Introduction
The community pharmacist is one of the fundamental healthcare providers in the community (Kennie-Kaulbach et al., Reference Kennie-Kaulbach, Farrell, Ward, Johnston, Gubbels, Eguale, Dolovich, Jorgenson, Waite and Winslade2012). They are considered easy to access and among the most dependable healthcare (Crossley Reference Crossley2019; Tsuyuki et al., Reference Tsuyuki, Beahm, Okada and Al Hamarneh2018). In the pharmaceutical care era, the professional roles of pharmacists have substantially developed to not only focus on product-related services but also provide patient-centred care (PCC) via direct patient–pharmacist interaction (Olson et al., Reference Olson, Vaidyanathan, Stratton, Isetts, Hillman and Schommer2021). In PCC, patients should be actively involved in deciding the best therapy that meets their personalized needs. Therefore, providing drug information becomes one of the main elements in PCC, in which pharmacists, as drug experts, are expected to provide this service (Ghaibi et al., Reference Ghaibi, Ipema and Gabay2015). Delivering drug information to patients is essential in ensuring the safety, effectiveness, and appropriate medicine use to achieve the expected clinical outcomes (Alfian et al., Reference Alfian, van Boven, Abdulah, Sukandar, Denig and Hak2021; Mino-León et al., Reference Mino-León, Reyes-Morales and Flores-Hernández2015).
However, in some developing countries, pharmacists still spend most of their time in their traditional role of drug compounding and dispensing instead of doing cognitive services such as providing drug information (Bhagavathula et al., Reference Bhagavathula, Sarkar and Patel2014; Fathelrahman et al., Reference Fathelrahman, Ibrahim and Wertheimer2016). Several barriers have been reported to hinder the implementation of the pharmaceutical care model in these developing countries, from human resources-related problems to unsupported healthcare systems, including remuneration system (Puspitasari et al., Reference Puspitasari, Aslani and Krass2015; Scahill & others 2014).
The provision of drug information is an essential and standard pharmacy service that is professionally and legally expected to be provided by community pharmacists in Indonesia (Andayani & Satibi Reference Andayani and Satibi2016; Faller Reference Faller2022). However, Indonesia is still among those countries where its community pharmacists struggle to adapt to their new role as clinical healthcare providers (Herman & Handayani Reference Herman and Handayani2015; Hermansyah et al., Reference Hermansyah, Wulandari, Kristina and Meilianti2020).
Lack of remuneration is one of the commonly cited problems to hamper the implementation of pharmaceutical care services in Indonesia (Hermansyah et al., Reference Hermansyah, Pitaloka, Sainsbury and Krass2018a). Consequently, the pharmaceutical care service cannot be optimally provided, leading to an unrecognized role among health care providers and the community.
A previous study indicated that the current remuneration system in Indonesia has not adequately supported the provision of these cognitive clinical activities (Hermansyah et al., Reference Hermansyah, Sukorini and Rahem2021). The same study reported that although more than 80% of the community pharmacists perceived that they should have received a compensation for their services, only less than 50% received incentives for delivering patient care services such as medication review and drug information services (Hermansyah et al., Reference Hermansyah, Sukorini and Rahem2021).
The limited study has analyzed remuneration issues in drug information services provided by community pharmacists. Therefore, we aimed to identify the proportion and characteristics of Indonesian community pharmacists compensated for providing drug information services and to investigate which characteristics independently influence this practice. Identifying these determinants is expected to help the decision-makers develop a proper intervention to accelerate the optimal pharmaceutical care service in community settings.
Methods
Study design and setting
A multi-centre cross-sectional study was conducted from July to October 2021 to assess the characteristics of Indonesian community pharmacists (Apoteker Komunitas in Indonesia) compensated economically for providing drug information services. A self-developed, valid, and anonymous questionnaire was distributed among community pharmacists in four different regions representing the western (Medan city), central (Bandung city and regency), and eastern parts (Makassar city) of Indonesia. All participants filled out an informed consent before participating in this study. Ethical approval was obtained from ’the ethics committee of Universitas Sumatera Utara No. 599/KEP/USU/2021. The research was conducted in accordance with the Declaration of Helsinki.
Instrument and variables
The data collection instrument was part of a valid and reliable questionnaire developed to study the ‘knowledge, attitude, and practice of Indonesian community pharmacists in tuberculosis patient detection’ (Pradipta et al., Reference Pradipta, Khairunnisa, Bahar, Kausar, Fitriana, Ruslami, Aarnoutse and Abdulah2022). The questionnaire items were carefully developed based on a thorough literature study and were reviewed by professionals, including a community pharmacist and a pharmacy technician. To improve its content, the questionnaire was pre-tested with a sample of 32 individuals who were typical of the target community. Please see our prior article for a thorough overview of the whole validation procedure (Kausar et al. Reference Kausar, Fitriana, Khairunnisa, Faruque, Bahar, Alfian and Pradipta2023). The questionnaire comprises two types of questions: multiple choice and short answer questions. The latter includes inquiries regarding age, years of working experience, weekly working hours, and staff count. These variables underwent a grouping process based on theoretical considerations and their distribution patterns, aiming to enhance comparability among different segments within the dataset. We defined sociodemographic and pharmacy characteristics as the exposure variables, while remunerated drug information provision practice was defined as the outcome variable in this study.
Participants
This study used purposive sampling, which included only community pharmacists working in the pharmacy (Apotek in Indonesia) with at least 6 months of experience. The 6 months were used to ascertain that the community pharmacist regularly provided drug information services during their daily practice. Pharmacists working in the community health centre, called Puskesmas in Indonesia, were excluded. Puskesmas is the primary health care centre and is managed by the local government. The pharmacists working in Puskesmas are civil servants and their payments are regulated by the government. Therefore, they are not eligible for this study. Considering the COVID-19 pandemic, the researchers distributed the questionnaire online (via social media such as WhatsApp, Facebook, and Telegram) and offline (direct visits to the community pharmacies) with the help of the local pharmaceutical professional organizations in each district.
Sample size
According to the formula proposed by Green (Reference Green1991) (n > 50 + 8m, where ‘m’ is the number of potential determinants), the sample size required for this study (nine variables) should be more than 122 patients (Green, Reference Green1991).
Data analysis
Descriptive statistics were used to summarize pharmacists’ and pharmacies’ essential characteristics. Categorical data were displayed in the form of numbers and percentages. Meanwhile, normally distributed continuous data were presented as a mean and standard deviation. Skewed distributed variables were presented as median and interquartile range (IQR). Bivariate logistic regression was applied to assess the relationship between the independent (characteristics of pharmacists and their pharmacies) and dependent (remunerated drug information services) variables. A p-value <0.25 was used as a threshold to include potential variables in the multivariate analysis. Adjusted odds ratio (OR) and 95% confidence interval (CI) were obtained for each determinant using multivariate logistic regression analysis. A p-value of 0.05 indicated a statistically significant association between the determinants and outcome.
Results
We collected information from 639 community pharmacists, comprising pharmacists from Medan City (21.9%), Bandung City (20.8%), Bandung Regency (26%), and Makassar City (31.3%). Most of the participants were female (78.6%) with a median age of 31 years old (IQR: 9). Some parts of the respondents held master’s or Ph.D. degrees (13.8%), and most of them (70.6%) had five years or less working experience. We identified that 35.8% of the participants had a 20-hour or less duration of work in a week, and most of the pharmacists (87.2%) only handled one pharmacy. Most of the pharmacies (77.8%) were independent pharmacies, and 43% of the pharmacies were embedded with medical doctor’s practice. About 39% of the pharmacies had three to four staff, and around 37% had five or more staff. Characteristics of the subjects are presented in Table 1.
Characteristics of pharmacists and pharmacies (n = 639)
We identified that only 75 participants (12%) received compensations for drug information services to the patients. Most of them were female (69.3%) and were young age (60% were in the age category of 20–30). Our data showed that 78.7% had equal to or less than five years of working experience, and most subjects worked more than 40 hours per week. In terms of pharmacy characteristics, we identified that 82.7% were responsible for only one pharmacy, and about 59% worked in an independent pharmacy. In total, 56% of these community pharmacists worked with a physician in their pharmacies; lastly, more than 80% worked with more than two personnel (Table 2).
Potential determinants of incentivized drug information services
The bivariate analyses indicated that sex, age, working week, number of workplaces, type of pharmacy, and the presence of physician practice were potential determinants of compensated drug information services (p < 0.25) (Table 2). Furthermore, multivariate logistic regression revealed that male (OR: 2.04 [95% CI: 1.16–3.58]), age group of 20–30 years old (OR: 3.25 [95% CI: 1.10–9.58]), more than a 40-hour working week (OR: 2.30 [95% CI: 1.16–4.58]), chain pharmacy (OR: 2.08 [95% CI: 1.18–3.67]), and the presence of physician practice (OR: 1.72 [95% CI: 1.04–2.85]) were significantly associated with the incentivized drug information practice (Table 3).
Independent determinants of incentivized drug information services
Discussion
In Indonesia, the provision of drug information has been reported to increase patients’ compliance with their medication, decrease drug-related problems, and improve clinical outcomes (Athiyah et al., Reference Athiyah, Rahem, Setiawan and Hermansyah2021; Darmawan et al., Reference Darmawan, Ahmad, Perwitasari and Kusumawardani2020; Sauriasari & Sakti Reference Sauriasari and Sakti2018). According to ‘Government Regulation Number 51 of 2009 on Pharmacy Practice’, one of the mandatory services that a community pharmacist must provide to customers is drug information (Andayani & Satibi Reference Andayani and Satibi2016). However, an economic barrier has hampered the implementation of this service daily. The current remuneration systems in Indonesia for community pharmacist is predominantly in the form of fixed monthly payments and mainly without any extra incentives for cognitive clinical care (Hermansyah et al., Reference Hermansyah, Pitaloka, Sainsbury and Krass2018a, 2021). In this present study, we found that only 12% of the participants were compensated with an additional payment for providing drug information services. These results indicated that despite the vital role of the pharmacist in providing drug information services, compensation for their work has been minimal to support such a role.
Previous research reported that community pharmacists’ drug information services in Indonesia is generally low (Herman & Susyanty Reference Herman and Susyanty2012; Listyorini et al., Reference Listyorini, Saibi and Nurmeilis2021). Furthermore, the pharmacist generally provides this drug information services as a free service (Hermansyah et al., Reference Hermansyah, Sukorini and Rahem2021). If they receive economic compensation, the commission often comes from the patients, with the pharmacist billed for the service to be included in the dispensing cost. However, this system might not be feasible in the long term to support the viability of pharmacist services since it is difficult to demonstrate to patients the benefits and values underlying the payment (Hermansyah et al., Reference Hermansyah, Sukorini and Rahem2021).
We found that male pharmacists were more often to receive financial benefits when providing drug information services than female pharmacists. This disparity might be related to differences in communication skills between the sexes, though the data are conflicting. A study assessing the communication skills of pharmacy students indicated that female students were more hesitant and less confident than their male counterparts (Ubaka & Ukwe Reference Ubaka and Ukwe2019). Similar findings were observed among medical students, where female students appeared less confident and more doubtful, often underestimating their competence as health practitioners compared to male students (Blanch et al., Reference Blanch, Hall, Roter and Frankel2008). Other studies found contradictory results. Female pharmacy students have shown a better attitude towards learning communication skills than male students (Svensberg et al., Reference Svensberg, Brandlistuen, Björnsdottir and Sporrong2018). Additionally, a literature review indicated that female doctors were more involved in patient-centred communication than male doctors (Roter and Hall Reference Roter and Hall2004). However, a study conducted in Australia found no correlation between gender and a patient-centred communication style, although this study had a small sample size of 20 pharmacists (Chong et al., Reference Chong, Aslani and Chen2014). The mixed results might be influenced by factors such as culture, study type, and sample size, underscoring the need for further research on this issue. Moreover, it is possible that female pharmacists provide drug information services but they do not charge their services. Our questionnaire simplified the inquiry to identify who had remunerated drug information services and who did not, thus we lack data on the proportion of pharmacists who share drug information, categorized by gender, without charging for the service.
The next characteristic associated with compensating drug information services is age. The younger the community pharmacists, the higher chance they get compensation for providing drug information services. A previous study reported that younger pharmacists provide more detailed information about drugs to consumers than older pharmacists (Svarstad et al., Reference Svarstad, Bultman and Mount2004). It might be related to access to drug information resources. Younger pharmacists were reported to mostly use electronic drug information knowledgebase (Carvajal et al., Reference Carvajal, Clauson, Gershman and Polen2013). Consequently, they can provide faster and more complete information than older pharmacists using the printed version of drug information resources (Carvajal et al., Reference Carvajal, Clauson, Gershman and Polen2013). Patients were reported to be willing to pay for the counselling session if they found their pharmacists were helpful and provided complete information (AlShayban et al., Reference AlShayban, Naqvi, Islam, Almaskeen, Almulla, Alali, AlQaroos, Raafat, Iqbal and Haseeb2020).
In this study, we found that more than 70% of the participants had less than five years of working experience. Surprisingly, we found that this particular variable did not exhibit a significant independent association with the provision of incentivized drug information services. This observation prompts further examination into potential underlying factors contributing to this lack of correlation. One possible explanation is that recent pharmacy graduates might have received updated training programs emphasizing the importance of providing drug information services. In this scenario, formal education and training could compensate for the lack of practical experience.
We also found that the longer the duration of working at the pharmacy in a week, the higher the chance of pharmacists receiving additional incentives for their drug information services. Pharmacists with a long duration of work in a week can have flexible time to provide individualized drug counselling to patients. Therefore, patients might feel the importance of the service. It was reported that if patients could get counselling services without difficulties and with proper time duration, they would be willing to pay for the service (AlShayban et al., Reference AlShayban, Naqvi, Islam, Almaskeen, Almulla, Alali, AlQaroos, Raafat, Iqbal and Haseeb2020). Another finding from this study was that pharmacists working at the chain pharmacy were more likely to get financial benefits in providing drug information services than those working in the independent pharmacy. Herman & Handayani (Reference Herman and Handayani2015) reported that pharmacists working in an independent pharmacy are less prepared to provide pharmaceutical care services than those working in a chain pharmacy (Herman & Handayani Reference Herman and Handayani2015). Indonesian chain pharmacists mostly operate under centralized management systems with relatively big capital (Athiyah et al., Reference Athiyah, Setiawan, Nugraheni, Zairina, Utami and Hermansyah2019). Therefore, they can implement standard operating procedures for delivering high-quality care to their customers (Athiyah et al., Reference Athiyah, Setiawan, Nugraheni, Zairina, Utami and Hermansyah2019). They also have a good training system to provide pharmacists with clinical skills in pharmaceutical care services, including drug information. Consequently, they provide a reasonable compensation for each cognitive service provided by their pharmacists (Hermansyah et al., Reference Hermansyah, Sainsbury and Krass2018b).
Lastly, we also found that pharmacists who work with physicians more often receive remuneration for their drug information services than those who work independently. It might be related to peer pressure created by the collaborative work between the two health professionals. Ebeling et al. (Reference Ebeling, Fellner and Wahlig2012) reported that effort provision increases when peer pressure is present (Ebeling et al. Reference Ebeling, Fellner and Wahlig2012). Therefore, the pharmacist might provide good cognitive service, including drug information provision, when working with physicians. Ultimately, patients may voluntarily choose to pay for such high-quality services.
Some limitations are worth mentioning. First, this study might not represent the overall condition of Indonesian community pharmacists since this study used a purposive sampling method. To minimize the limitation, we tried to sample the community pharmacists from three big cities in the western, central, and eastern parts of Indonesia to get a comprehensive picture of the practice. We also sampled pharmacists from a suburban area to increase the coverage of our study. Second, we only found a small proportion of pharmacists having extra payment for delivering drug information. However, it needs to be interpreted cautiously. In Indonesia, there is a low rate of pharmacists’ attendance in the community pharmacy, with less than 25% of them working full-time hours, leaving pharmacy-related services being delivered by the pharmacy technicians (Dominica et al., Reference Dominica, Putra and Yulihasri2016; Hermansyah et al., Reference Hermansyah, Sainsbury and Krass2018b; Kartinah et al., Reference Kartinah, Annisa, Yuniarti, Setyanto, Mangkurat and Yani2015). Therefore, it might be that some participants in this study did not get extra incentives simply because they did not deliver drug information services since they were mostly absent in the pharmacy. This study found that about 36% of the participants worked 20 hours or less in a week. Third, we found that male pharmacists were more likely than their female counterparts to receive financial incentives for providing drug information services. However, it is important to acknowledge the sex disparity among our participants, with female pharmacists comprising 78.6% of the sample. Nevertheless, it is pertinent to highlight that the pharmacy profession in Indonesia is predominantly female. According to the 2019 national analysis of Indonesia’s pharmacy workforce, it was documented that 78% of pharmacists in Indonesia were women (Meilianti et al., Reference Meilianti, Smith, Kristianto, Himawan, Ernawati, Naya and Bates2022). This sex distribution also aligns with findings from previous studies conducted in Indonesia, which have consistently reported a comparable proportion of female pharmacists (Kusuma et al., Reference Kusuma, Pratiwi, Umami, Kurniasih, Pitaloka, Suherman and Juhász2023; Rendrayani et al., Reference Rendrayani, Alfian and Wahyudin2023; Wathoni et al., Reference Wathoni, Lestari, Iftinan, Rahayu, Nurlatifah, Khairinisa and Elamin2023). Fourth, we distributed the questionnaire online due to the COVID-19 pandemic. Consequently, we may not have reached a representative number of older pharmacists with limited smartphone usage capabilities. We only encountered approximately 15% of pharmacists aged over 40 years old. Therefore, our sample might be potentially biased towards younger pharmacists. Another possible reason is that most of older Indonesian pharmacists (>36 years old) work in industry and government institutions, while younger pharmacists are predominantly employed in patient-facing roles such as hospitals, community pharmacies, and clinics (Meilianti et al., Reference Meilianti, Smith, Kristianto, Himawan, Ernawati, Naya and Bates2022). Fifth, there was a possibility that the COVID-19 pandemic might influence the ability of community pharmacists with only 6 months of experience in delivering drug information services. However, in our sample, only 9% of participants had approximately 6 months of experience working as community pharmacists. Among these, only eight pharmacists reported providing remunerated drug information services. Due to the small sample size for this subset, we cannot draw definitive conclusions from our current data. Future studies with larger sample sizes and a focus on the pandemic’s impact on pharmacists’ roles and capacities, especially for those early in their careers, would be beneficial to provide more comprehensive insights. Sixth, the causality between the exposure and outcome should be interpreted cautiously since this cross-sectional study did not consider the time difference between exposure and outcome.
This study has several strengths. This is the first study exploring the rate of incentivized drug information services among community pharmacists in Indonesia. Additionally, this study is also the first to identify factors that independently influence this practice. Indonesian consumers in the community pharmacy expect their pharmacists to provide more time and detailed information during drug consultation to support self-medication (Alfian et al., Reference Alfian, Sinuraya, Kautsar and Abdulah2016). However, the general provision of cognitive services by community pharmacists has been hampered by the absence of payment for the service (Hermansyah et al., Reference Hermansyah, Sukorini and Rahem2021). The economic compensation of pharmaceutical care activities has been identified as one factor facilitating changes in pharmacy practice (Roberts et al., Reference Roberts, Benrimoj, Chen, Williams and Aslani2008). Therefore, the results of this study can be beneficial for stakeholders such as the government, insurance companies, pharmacist’s associations, and pharmacy owners as foundational data to deliver personalized interventions to enhance the delivery of optimal pharmaceutical care services in community settings.
Several future studies could further enhance our understanding of drug information services among community pharmacists in Indonesia. First, qualitative studies could explore the perceived barriers and facilitators for pharmacists who are not compensated for providing these services. Second, a cross-sectional study could be designed to investigate the knowledge, skills, perceptions, and attitudes of community pharmacists regarding drug information services. Lastly, cost-effectiveness studies could be developed to integrate these services into the health insurance system, ensuring a sustainable pharmacist remuneration system and high-quality drug information services. Coverage of health insurance in the drug information services may be beneficial to improve drug information services in Indonesia.
Conclusion
In conclusion, this study found that only a few Indonesian community pharmacists receive compensation when providing drug information services. Several characteristics independently associated with this compensated drug information services are sex (male), age (younger pharmacists), type of pharmacy (chain pharmacy), and the presence of a medical doctor in the pharmacy.
Acknowledgements
We would like to thank the Indonesian Pharmacist Association (IAI = Ikatan Apoteker Indonesia) for their support during the data collection.
Author contributions
Muh. Akbar Bahar: Conception and design of the work, data acquisition, data analysis and interpretation, preparing the first draft, substantial revised the manuscript, approval for the final manuscript; Mersa N. Kausar: Conception and design of the work, data acquisition, substantial revised the manuscript, approval for the final manuscript; Khairunnisa Khairunnisa: Conception and design of the work, data acquisition, data analysis and interpretation, substantial revised the manuscript, approval for the final manuscript; Ivan S. Pradipta: Conception and design of the work, data acquisition, data analysis and interpretation, substantial revised the manuscript, approval for the final manuscript.
Funding statement
This work was supported by the Program Penelitian Kolaborasi Indonesia (PPKI) 2021 scheme of the Ministry of Education, Culture, Research, and Technology, Republic of Indonesia.
Competing interests
None.
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