جهاد حماد بعد التعديل.doc

IUG Journal of Natural and Engineering Studies
Vol.20, No.1, pp 31-39 2012, ISSN 1726-6807,
The Dispensing Practice Of The Over The Counter Drugs In
The Gaza Strip.
Jehad Hammad1, Hisham Qusa1, Khamis Elessi1, Yousif Aljeesh2 1- Department of pharmacology, Faculty of Medicine, Islamic University Gaza (IUG)
2- Department of Public Health, Faculty of Medicine, Islamic University Gaza (IUG)
Abstract
Background
There has been no systematic assessment of dispensing practices of over the
counter (OTC) drugs in the Gaza Strip.
Methods
We surveyed a random sample of 127 pharmacists working in public
pharmacies in the Gaza Strip using a pre-piloted questionnaire.
Results
Most pharmacists in the Gaza Strip dispense prescription-only drugs without
valid prescriptions. For example, amoxicillin comes second only to
paracetamol in a list of twenty two drugs dispensed without prescriptions.
Drugs for cardiovascular diseases and diabetes mellitus are prescribed less
frequently (metformin and amlidopine were dispensed by 16 % and 14 % of
pharmacists respectively). Among the many factors for dispensing
malpractice, the most important identified by pharmacists were economic
competition among pharmacists (77%) and economic difficulties among
patients (73%). Three quarters of respondents blamed the Ministry of Health
and the Pharmacists' Syndicate for acquiescing in dispensing malpractice.
Interpretation
Our study has highlighted the importance of cooperation between the Ministry
of Health, the Pharmacists' Syndicate and the College of Pharmacy to
improve dispensing practice in the Gaza Strip.
Key words: The Gaza Strip, OTC, pharmacists, malpractice, dispensing
practice.
Acknowledgement
We are grateful to Sir. Iain Chalmers, the coordinator of the James Lind
Initiative, Oxford, UK. for comments on an earlier draft of this paper
ﺓﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺔﻴﺒﻁ ﺔﻔﺼﻭ ﻥﻭﺩﺒ ﺔﻴﻭﺩﻷﺍ ﻑﺭﺼ ﺔﺴﺭﺎﻤﻤ
: ﺤﺒﻟﺍ ﺔﻴﻔﻠﺨ
ﺓ.ﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺔﻴﺒﻁ ﺔﻔﺼﻭ ﻥﻭﺩﺒ ﻉﺎﺒﺘ ﻲﺘﻟﺍ ﺔﻴﻭﺩﻷﺍ ﻑﺭﺼ ﺔﻴﻠﻤﻌﻟ ﻡﻅﻨﻤ ﻡﻴﻴﻘﺘ ﺩﺠﻭﻴ ﻻ : ﺤﺒﻟﺍ ﺔﻘﻴﺭﻁ
ﻡﺍﺩﺨﺘﺴﺎﺒ ﺓﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺔﺼﺎﺨﻟﺍ ﺕﺎﻴﻟﺩﻴﺼﻟﺍ ﻲﻓ ﻥﻭﻠﻤﻌﻴ ﻲﻟﺩﻴﺼ 127 ﻥﻤ ﺔﻴﺌﺍﻭﺸﻋ ﺔﻨﻴﻋ ﺔﺴﺍﺭﺩﺒ ﺎﻨﻤﻗ ﺀﺍﺩﻷﺍ ﺕﺎﺒﺜﻟ ﺭﺎﺒﺘﺨﺍ Jehad Hammad et al
:ﺙﺤﺒﻟﺍ ﺞﺌﺎﺘﻨ
ﺔﻔـﺼﻭ ﺭﺎـﻬﻅﺇ ﻥﻭﺩﺒ ﺔﻴﺒﻁ ﺔﻔﺼﻭﻟ ﺝﺎﺘﺤﺘ ﻲﺘﻟﺍ ﺔﻴﻭﺩﻷﺍ ﻥﻭﻓﺭﺼﻴ ﺓﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺔﻟﺩﺎﻴﺼﻟﺍ ﻡﻅﻌﻤ ﻲﻓ لﻭﻤﺎﻜﻷﺍ ﺩﻌﺒ ﺔﻴﻨﺎﺜﻟﺍ ﺔﺒﺘﺭﻤﻟﺍ ﻲﻓ ﻲﺘﺄﻴ ﻥﻴﻠﻴﺴﻴﺴﻜﻭﻤﻷﺍ ﺭﺎﻘﻋ لﺎﺜﻤﻟﺍ لﻴﺒﺴ ﻰﻠﻋ ﺏ . ﻴﺒﻁﻟﺍ ﻥﻤ ﺓﺩﻤﺘﻌﻤ ﻱﻭﻤﺩـﻟﺍ ﺯﺎـﻬﺠﻟﺍﻭ ﺏﻠﻘﻟﺍ ﺔﻴﻭﺩﺃ ﺔ . ﻴﺒﻁ ﺔﻔﺼﻭ ﻥﻭﺩﺒ ﺕﺎﻴﻟﺩﻴﺼﻟﺍ ﻲﻓ ﻉﺎﺒﺘ ﺭﺎﻘﻋ ﻥﻴﺭﺸﻋ ﻥﻤ ﺔﺤﺌﻻ % ﺔﺴﻨﺒ ﻑﺭﺼ ﻥﻴﺒﻴﺩﻭﻠﻤﻷﺍﻭ ﻥﻴﻤﺭﻭﻔﺘﻴﻤﻟﺍ ﺭﺎﻘﻋ )لﻗﺃ ﺔﺠﺭﺩﺒ ﻑﺭﺼﺘ ﺭﻜﺴﻟﺍ ﺽﺍ ﺔﻴﻭﺩﺃﻭ ﺭﻅﻨ ﺔﻬﺠﻭ ﻥﻤ ﺎﻬﻤﻫﺃ ﻥﺎﻜ ،ﺔﻴﻭﺩﻷﺍ ﻑﺭﺼﻟ ﺔﺌﻁﺎﺨﻟﺍ ﺔﺴﺭﺎﻤﻤﻠﻟ ﻱﺩﺅﺘ ﺓﺩﻴﺩﻋ لﻤﺍ .( ﻴﺘﺭﺘﻟﺍ ﻰﻠﻋ ﺜﻼﺜ .(%73 )ﻰﻀﺭﻤﻟﺍ ﻯﺩﻟ ﺔﻴﺩﺎﺼﺘﻗﻹﺍ ﺕﺎﺒﻭﻌﺼﻟﺍﻭ (% 77 ﺔﻟﺩﺎﻴﺼﻟﺍ ﻥﻴﺒ ﺔﺴﻓﺎﻨﻤﻟﺍ ﺔﻟﺩﺎﻴﺼﻟﺍ ﺓ.ﺭﻫﺎﻅﻟﺍ ﻩﺫﻫ ﺭﺎﺸﺘﻨﺍ ﻲﻓ ﺔﻟﺩﺎﻴﺼﻟﺍ ﺔﺒﺎﻘﻨﻭ ﺔﺤﺼﻟﺍ ﺓﺭﺍﺯﻭ ﻰﻠﻋ ﻠﻟﺎﺒ ﻡﻭ ﺍﻭﻘﻟﺃ ﺔﻟﺩﺎﻴﺼﻟﺍ ﻉﺎﺒﺭﺃ : ﺤﺒﻟﺍ ﺔﺼﻼﺨ
ﻥﻴﺴﺤﺘﻟ ﺔﻟﺩﻴﺼﻟﺍ ﺔﻴﻠﻜﻭ ﺔﻟﺩﺎﻴﺼﻟﺍ ﺔﺒﺎﻘﻨﻭ ﺔﺤﺼﻟﺍ ﺓﺭﺍﺯﻭ ﻥﻴﺒ ﻥﻭﺎﻌﺘﻟﺍ ﺔﻴﻤﻫﺃ ﻰﻠﻋ ﺀﻭﻀﻟﺍ ﺕﻘﻟﺃ ﺎﻨﺘﺴﺍﺭﺩ ﺓﺯﻏ ﻉﺎﻁﻗ ﻲﻓ ﺔﻴﻭﺩﻷﺍ ﻑﺭﺼ ﺔﺴﺭﺎﻤﻤ Introduction
In many countries drugs are divided into two categories: over-the-counter (OTC) drugs that
can be dispensed to consumers without prescription and prescription-only drugs that
require valid prescriptions from health care professionals [1,2]. In some countries there is a
third category known as pharmacy-only-medication (also known as behind-the-counter
drugs), which do not require medical prescriptions but do require consultation with a
pharmacist [3].
Despite concerns about the safety of some OTC drugs, especially for elderly people
[4-8], increasing numbers of drugs have been shifted from the prescription-only
category to the OTC category, and access to more drugs seems likely to be
deregulated in this way [9,10]. Although there is increasing interest in official
marketing figures of OTC drugs [11-13] and the attitudes of customers [4,14,15] in
developing countries, there is little information about the knowledge, attitudes and
practice of pharmacists about OTC dispensing policies. For the first time we have
assessed the OTC status in the Gaza Strip from the pharmacists' point of view. Our
aim was to understand the dispensing practices of OTC and prescription-only
drugs.
Methodology
Between September and November 2009 we surveyed a probability convenience
sample of 127 pharmacists working in public pharmacies in the five governorates
of the Gaza Strip (North Zone [12], Gaza City [43], Middle Zone [12], Khan
Younis [37], and Rafah [23],). The sample was drawn from the 420 pharmacists
officially registered in the Palestinian Pharmacists' Syndicate (PPS) by
convenience sample and the pharmacists who fit inclusion criteria. The inclusion
criteria were all pharmacists who were registered by the PPS and their age between
25 to 60 year old. In addition the exclusion criteria were all pharmacist were not
registered by the PPS and their age less than 25 and over 60 year old.
Our survey instrument was a self-administered questionnaire. Prior to its use
in the main survey, this was reviewed by a team of consultants with
The Dispensing practice of the over the Counter Drugs
expertise in the development of survey instruments. It was piloted using 10
pharmacists, after which minor modifications to wording were made.
The questionnaire covered several domains, including pharmacists'
demographic information, knowledge of OTC drugs and the practice of
dispensing drugs without prescription, the presence of reference lists of
OTC drugs in the pharmacy, the role of health institutions in regulating drug
dispensing, and the causes underlying dispensing prescription-only drugs
without prescription. The questionnaire also included a list of twenty two
drugs chosen because of their popularity among medical professionals in
Gaza, and which pharmacists often decided to dispense without prescription.
This list helped us to assess whether pharmacists may have underestimated
the extent to which they dispensed prescription-only drugs.
Continuous variables are represented as means (± standard deviations) and
categorical variables as percentages.
Results
Characteristics of participants
The demographic characteristics of the 127 pharmacists surveyed are
summarized in Table 1. Over a third (37%) were women; most (97.6%) had
only a first (Bachelor's) degree; and nearly one in five (18.9) had less than 2
years professional experience.
Drug dispensing practice
When asked about OTC concept, 83% of the pharmacists think that they
have good knowledge, and 17% of them think that they have either weak or
no knowledge. 39% admitted dispensing prescription-only drugs without
valid prescriptions. Only 11 pharmacists (8.7%) reported that they relied on
a list of OTC drugs to guide their dispensing. Nearly two thirds (62.4%)
obtained information about OTC drugs from text or internet websites.
Considerable percent (49.6) of pharmacists distinguish OTC drugs and get
information about these drugs from the pamphlet or from friends, university
lecturers or doctors.
Most (89%) of our respondents believe that dispensing prescription-only
drugs without valid prescriptions may harm patients. 78% wanted formal
policies to regulate dispensing in community pharmacies, and 82%
supported punishments for pharmacists who dispense prescription-only drug
without valid prescriptions. The Ministry of Health and the Pharmacists'
Syndicate were judged by most respondents to be responsible for the
absence of such policies (strongly by 77.6% and 74.2%, respectively),
although 43.7% also judged the colleges of pharmacy to be blameworthy.
Jehad Hammad et al
Reported reasons for dispensing prescription–only drugs without
prescriptions
Several causes of the violation of prescription-only drugs were reported.
Competition among pharmacists was considered by most pharmacists
(77.6%) to have a strong effect, Economical situation have forced most
pharmacists to accept the patients requests even if they do not have valid
prescription in order not to loose valuable customers. Similarly 73.6%
reported that the poverty of patients forces pharmacists to dispense
prescription-only drugs. Due to poverty most patients bypass the doctors in
order not to pay for them. Instead they go directly to the pharmacists and
consult them about their diseases.
Less important causes included incomplete patient knowledge about drugs,
patients forcing pharmacists to dispense prescription-only drugs without
valid prescriptions, and the weak trust of patients in physicians and primary
health care centers. The health centers and hospitals in Gaza strip are very
crowded and the level of health services is relatively poor. Additionally
most of the doctors in Gaza strip were graduated from Eastern Russian
universities with low standard qualifications. Therefore many patients lost
the trust in the doctors (Figure 1).
In order to assess dispensing practice of OTC and prescription-only drugs
indirectly, respondents were asked about their dispensing of specific drugs.
In contrast to the high proportion of pharmacists who claimed complete
knowledge about the concept of OTC drugs, many prescription-only drugs
were dispensed without valid prescriptions, and at a similar rate to known
OTC drugs (Figure 2).
Discussion
Although most pharmacists (83.5%) in our study claimed that they were
aware of the Over The Counter (OTC) concept only 9.4% reported having a
list of OTC drugs in their pharmacies: 49.6% depended on the labels on
drug packages as the main source of OTC information (data not published).
Over a third (39%) of our respondents admitted dispensing prescription-only
drugs in community pharmacies without valid prescriptions. However, data
reflecting actual practice (Figure 2) suggests that the self-reported
proportion of Gazan pharmacists dispensing prescription-only drugs is
probably an underestimate. The vast majority (96 %) admitted prescribing
amoxicillin without valid prescriptions. Similar results were obtained with
ciprofloxacin, despite the fact that these oral antibiotics are not included in
any OTC list worldwide [2,16].
This indicates that the pharmacists we surveyed (all of whom had at least
first university degree in pharmacy) have unsatisfactory knowledge about
The Dispensing practice of the over the Counter Drugs
the OTC concept. Three quarters of our respondents blamed the Ministry of
Health and the Pharmacists' Syndicate for this situation, although nearly a
half also blamed colleges of pharmacy. This suggests that there is a need
for better cooperation between these three bodies in improving pharmacists'
knowledge about OTC drugs.
Lack of knowledge was not the only reason for dispensing malpractice in
the Gaza Strip, however. Other important factors included loss of patients'
trust in doctors, and loss of pharmacists' trust in physicians and health care
centers. The most prominent causes were deemed by pharmacists to be
patients' economic situation (mentioned by 94.4% of respondents) and
economic competition among pharmacists (mentioned by 83.1% of
respondents).
The attitudes of the pharmacists revealed in the list of twenty two drugs
relevant to a variety of physiological systems and diseases demonstrate that
most pharmacists here lack clear dispensing guidelines. Even parentral
prescription-only drugs, such as gentamicin and insulin, are being dispensed
without valid prescriptions. Amoxicillin comes second only to paracetamol
in the list of the drugs frequently prescribed without valid prescriptions.
This might explain the high incidence of antibiotic resistance in Gaza [18-
21]. On the other hand, most pharmacists were reluctant to prescribe drugs
for cardiovascular diseases and diabetes mellitus. High percentages of our
respondents reported that they never dispensed digoxin (79.5%), enalpril
(72.0%),
prescriptions, reflecting their concerns about the side effect of these drugs.
However, drugs such as gentamicin with narrow therapeutic windows were
dispensed OTC by 23% of pharmacists. The ranking of drugs in the list is
not consistent with the OTC drug lists in developed countries [2,17] and this
may indicate lack of pharmacist knowledge about the adverse effects of the
drugs in the list.
In the light of our findings we offer the following recommendations:
1) improve cooperation between the Ministry of Health, the Pharmacists'
Syndicate, and the College of Pharmacy in orientating pharmacists to good
OTC practices;
2) encourage the only College of Pharmacy in the Gaza Strip to give
increased attention to OTC studies in their undergraduate curricula; And
3) cooperation between the Ministry of Health, the College of Pharmacy and
an international organization such WHO to draw up a modified OTC list,
taking account of the economic and political situation in the Gaza Strip.
Jehad Hammad et al
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pneumococci in Gaza Strip children. Pediatr Infect Dis J 1997; 16(9):905-7. Table 1. Participant characteristics.
Percentage
Governorate
Khanyounis
Bachelor
Postgraduate
Experience years
Less than 2 years
From 2 to 4 years
From 5 to 9 years
More than 10 years
Jehad Hammad et al
Competition between Poverty of patients Characteristics of Weak trust in primary health care centers Percent of pharmacists
Figure 1. Factors that affect the dispensing of prescription only drug without
valid prescription expressed as a percent of pharmacists who claim that certain
factor has strong effect (blue columns) or weak effect (red columns).
The Dispensing practice of the over the Counter Drugs
Percent of pharmacists who dispense drug without prescription
Figure 2. Percent of pharmacist who dispense the mentioned drugs without valid

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