reported to be affecting the effective implementation of CPS.
The provision of CPS by pharmacists to has proven to have benefits, including improving the appropriateness of medication prescribing, implementing antimicrobial stewardship, and reducing morbidity and mortality among patients [
2]. Awareness regarding CPS should be ensured from the level of administration to the level of HCPs. Pharmacists should be encouraged to participate in ward rounds and clinical meetings with other HCPs in the hospitals. The study done to assess the communication between medical doctors and pharmacists found that the acceptance rate of pharmacists’ interventions by doctors ranged between 39 and 70% when the assessment was done online, while the acceptance rate was much higher at 88.4% when the assessment was conducted through face-to-face interviews [
22,
23]. These findings indicate that if proper information is provided about the roles of pharmacists in patient care, medical doctors are willing to work with pharmacists in the provision of CPS. Nevertheless, on-job training is needed to build their competencies in pharmacotherapy which is core for provision of CPS.
This study demonstrated that the acceptability of CPS by other HCPs, the positive perception of the pharmacists towards the provision of CPS, the readiness of the administration to offer support to pharmacists, and the recognition of CPS by the Pharmacy Act and regulations are factors motivating integration of pharmacists in the provision of CPS. In Brazil, a study on factors influencing the provision of CPS reported that responsible regulatory authorities and the government, through the Ministry of Health, encourage pharmacists to participate in the provision of CPS [
24]. Other studies have reported attitudes and mindsets, adequate resources and space, support and mentorship, and pharmacists’ role definition are the determinants of CPS provision by the pharmacists [
1,
20]. Furthermore, pharmacists with adequate confidence and assertiveness integrate well with other HCPs in providing primary healthcare services to patients.
Trust and rigor of the study
The study follows four criteria to ensure trustworthiness: credibility, dependability, confirmability, and transferability. Triangulation approaches of mixing participants with different experiences using FGDs and IDIs approach in data collection and using researchers with different professions in data collection and analysis ensured the rigorousness of the study. Furthermore, the use of Swahili interview guides, a common language used by researchers and participants, and the availability of transcripts in Swahili made the analysis more robust. Results are presented using themes, sub-themes, and quotes to display the participants’ thoughts rather than the researchers’ interpretation. For the transferability of the findings, a detailed process of study design, setting, and the whole process of data collection and analysis has been provided. The findings from this study can be usefully in improving provision of CPS in developing countries with healthcare system equivalent to Tanzania.
Conclusion
The facilitators and barriers to the integration of pharmacists in the provision of CPS lie at the individual, health facility, and health system levels. Acceptability of CPS by other HCPs and reliable administrative support are the key facilitators while limited skills, poor communication, shortage of staff, and lack of SoPs and guidelines are the main barriers to CPS provision. Therefore, the study recommends in-job pharmacists training, fostering teamwork among HCPs, developing CPS SoPs, and guidelines, and increasing the number of pharmacists per facility.
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