Assessment of community pharmacy professionals’ knowledge and counseling skills achievement towards headache management: a cross-sectional and simulated-client based mixed study

Headache or cephalalgia affects infrequently almost everyone [1]. The Global Burden of Disease Study 2015 (GBD2015) ranked migraine as the third highest cause for disability worldwide in persons younger than 50 years in both sexes [2]. and nearly 40% of people suffered from a headache at some time in their lives [1]. Around 15% of UK adult patients experience a migraine with a three-to-one ratio of women-to-men [1]. According to a population-based national survey of headache burdens in Ethiopia, the prevalence had been reported as migraine (17.7%), tension-type headache (TTH) (20.6%), probable medication-overuse headache (pMOH), and headache yesterday 6.4% [3]. Patients most regularly seek professional counseling from general and neurologic clinics [1, 4]. Headache challenges healthcare professionals in many ways and represents enormous social and economic burden to the health care system.; for example, 20 billion USD is lost every year in the United States for migraine [1, 2, 5].

Community pharmacists are the most accessible healthcare professionals to the public owing to their convenient location at the heart of the community and wide geographic distribution [6]. Patients with a headache successfully self-medicate by means of over-the-counter (OTC) medications that are available via CMROs [7]. This provides a unique opportunity for pharmacy staffs to play a crucial role in ensuring the quality use of medications by providing patients with counseling on the safe, correct and effective use of medicines, and solving potential drug-related problems [8, 9]. Even though CMROs can sufficiently treat minor ailments and contribute in self-care management such as headaches, still they need to be careful while recommending OTC drugs since even these drugs can cause health threats if used inappropriately [10]. Findings from developing countries showed that dispensers working in the pharmacies hardly keep sufficient knowledge and skills for effective syndrome management [11]. On the other hand, pharmacists in developed nations, such as the United Kingdom and Australia, successfully incorporated minor ailment management with other public-health programs [12‐15]. In Ethiopia as in most developing countries pharmacy staff are largely confined to the traditional medication dispensing and counseling practices and once in a while delivering such public health services [16, 17] which is worsened by the absence of standard and consistence treatment (counseling) guidelines for headache and other common minor ailments [18]. Regarding self-medications and related issues, a variety of investigations were conducted in many parts of Ethiopia, though many of them used client perceptions [19, 20]. Owing to the burden of headache in Ethiopia [3], patients usually look for immediate therapy in the nearby public pharmacies. A recent study conducted by Ayele et al. identified lack of access to clinical training and poor community awareness as the most commonly cited barriers for providing public health services in CMROs such as headache management [21]. Yet, the extent to which pharmacy professionals interacts with patients for headache management is not studied in detail, and there is no published data that explores pharmacy staff knowledge and counselling skills when it comes to handling patients’ request of analgesic medications. Thus, the current study aimed at assessing the knowledge and extent of community pharmacy professionals’ involvement in counseling practices and overall management of a headache as well as to explore the challenges and hidden reasons that hindered professionals from delivering the standard care to the clients.

The present study evaluated the counseling manners and headache management practices of CMROs dispensers without a prescription in Gondar city. Essential variations concerning information provision and headache management practices of dispensers were discovered by comparing results found from the pseudo-client visits and the cross-sectional survey. Based on the SPs findings, the overall counseling approach was found to be 42.6%; however, it was improved to 58.3% when the pseudo-client demanded it. In the same way, findings in Riyadh, Saudi Arabia showed that the counseling level was found to be 43% even though it was enhanced when SPs demanded more information [28]. Depending on the type of investigation methodologies, the stated advising levels fluctuated from 8 to 100% in the worldwide literature [29]. Based on this, the reasons for such poor counseling practices might be multifactorial. The main challenges include lack of interest, poor experiences, knowledge and communication skills, and lack of standard counseling guideline.

In the real dispensing practices, 95% of dispensers provided medications for the pseudo-customers who were taking paracetamol while three dispensers advised the client to consult the physicians for identifying the cause of a headache without any further professional trail to help. This study is quite comparable with the study done in Saudi Arabia [28]. Contrarily, in the cross-sectional survey, 60.8% of participants referred the client to the hospital. This indicates that community pharmacists were not dispensing drugs based on knowledge and guidelines rather they sold for only cheesing money. Since most of CMROs are established for profit, no matter what the cause is, they sell every product without any hesitations. Moreover, unless they are profitable, their survival will be jeopardized and mainly unserved customers might disclose them to others clients that they do not serve well.

Concerning headache management using OTC medications, analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and weak opioids like tramadol are suggested as first-line drugs. Nevertheless, 64.7% of participants in the cross-sectional survey agreed that managing headache symptomatically is challenging, 78.4% of dispensers recommended acetaminophen for a non-examined headache, and about 40% of them added diclofenac, tramadol, and ibuprofen to paracetamol for better treatment. On the other hand, in the SPs approach, 95% of the participants primarily added Ibuprofen (45%), diclofenac (41.5%) and tramadol (5%) to acetaminophen for a headache management, though dispensers reported that customers chose brand products in the survey. Higher proportions of the dispensers selected the medications based on their effectiveness (61.7%) and cost (21.7%) which had similarities with survey results. In contrast, a pilot study in Brazil reported sodium dipyrone was the most recommended medication [30]. Even though customers do want brand products, suppliers rarely made them available for the community so that acetaminophen, ibuprofen, and diclofenac would be the first choice, since these drugs are safe, effective, readily available and affordable for most of the local customers.

During the pseudo-client approach, headache duration and signs or symptoms, medication profile and previous or current medical conditions were inquired by the dispensers. It is very important that dispensers pursue relevant evidence about clients’ history and compliant characteristic which enables them to choose appropriate pharmacotherapeutic alternatives for customers. However, forwarding many questions towards clients requires strong communication skills and knowledge, and increases client confidence and counseling satisfaction on dispensers. Such types of questions are highly supported by many comparative findings [31, 32].

Though higher proportions of participants (54.9%) in the cross-sectional survey agreed with the clients’ involvement of medication selection, smaller number of dispensers practically allowed the pseudo-client to be involved with their medication selection process. Surprisingly, nobody asked about whether the pseudo-client needed additional information, the presence of allergic history, adverse drug reaction history, and alleviating factors of a headache. Since self-medications are retailed without any prescription dispensers thought that many questions might discourage the patients form taking the medications [33]. Furthermore, in order to provide additional information and understand typical allergic history and adverse drug reactions providers should be trained for such types of evidence and clients’ interest. The survey revealed that clients’ absence of interest on dispensers and lack of updated medication information were found to be the major challenges for better counseling. However, 95% of respondents reported that the community was award of the role of community pharmacists in headache management.

When dispensing pharmaceutical formulations, there are important points that every dispenser should acknowledge and counsel the clients during providing drugs. However, the findings of this study revealed that only a few of the dispensers informed the clients about drug administration times (frequency), medication indication, dosage (strength), pharmaceutical forms, and route of drug administration during interaction with the simulated patients. To the contrary, none of the dispensers discussed important items such as contraindications, drug interactions, adverse drug reactions, adherence to treatment, and safe storage of the dispensed medications with the pseudo client. The findings of this study were similar to previous studies with regard to the rare provision of essential information by community pharmacists on precautions, adverse effects, drug interactions, contraindications, and safe storage [23, 24, 34]. But a Saudi study reported somewhat different results where 97% of the SPs visits provided information about dose, whereas a very small number of SPs were counseled on precaution. To the contrary, about half of the respondents never counseled on the side effects and drug interactions [28]. As explained earlier most of the provided counseling was superficial, easy and common that any health professionals might provide for every client. Mainly dispensers merely focus particularly on sales rather than counseling, because detailed discussions need further professional skills and extensive knowledge to deliver. Moreover, most of the patients do not seek more detailed information. Rather they need only what they want to know.

Every pseudo-client visit was audio-recorded to reduce the challenges associated with the human cognitive processes in conducting SP studies. After all, this study showed the real gap between the practical services and the theoretical expectations of community pharmacies. However, we used a convenience sampling method in only Gondar city. Therefore, generalizations of the study findings to other regions and populations should be with caution as it might lead to under or over representations. In addition, because only a specific case scenario was employed that leads to specific replies, it may not comprehensively assess the professionals’ competency towards a headache management. Moreover, because of the pseudo-client visit and the cross-sectional survey was conducted at different times, the respondents might not be the same and the responses to the self-administered questionnaire depended on the respondents’ trustworthiness which is subjected to socially desirable responses.

Community pharmacists, being one of the most easily accessible health professionals in the community, are uniquely positioned to treat and manage minor ailments such as headache in their practice areas. According to findings from this study, community pharmacies demonstrated a very poor and inadequate skill headache management. Providing continuous clinical training and educational interventions are needed in order to mitigate the knowledge and skill gap. One suggestion is providing a hands-on evidence-based summary of headache management in their practice areas by academic institution and other stakeholders. Large scale studies that can explore community pharmacists’ involvement in managing headache in community pharmacies and that further could assess clients’ (purchasers’) level of satisfaction towards the community pharmacy service particularly regarding headache management is recommended to identify practice barriers and to better inform regulatory bodies.