A cross sectional study of a quasi-random sample of 327 pharmacies was conducted in Riyadh, the capital of Saudi Arabia with about 5 million habitants, in November 2010. The sample was intended to be representative of all Riyadh pharmacies. The sample was stratified by the five regions of Riyadh (Eastern, Western, Northern, Southern, Central) regardless of the pharmacy's size, deprivation level of the area. A convenience sample of streets was chosen from each region and a complete enumeration of all pharmacies in each street was considered. Each pharmacy was visited once by two investigators (total of 6 male physicians and 2 male medical students participated) who simulated having a brother/sister with a predetermined clinical scenario according to simulated-client method pharmacy surveys [19 (link),20 ]. The scenarios included sore throat, acute bronchitis, otitis media, acute sinusitis, diarrhea, and urinary tract infection in a pregnant (childbearing age) women. The investigators concealed their identity and the study objective of their visits from the approached pharmacists who were identified by their licenses and pictures on the front wall of the pharmacy. The clinical scenarios were presented as follow; one investigator talked to the pharmacist while the other observed the discussion and memorized the responses. Immediately after leaving the pharmacy, both investigators completed a standardized data form that included information about the location of the pharmacy, antibiotics dispensing practice, pharmacists' inquiries about associated symptoms (e.g. fever/shortness of breath/abdominal pain/loin pain), allergy history, pregnancy status in case of UTI; type of antibiotic, if dispensed; and information about drug interactions if this was provided by the pharmacist.
Two sessions of standardization took place in the presence of all actors. Each group rehearsed simulating all the clinical scenarios to the senior investigator using the same complaints (terminology and statements). Rehearsal was repeated to ensure reliability of the simulated scenario. The actors used lay language and refrained from using any jargon.
Only the following clinical information was presented to the pharmacist. Any additional information was only provided if the pharmacist inquired about it. The sore throat scenario: a healthy young male relative was described as having difficulties in swallowing with slight fever of 24 hours duration. Acute bronchitis scenario: an elderly man relative was described as having sore throat, cough with sputum production. Additional information provided upon request was the patient had multiple comorbid conditions and was using warfarin.
Acute sinusitis scenario: a young male relative was described as having running nose, facial pain, and headache. Otitis media scenario: a 5-year-old relative child was described as having ear pain and discharge. Urinary tract infection scenario: a childbearing female relative was described as having dysuria and urinary frequency. Diarrhea scenario: a young male relative was described with loose bowel motion for one day.
Three levels of demand were used sequentially until an antibiotic was dispensed or denied [4 (link)]: 1) Can I have something to relieve my symptoms?: 2) Can I have something stronger? 3) I would like to have an antibiotic.
Data are presented as percentage of the pharmacists' responses toward the simulated clinical scenarios.
The study was approved by the Institutional Review Board at King Fahd Medical City. Deception and incomplete disclosure to study subjects (pharmacists) were considered ethically acceptable because this was a minimal risk study and it could not have been performed with complete disclosure of investigator entity. Data were kept anonymous.
Two sessions of standardization took place in the presence of all actors. Each group rehearsed simulating all the clinical scenarios to the senior investigator using the same complaints (terminology and statements). Rehearsal was repeated to ensure reliability of the simulated scenario. The actors used lay language and refrained from using any jargon.
Only the following clinical information was presented to the pharmacist. Any additional information was only provided if the pharmacist inquired about it. The sore throat scenario: a healthy young male relative was described as having difficulties in swallowing with slight fever of 24 hours duration. Acute bronchitis scenario: an elderly man relative was described as having sore throat, cough with sputum production. Additional information provided upon request was the patient had multiple comorbid conditions and was using warfarin.
Acute sinusitis scenario: a young male relative was described as having running nose, facial pain, and headache. Otitis media scenario: a 5-year-old relative child was described as having ear pain and discharge. Urinary tract infection scenario: a childbearing female relative was described as having dysuria and urinary frequency. Diarrhea scenario: a young male relative was described with loose bowel motion for one day.
Three levels of demand were used sequentially until an antibiotic was dispensed or denied [4 (link)]: 1) Can I have something to relieve my symptoms?: 2) Can I have something stronger? 3) I would like to have an antibiotic.
Data are presented as percentage of the pharmacists' responses toward the simulated clinical scenarios.
The study was approved by the Institutional Review Board at King Fahd Medical City. Deception and incomplete disclosure to study subjects (pharmacists) were considered ethically acceptable because this was a minimal risk study and it could not have been performed with complete disclosure of investigator entity. Data were kept anonymous.
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