Corresponding author: Lily Peikova (
The aim of this study was to assess the attitudes and perceived barriers towards pharmaceutical care provision for pregnant women in Bulgarian community pharmacies.
A cross-sectional web-based study was carried out among community pharmacists in Plovdiv region, Bulgaria. The survey instrument was a self-administered questionnaire including 18 statements based on a five-point Likert scale. Descriptive statistics were applied to respondents’ characteristics and opinion regarding attitudes and barriers towards pharmaceutical care provision for pregnant women. A total of 122 community pharmacists completed the survey. The majority of respondents (90%) agreed or strongly agreed with the statement that providing pharmaceutical care will improve health and awareness of pregnant women. The statement that providing pharmaceutical care brings professional satisfaction, obtained the highest mean score of 4.61. Half of the respondents (50.8%) were worried about taking risks associated with assuming responsibility for the treatment outcomes of pregnant women. One of the main barriers for providing pharmaceutical care was the lack of time (mean score = 4.10). Other major barriers were the lack of additional training (83.9%) and electronic medical record of the pregnant women (68.9%). Overall Bulgarian community pharmacists have positive attitudes towards providing pharmaceutical care to pregnant women. Conducting additional training courses and workshops will help for the active involvement of the pharmacist in the care of pregnant women.
Pharmacy is an ever-evolving profession in which the pharmacist, with his knowledge and skills, is committed to meeting the health care needs of patients. In addition to their traditional role of dispensing prescription medicines and advising patients, pharmacists are providers of pharmaceutical care. They take responsibility for the treatment outcome and actively participate in the monitoring of therapy. Pharmacists are also advisors to the patient regarding the safe and rational use of medications (
Pharmaceutical care is an integral part of modern pharmacy practice, which requires direct collaboration of the pharmacist with a patient to accurately assess their needs for drug therapy, and cooperation with other health professionals to achieve specific therapeutic goals (
The definition of the concept of “pharmaceutical care” was first established by Charles Hepler and Linda Strand in 1990 and reads: “Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes which improve a patient’s quality of life. These results are: (1) treatment of the disease, (2) elimination or reduction of the patient’s symptomatology, (3) arresting or slowing down a disease process, (4) preventing a of disease or symptomatology” (
During its forty years of development, the concept of “pharmaceutical care” has shown the ability of pharmacists to be an equal part of the team of health professionals who share responsibility for the patient’s health. In European countries, this concept has been successfully applied for more than 20 years (
Although pregnancy is a physiological condition, during this period a number of changes occur in a woman’s body related to ensuring the foetus development and successful completion of the pregnancy (
Safe drug use during pregnancy is an important element of prenatal care, so pregnant women and their physicians often turn to pharmacists for information and advice. The largest study assessing the risk associated with the use of medicines during pregnancy indicates that the three most used sources of information are the physician, the patient leaflet, and the pharmacist (
In 2011, The International Pharmaceutical Federation (
Growing health care needs have motivated the implementation of additional professional training of specialists with skills for modern care, adaptability, communication, mobility and teamwork (
Basic knowledge about drugs, their safe use during pregnancy, teratogenic effect, pharmacy students obtain from the disciplines of Pharmacology, Toxicology and Pharmacotherapy. The pharmaceutical care course covers only some aspects of prenatal care such as communication with the patient and self-medication.
The aim of this study was to assess the attitudes and perceived barriers towards providing pharmaceutical care for pregnant women in Bulgarian community pharmacies.
A cross-sectional, questionnaire-based study was performed between July – October 2018. The study was conducted among pharmacists working in community pharmacies in the administrative district of Plovdiv, Bulgaria. An invitation to participate in the study was sent to all active members of the Regional Pharmaceutical Chamber – Plovdiv of the Bulgarian Pharmaceutical Union (n = 716, July 2018). A web application was used for distribution of the survey. A total of 122 surveys were completed and returned (17% response rate).
The study tool included statements regarding pharmacists’ attitudes and barriers towards providing pharmaceutical care for pregnant women. The questionnaire was divided into 3 sections: (1) demographic and professional data; (2) attitudes towards providing pharmaceutical care to pregnant women; (3) perceived barriers for providing pharmaceutical care for pregnant women. Sections (2) and (3) included a total of 18 items (9 statements in each section) to which respondents must answer according to the five-point Likert scale, ranging from 1 – “strongly disagree” to 5 – “strongly agree”. The items included in sections (2) and (3) were based on previously used instruments regarding the attitudes and perceived barriers towards providing pharmaceutical care (
The data was analysed using SPSS ver. 19. Descriptive statistics were used to describe the demographic and occupational characteristics of respondents, as well as attitudes and barriers to pharmaceutical care for pregnant women. Quantitative data are presented as means and standard deviations (
The demographic and professional characteristics of the surveyed pharmacists are presented in Table
Demographic and professional characterics of the surveyed pharmacists.
Characteristics | Frequency | Percentage |
---|---|---|
Gender | ||
Female | 89 | 72.9% |
Male | 33 | 27.0% |
Аge groups (years) | ||
20–29 | 74 | 60.6% |
30–39 | 32 | 26.2% |
40–49 | 12 | 9.8% |
>50 | 4 | 3.3% |
Work experience (years) | ||
1–5 | 77 | 63.1% |
6–10 | 32 | 26.2% |
11–15 | 9 | 7.4% |
>15 | 4 | 3.3% |
Pharmacy type | ||
Independent | 42 | 34.4% |
Chain | 80 | 65.6% |
Position | ||
Pharmacy manager | 45 | 36.9% |
Pharmacy staff | 77 | 63.1% |
Postgraduate specialization | ||
Yes | 5 | 4.1% |
No | 117 | 95.9% |
The statements included in the survey aimed to establish pharmacists’ opinion about providing pharmaceutical care for pregnant women. The results regarding attitudes and barriers of providing pharmaceutical care for pregnant women are presented in Tables
Pharmacists’ attitudes towards pharmaceutical care.
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1 | 2 | 3 | 4 | 5 | ||
1. I think that providing pharmaceutical care will improve the health and awareness of pregnant women | 0.0% | 0.0% | 0.0% | 41.8% | 58.2% | 4.58±0.50 |
(4.49–4.67) | ||||||
2. Pharmaceutical care would improve pregnant woman’s appreciation of the pharmacist’s role. | 0.0% | 0.8% | 9% | 32.8% | 57.4% | 4.47±0.69 |
(4.34–4.59) | ||||||
3. Providing pharmaceutical care offers me professional satisfaction | 0.0% | 0.0% | 2.5% | 33.6% | 63.9% | 4.61±0.54 |
(4.52–4.71) | ||||||
4. I believe that preventing and solving health-related and drug-related problems in vulnerable patients like pregnant women, are my responsibilities. | 1.6% | 6.6% | 12.3% | 42.6% | 36.9% | 4.07±0.95 |
(3.90–4.24) | ||||||
5. In Bulgarian community pharmacies there is no effective provision of pharmaceutical care for pregnant women | 2.5% | 9% | 15.6% | 43.4% | 29.5.% | 3.89±1.01 |
(3.70–4.07) | ||||||
6. I do not think that provision of pharmaceutical care would result in any significant benefit to pregnant women | 31.1% | 39.3% | 9% | 9.8% | 10.7% | 2.30±1.30 |
(2.06–2.53) | ||||||
7. I am not comfortable with taking risks associated with assuming responsibility for the treatment outcomes of pregnant women | 3.3% | 24.6% | 21.3% | 33.6% | 17.2% | 3.37±1.13 |
(3.17–3.57) | ||||||
8. Bulgarian community pharmacists do not have enough knowledge and skills to provide effective pharmaceutical care | 5.7% | 21.3% | 23% | 32% | 18% | 3.35±1.17 |
(3.14–3.56) | ||||||
9. I need to attend additional courses to be an effective health adviser for pregnant women | 0.0% | 3.3% | 4.9% | 43.4% | 48.4% | 4.37±0.73 |
(4.24–4.50) |
The majority of respondents (90%) agreed or strongly agreed with the statement that providing pharmaceutical care will improve health and awareness of pregnant women. The statement that providing pharmaceutical care brings professional satisfaction, obtained the highest mean score (4.61±0.54). The predominant part (79.5%) of the respondents agreed or strongly agreed that detecting and solving problems related to the health and drug therapy of pregnant women is an important responsibility of the pharmacist. The majority (72.9%) of the respondents believed that there is no effective provision of pharmaceutical care for pregnant women in Bulgarian community pharmacies. One in five pharmacists (20.5%) stated that the provision of pharmaceutical care would not benefit pregnant women, while 70.4% thought the opposite. Half of the respondents (50.8%) were worried about taking risks associated with assuming responsibility for the treatment outcomes of pregnant women. The same percentage of the respondents reported that pharmacists in Bulgaria do not have enough knowledge to provide effective pharmaceutical care. Over 90% of the respondents said they need additional courses and specializations to be effective health advisers for pregnant women. Cronbach’s alpha over the 9 statements was 0.587.
Perceived barriers for providing pharmaceutical care for pregnant women.
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1 | 2 | 3 | 4 | 5 | ||
1. Lack of time to provide pharmaceutical care | 0.8% | 4.9% | 11.5% | 49.2% | 33.6% | 4.10±0.85 |
(3.95–4.25) | ||||||
2. Lack of private consultation area | 3.3% | 11.5% | 18% | 45.1% | 22.1% | 3.71±1.04 |
(3.53–3.90) | ||||||
3. Lack of training regarding provision of pharmaceutical care for pregnant women | 0.8% | 5.7% | 9.8% | 50.8% | 32.8% | 4.09±0.85 |
(3.94–4.24) | ||||||
4. Lack of effective communication between pharmacist and pregnant woman | 4.1% | 27% | 27% | 41.8% | 16.4% | 3.56±1.02 |
(3.37–3.74) | ||||||
5. Lack of acceptance of the pharmacist’s role by the pregnant woman | 2.5% | 19.7% | 19.7% | 37.7% | 18.9% | 3.49±1.10 |
(3.29–3.69) | ||||||
6. Lack of knowledge about the medication safety during pregnancy | 4.1% | 27% | 22.1% | 28.7% | 18% | 3.30±1.17 |
(3.09–3.50) | ||||||
7. Lack of documentation (e.g., software for keeping the patients’ medical data and other technical resources) | 5.7% | 23.8% | 24.6% | 28.7% | 17.2% | 3.28±1.17 |
(3.07–3.49) | ||||||
8. Lack of access to patient medical records | 2.5% | 8.2% | 20.5% | 41% | 27.9% | 3.84±1.01 |
(3.66–4.02) | ||||||
9. Lack of funding (e.g., reimbursement) for providing pharmaceutical care | 2.5% | 9.8% | 13.9% | 43.4% | 30.3% | 3.89±1.03 |
(3.71–4.08) |
One of the main barriers for providing pharmaceutical care was the lack of time. This statement received the highest mean score (4.10±0.85). Other important barriers were the lack of additional training (83.9%) and electronic medical record of the pregnant woman (68.9%). For 73.7% of the participants in the study, the lack of funding for the “pharmaceutical care” service was a major obstacle to its provision to patients. Less than half of the respondents (45.9%) reported that the lack of specialized software or other technical resources would negatively affect the provision of pharmaceutical care, while 24.6% of the respondents cannot give a definite answer. More than half of the pharmacists stated that the lack of effective communication (58.2%) as well as a pregnant woman’s reluctance to take pharmaceutical care (56.6%) can be barriers. Cronbach’s alpha over the 9 statements was 0.756.
According to our respondents, the main barriers that prevent the implementation of pharmaceutical care for pregnant women are the lack of sufficient time, the lack of a database, the lack of additional training, and funding for the service. Very often in the pharmacy there are organizational barriers (lack of time, insufficient staff, lack of private space), which can obstruct the implementation of pharmaceutical care services. Our results confirm the data from studies conducted in different countries, namely that the lack of time is a major barrier to the application of pharmaceutical care (
Examples for European countries with high implementation of pharmaceutical care are Belgium, Netherlands, and France (
The importance of communication is essential for providing effective pharmaceutical care for pregnant women. More than half of community pharmacists participated in our survey, reported communication barriers between them and pregnant women. Effective communication skills and professional behavioral models suggest a high level of competence related to humanity and empathy. (
A recent study conducted in Belgium examined community pharmacists’ attitudes, barriers, knowledge, and counselling practice regarding pharmaceutical care during preconception, pregnancy, and lactation. The study, which was conducted in the form of an online survey, involving 63 community pharmacists. According to the participants’ responses, the main barriers to pharmaceutical care provision during preconception, pregnancy and lactation include difficulties in identifying the woman’s status (71%) and lack of education (67%) (Ceulemans 2020a). Another study conducted by the same authors assessed the impact of a blended learning program on community pharmacists’ barriers, knowledge, and counselling practice regarding preconception, pregnancy, and lactation (Ceulemans 2020b). The intervention included an e-learning and an on-site training day. The results of the training program showed decreased pharmacists’ barriers and improved knowledge (Ceulemans 2020b).
Although community pharmacists are the most accessible health care providers there are gaps in knowledge and consulting practices with regard to medication use during pregnancy, which is confirmed by a number of studies (Bains 2014; Alrabiah 2017). In order to provide effective counselling for pregnant women, pharmacists must have appropriate and evidence-based information. This will help for the full implementation of pharmaceutical care services regarding pregnancy.
Our results confirm the need for educational interventions regarding the counselling of pregnant women. Continuing education organized by the Bulgarian Pharmaceutical Union (
Based on our findings, we can summarize that Bulgarian community pharmacists generally have positive attitudes towards providing pharmaceutical care to pregnant women. The establishment of a framework for the development of standards for pharmaceutical care in Bulgaria is one of the main objectives in the Good Pharmacy Practice Rules of the