|Year : 2023 | Volume
| Issue : 1 | Page : 9-20
A qualitative study of the knowledge, experiences, perceived roles, cultural barriers, and skills of community pharmacists dealing with Saudi Patients with asthma
Clinical Pharmacy Practice Mohammed Al-Mana College for Medical Sciences, Abdulrazaq Bin Hammam Street, Al Safa, Dammam, Saudi Arabia
|Date of Submission||25-Nov-2022|
|Date of Acceptance||01-Feb-2023|
|Date of Web Publication||30-Mar-2023|
Dr. Reem Alzayer
Clinical Pharmacy Practice Mohammed Al-Mana College for Medical Sciences, Abdulrazaq Bin Hammam Street, Al Safa, Dammam
Source of Support: None, Conflict of Interest: None
Background: In Saudi Arabia, asthma is one of the most common chronic respiratory diseases. Previous studies have identified that asthma management can be influenced by patients’ cultural beliefs and levels of asthma education. Therefore, community pharmacists should have good knowledge of both asthma and Saudi cultural beliefs to be able to effectively educate Saudi patients. Objective: The purpose of this study was to explore Saudi community pharmacists’ knowledge, experiences, and perspectives on providing care for Saudi patients with asthma. Materials and Methods: A qualitative method was employed to conduct semistructured interviews in the Eastern Province of Saudi Arabia. Community pharmacists were interviewed on the phone using an interview guide, and participants were recruited purposively. Verbatim transcripts of interviews were then thematically analyzed. Results: Analysis of 22 interviews resulted in five emergent themes: (1) lack of asthma knowledge among community pharmacists; (2) cultural and religious issues; (3) counseling issues; (4) patient medication issues and navigating the healthcare system; and (5) the need for asthma recourse and training. The findings indicate that community pharmacists have unsatisfactory levels of asthma knowledge and lack access to asthma guidelines in Saudi Arabia. It was also evident that the asthma management of Saudi patients was influenced by patients’ cultural and religious beliefs, which pharmacists needed to consider during patient counseling. Conclusions: Due to the lack of knowledge about asthma among our participants, there is an urgent need for asthma training. Furthermore, pharmacists should consider the impact of cultural issues on Saudi asthma patients to achieve better clinical outcomes.
Keywords: Asthma management, community pharmacy, cultural beliefs, pharmacists′ experience, Saudi Arabia
|How to cite this article:|
Alzayer R. A qualitative study of the knowledge, experiences, perceived roles, cultural barriers, and skills of community pharmacists dealing with Saudi Patients with asthma. Saudi J Clin Pharm 2023;2:9-20
|How to cite this URL:|
Alzayer R. A qualitative study of the knowledge, experiences, perceived roles, cultural barriers, and skills of community pharmacists dealing with Saudi Patients with asthma. Saudi J Clin Pharm [serial online] 2023 [cited 2023 Jun 9];2:9-20. Available from: http://www.sjcp.org/text.asp?2023/2/1/9/372930
| Background|| |
Asthma is a chronic condition of the airways which is distinguished by persistent airway inflammation and constriction, causing wheezes, dyspnea, and cough. In 2019, The World Health Organization estimated that asthma affected 262 million and caused 455,000 deaths globally. It has a detrimental effect on patients’ quality of life, poorly controlled asthma can limit patients’ physical health and lower their daily activities. Thus, for patients with asthma to have it well-controlled, it’s vital for the patients to have ongoing medical attention from healthcare professionals.
One of the most accessible healthcare professions is community pharmacies., Because of the easy accessibility, medical knowledge among community pharmacists, and regular interaction with patients, community pharmacists are well-positioned to improve the management of chronic diseases, such as providing asthma care. In order for community pharmacists to help patients with asthma to manage their symptoms, pharmacists must possess the appropriate knowledge, monitoring asthma inhaler techniques, identifying asthma-triggering factors cooperating with the patient and their doctor to ensure implementing of asthma action plan, and addressing patients’ fears about possible adverse effects of drugs to enhance adherence to asthma medications. Many evident reported community pharmacist-led interventions improved medication adherence to asthma medications which led to better clinical outcomes for patients with asthma.
There are around 7322 community pharmacies in Saudi Arabia, employing 12,506 pharmacists in total. Although all pharmacists in Saudi Arabia must be registered with the Saudi Commission for Health Specialties (SCFHS) and Ministry of Health regulations., Community pharmacists’ asthma knowledge should be evaluated to ensure that it meets the standards established by the local guidelines, Saudi Initiative for Asthma (SINA), which includes updated asthma management recommendations from experienced specialist physicians in respiratory diseases in Saudi Arabia., These new recommendations were adopted based on the regulations suggested by the international guidelines for asthma management, Global Initiative for Asthma (GINA) in 2019.
In addition, community pharmacists are required to be competent to counsel their patients with asthma., Pharmacists should have good communication skills as it is a critical component in making the consulting process effective and to ensure optimal therapeutic outcomes., Many patients are unaware that community pharmacists have a medical background to provide healthcare services in asthma management; therefore, this could be one of the reasons patients avoid seeking pharmacists’ help in Saudi Arabia.,,,
This study explores pharmacists’ experiences with Saudi patients with asthma and assesses pharmacists’ knowledge of asthma management in the Eastern Province of Saudi Arabia.
| Materials and Methods|| |
The study was approved by Institutional Review Boards (IRB)-Scientific Research Unit. The IRB approval no. SR/RP/74.
This study was conducted in the Eastern Province of Saudi Arabia.
Study design and instrument
The study employed qualitative methodologies, including semistructured interviews with participants until data saturation was reached. A semistructured interview guide was created based on the study’s aims, the general literature, and the clinical experience of a practicing research member. The interview outline included nine essential questions, ranging from easy topics, such as the reason for and frequency of interaction with Saudi asthma patients, to more cognitively challenging topics, such as techniques employed when dealing with Saudi asthma patients or suggestions for increasing patient counseling in community pharmacies.
A convenience-based purposive sample of community pharmacists was recruited from the Saudi Arabian Eastern Province. The sample’s purposive element was produced by inviting pharmacists working in the Eastern Province (convenience sampling) known to the research team through personal or professional networks. Finally, consenting participants were asked to share project information and invite colleagues who met the inclusion criteria to participate in the study, utilizing a passive snowballing strategy. Snowballing strategy is a nonprobability sampling strategy in which current study participants recruit prospective study participants from their social circles. As a result, the sample of the study is said to grow as just as a snowball.
The sample size goal was to interview 20–25 participants. This number was based on previous qualitative investigations with homogeneous respondents, which suggested that this number would be sufficient for data saturation. A brief letter detailing the initiative and project aim, as well as information on what was required of possible participants, was sent to identified community pharmacies through email, hard copy, or social media. After 2 weeks, nonresponsive pharmacies received a phone call, a social media message, and/or an email reminder. Participants who were willing to participate were able to contact the research team directly to schedule an interview and were evaluated as follows.
- Pharmacists registered for at least 12 months and working in the Eastern Province of Saudi Arabia.
- Pharmacists without current experience or who have not worked in the past 12 months.
- Pharmacists’ trainees/interns.
Participants who met the inclusion criteria were requested to sign a consent form.
Data collection and analysis
Because of social distancing due to COVID-19, the interviews were conducted over the phone until the data were saturated. Prior to the interview, the principal researcher informed potential participants about the study and requested their permission to record and/or take notes. A semistructured interview guide was used to conduct all the interviews in Arabic, which is the native language of Saudi Arabia. All transcripts were double-checked for identifying and clarifying any inconsistencies, if present, with the audio versions. The transcripts were subsequently coded and thematically analyzed using QSR NVivo 10 Software (NVivo 10, released in 2012 by QSR International). The inductive approach was utilized to measure emergent themes after the ground researcher read and coded all the transcripts.
The interviews were conducted in Arabic and coded into themes and translated into English by the ground researcher. Then both the Arabic and the translated English manuscripts were sent to a certified translator to check the accuracy of the coding and translation to ensure verbatim translation.
| Results|| |
The semistructured interviews, which took place between September 2021 and January 2022, involved 22 pharmacists. All of the participants in our study hold bachelor’s degrees in pharmacy and are registered and licensed pharmacists in Saudi Arabia by SCFHS. The majority of our participants were males. Purposive convenient sampling was used to acquire 32% of participants, whereas passive snowballing was used to recruit 68%. Due to the current state of the COVID-19 pandemic, all interviews were conducted over the phone. The interviews lasted from 16 to 52 min. Data saturation, which was reached after 19 interviews, determined the sample size. The demographics of the participants included a wide range of sizes of the community pharmacies where they worked and job experience, which are highlighted in [Table 1].
The participants vividly detailed a wide range of situations in their community pharmacy practice. The large amount of data allowed for a significant thematic analysis, which was categorized into five main themes and subthemes, which are highlighted in [Figure 1].
Themes and subthemes with data exemplars are highlighted in [Table 2].
Theme 1. Lack of asthma knowledge among community pharmacists
- Lack of asthma knowledge and skills
Some participants mentioned their need to update their knowledge about asthma medications, the purpose of each medication, and the differences between asthma inhalers. Their lack of knowledge hinders their work and makes them unable to educate patients with asthma.
All of the participants failed to recognize asthma the action plans and first aid strategies to help patients with asthma in cases of emergency.
Theme 2. Cultural and religious issues
a. Gender issues
Some participants mentioned gender issues due to Saudi culture. Where male patients prefer to seek male pharmacists' help and female patients prefer to seek female pharmacists' help. Although female pharmacists now work in community pharmacies, it seems that the patients were not fully aware of that. A patient may not be involved in communication due to cultural issues, where female patients ask their husbands to communicate with the pharmacist instead of themselves doing so. This gap in communication can increase the risk of wrong medical advice by pharmacists or lead to medication errors.
b. Use of herbal medicine
A few pharmacists mentioned that Saudi patients prefer natural or herbal medicines, as they have a strong belief in the safety of these organic products, unlike allopathic medicine, which can be harmful and cause side effects that negatively affect patients’ daily lives.
Stigma was mentioned by some of our participants among some patients with asthma who have felt embarrassed to use asthma inhalers in front of others. This is particularly true for those who are newly diagnosed with asthma or school-age students who may be afraid of being bullied by peers at school. These feelings drive patients with asthma to skip using asthma treatment, which can worsen their symptoms.
d. Religious issues (during Ramadan)
Patients with chronic diseases may struggle to use their medications during the holy month of Ramadan. This can be challenging for patients who are trying to avoid, skip, or delay treatment until eating is permitted at sunset. Patients may need to use their medications when they experience bothersome symptoms, but they do not want to ruin their fasting.
Theme 3. Counseling issues
a. Lack of patient engagement issues
Some participants thought that pharmacists must be more proactive with their patients to encourage communication and build trust. If pharmacists are passive, patients may not ask for any pharmacists’ help.
A few participants mentioned that the community pharmacy they work in lacks a private area, which makes patient counseling challenging; patients may be hesitant or feel embarrassed to ask questions in front of others in the community pharmacy.
Although all the participants in our study were native Arabic speakers, some of them mentioned that they sometimes faced language barriers when dealing with Saudi patients due to different accents. Some medical terms have different names in different Arabian countries, so pharmacists will not be familiar with them.
Some participants mentioned that they do not have a strategy to check patients’ understanding, nor do they ask their patients to provide feedback to confirm whether they have understood the instructions on how to use asthma medications correctly.
b. Profit focus
A few participants mentioned that some pharmacists do not fully engage with their patients in consultations, as the main goal of some pharmacists is just to sell medications to increase profit, understanding the community pharmacy as a business more than a place to ensure patient safety and care.
c. Time constraints
Some participants revealed that the shortage of time during their working hours prevents them from teaching patients about medications; they believe doctors should teach patients, as doctors have more time to spend with them. Pharmacists, on the other hand, are very busy in the pharmacy, needing to service their patients, who are often in a hurry and do not want to wait for a consultation.
d. Helplessness and distrust issues/underestimation of pharmacy services
Some participants believed that they have no role in asthma management and are only doctors. The participants agreed that patients should not trust pharmacists but doctors; this is because the pharmacist cannot help patients with asthma as pharmacist has no access to patient’s medical record and do not have the authority to change the medications or doses as doctors. In addition, patients may underestimate pharmacy services due to their easy access and free costs.
Theme 4. Patients’ medication issues and healthcare navigation
a. Lack of asthma medications knowledge
Some participants stated that patients with asthma do not have enough knowledge about their medications and the correct use of inhalers, which may lead to repeating their doses or even overdosing, as patients sometimes think the drug is ineffective.
Steroid phobia was reported by most of our participants. Many patients have these concerns; some believe that steroids can cause harmful side effects by affecting their hormones negatively and also cause addiction, whereas others believe that they need to use steroids because their asthma is severe and dangerous.
b. Unrealistic expectation
If patients with asthma do not understand that asthma is a chronic disease, they may skip visiting doctors for follow-up. Patients who have unrealistic expectations will visit doctors only if doctors can cure their disease, even though asthma is a chronic and noncurable disease.
c. Influence of social media on patients’ medication knowledge
Some participants revealed that the culture in Saudi Arabia has changed due to the influence of social media; for example, Saudi females care more about their health since watching influencers recommend using products for health benefits, such as vitamins and other medications to boost their immunity, particularly during the COVID-19 pandemic. The problem with this, they said, is that social media often communicates unreliable information, influencing patients to use harmful products; it’s also not customized to suit everyone’s health condition.
d. Challenges in navigation healthcare
In some cases, patients with asthma seek pharmacists’ help when they should go to a hospital, especially for critical and severe asthma symptoms. Pharmacists cannot help much at this stage; however, patients prefer to see pharmacists due to fast and easy access, while visiting doctors takes more time and costs more, particularly among private doctors.
Theme 5. The need for asthma recourse and training
a. No access to national or international asthma guidelines (SINA or GINA)/need for training
Most of our participants expressed their willingness to receive training about asthma, as they believe they lack up-to-date information. All of the participants failed to recognize the international asthma guidelines, GINA, and the local asthma guidelines used in Saudi Arabia, SINA.
b. The need for asthma resources/training
Most of the participants stated that they do not have reliable resources, and they use old sources, such as their university lectures, which are not up-to-date with current practice, including procedures concerning the COVID-19 pandemic.
| Discussion|| |
To our knowledge, this study is the first qualitative research study to explore pharmacists’ experiences with asthma management in the Eastern Region of Saudi Arabia. The findings have shown many issues regarding patient care at Saudi community pharmacies. A lack of asthma education was clear among the pharmacists, and it is not surprising that the patients also had a lack of asthma knowledge. This is because pharmacists are the last healthcare professionals seen by patients, and they are supposed to provide patients with all needed asthma medication information.
SINA guidelines 2021 have implemented a major change in the treatment of asthma among adults and adolescents in both step 1 and step 2, as shown in [Figure 2]. For step 1, short-acting bronchodilator (SABA), such as salbutamol, as needed, is no longer advised to be taken alone., Instead, inhaled corticosteroids (ICS) are advised to be used whenever SABA is needed in Step 1. Strong evidence suggests that using SABA alone has been shown to increase the risk of asthma exacerbation and asthma-related death. For step 2, using daily low-dose ICS (or as-needed ICS-formoterol), as this approach is successful in lowering severe exacerbations, hospitalizations, and deaths.,,
Almost all the participants in our study failed to recognize both asthma guidelines, SINA and GINA. In addition, some participants mentioned that they did not have enough knowledge about the types of asthma medications or inhalers and their mechanisms of action. Lack of asthma medication knowledge among pharmacists’ results in failure to explain the role of medications to patients, which may explain why many patients have a steroid phobia and overestimate the risks associated with ICS.,,
Some of our participants mentioned that Saudi patients do not understand pharmacists’ role and believe that pharmacists only sell medications. A systematic review was conducted in the UK in 2017, involving 30 studies to identify public perspectives on community pharmacy services. The results demonstrated that 48.3% of people in the UK viewed community pharmacies as medicine supply shops, 22% viewed them as locations to buy medicines, and 17.7% viewed them as locations to buy nonmedicinal products. As a result, only 1% of customers are inspired to visit a neighborhood pharmacy due to “confidence in the pharmacist.” Similar findings were reported in a previous study with Saudi patients with asthma, which revealed that they have never consulted pharmacists about their asthma medications, as they believed that the main role of community pharmacists is just to “sell” medications.
Interestingly, some pharmacists in our study agreed that patients should trust their doctors more than their pharmacists, whereas pharmacists can sometimes be unhelpful because they cannot access patients’ medical records and have no authority to change patient medications. Other participants believed that patients do not trust pharmacists due to stereotypes about pharmacy services; because pharmacies are available at any time and are easily accessible with free-of-charge appointment services, patients underestimate pharmacists’ help and trust only doctors who require an appointment and paid consultation. Interestingly, on the contrary, other studies have mentioned that costly medical services are considered a “traditional barrier” to medical care, which is the broadest umbrella category of reasons for avoiding medical care by patients.,
Furthermore, some of our participants mentioned language barriers lead to miscommunication with patients. Although all our participants were native Arabic speakers, and the official language in Saudi Arabia is Arabic, our participants faced some challenges dealing with Saudi patients due to different accents. One solution is that pharmacists should ask patients to give feedback about their treatment to help the pharmacists ensure that the patients have understood properly.,, Unfortunately, some of our participants failed to have a clear method for reviewing patients’ understanding. Pharmacists should have a clear strategy to assess patients’ understanding during consultations, to ensure patient safety, and optimize the use of asthma medications.,
Our participants also reported that asthma management in Saudi Arabia can be influenced by patients’ cultural issues, such as gender differences. Some of our male participants reported that it can be difficult to consult with female patients directly; it must be through a third party, such as her husband, which can make it difficult to understand the medical problem accurately. When female patients do speak with male pharmacists, they often feel uncomfortable discussing sensitive matters; female patients may provide male pharmacists with insufficient and brief information, which is not enough to discover the appropriate treatment., Especially in community pharmacies, where private consultation areas are lacking, patients may feel embarrassed to ask future questions; this issue was raised by a few of our participants.
In fact, asthma management can also be influenced by patients’ values, preferences, and religions. For example, it is common to use folk medicines among the Arabic population, which is driven by their cultural background and/or religion. Particularly Muslims who have strong beliefs in some treatments, such as honey, which is also used for the management of respiratory disorders, such as bronchitis and coughs.,,
Some participants in our study mentioned that many patients in Saudi Arabia are influenced by social media and use it as a source of health-related information. In 2020, the WhatsApp platform was estimated to be the most popular among Saudis, with an 89.8% usage rate, followed by Twitter.,, The most common reason for using health-related social media is the acquisition and exchange of knowledge., In addition, the public has shown great interest in using social media to communicate with other patients with similar diseases or to follow social media influencers.,, Such practices can be problematic if self-prescribing patients buy their medications based only on social media influencers’ recommendations, as the unregulated nature of the internet can lead to the spread of misleading information, which harms their health.,,
As is the case with any study, this study too has its limitations. The sample, as can be seen from the demographics table, was only from the Eastern Province of Saud Arabia. Other cities in Saudi may have different experiences; thus, the results cannot be generalizable since it is a qualitative research study.
Since all the interviews were conducted over the phone, nonverbal communication, such as body language, including eye contact and facial expressions, could not be observed. It was also easy to get distracted talking to others while they were on the phone.
| Conclusion|| |
There is a clear gap in asthma management among our participants. Our findings showed that there is an urgent need for community pharmacists to be trained on asthma management. Community pharmacists’ asthma knowledge should be assessed to ensure that it meets SINA standards. Online and/or onsite asthma training can be established to community pharmacists to enhance their asthma knowledge to be able to help patients with asthma control their symptoms. Community pharmacists have an important role in patient education by guiding the patient to access reliable resources, particularly these days when patients are eager to know more about their condition and use random websites as a source of information that may be harmful.
To enhance pharmacist–patient communication, community pharmacies need to be ready by offering privacy for a patient during counseling. It is also advisory to train non-Saudi pharmacists to be familiar with typical Saudi terminology for the most common drugs or diseases, to ease communication and encourage patients' engagement in the conversation, and to overcome language barriers. It’s also important to consider patients’ cultural and religious beliefs to educate patients and obtain feedback to ensure patients’ full understanding.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
We thank all the participants for their time and valuable input to this study. The Scientific Research Unit at Mohammed Al-Mana College for Medical Sciences for this chance of conducting this research. A special thanks to Abdullah Alsaif and Fatima Alsaif for helping with organizing the data and proof reading.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]