INTRODUCTION

Cough, a respiratory reflex to clear the upper airways, is a common condition that affects people worldwide.¹-³ Based on the duration, cough can be categorised as acute, sub-acute and chronic.⁴ Acute cough is defined as having a duration of less than three weeks and is commonly caused by upper respiratory tract infections and acute bronchitis.⁴,⁵ Sub-acute cough usually lasts between three to eight weeks and is most commonly due to post infectious cough or exacerbation of underlying disease, such as upper airways cough syndrome (UACS), asthma and other pulmonary diseases.⁴ Meanwhile, chronic cough is defined as cough lasting longer than eight weeks and can be attributed to bacterial infection such as Mycobacterium tuberculosis infections, environmental exposure such as tobacco smoke and air pollutants, adverse drug reactions to certain medications such as Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs), and underlying medical conditions, including asthma and other pulmonary diseases, gastro-oesophageal reflux disease, upper airway cough syndrome, and cardiac origins.⁴,⁶

Many patients with cough often self-medicate to alleviate their symptoms, with community pharmacies as well-known sources for medicine supply that are accessible to most patients.⁷-¹⁰ Self-medication in this paper refers to the use of medicines by people on their own initiative, without prescription by a medical doctor.¹¹,¹² Surveys have shown that cough medicines are one of the highest selling over the counter (OTC) product categories in community pharmacies in many countries.¹³,¹⁴ This situation emphasises the importance of the role of community pharmacists.⁹ They are health care professionals who are well positioned in the community to provide professional advice for patients with cough.

In general, the provision of pharmaceutical consultation in community pharmacies include two important steps, which are: patient assessment and the provision of advice.¹⁵-¹⁷ During patient assessment, pharmacists should gather relevant information, such as information on patient identity, symptoms (such as nature and duration of the symptoms, accompanying symptoms, etc.), action that has been taken to alleviate the symptoms, medical conditions, current medications used, and allergies.¹⁸ Then, pharmacists need to use their knowledge to analyse the information gathered to decide what best advice that can be provided to patients. This could be medical referral, recommended products along with the product information, provided non-pharmacological advice, or other advice that are relevant to patient symptoms.¹⁷,¹⁹

Internationally, the provision of pharmaceutical consultations for patients with cough in community pharmacies is suboptimal, including Indonesia.²⁰-²² There are deficiencies in many aspects of pharmaceutical counselling for cough, including lack of history taking and inappropriate advice provision.²⁰-²² In developing countries, studies have identified several factors contributing to these deficiencies.²³-²⁵ In Indonesia, previous research has identified three main factors influencing pharmaceutical consultation performance: pharmacy staff-patient interaction, the organisational context of the pharmacy, and the external pharmacy environment (Figure 1).²³ These factors are complex and inter-related; for example the lack of knowledge and competency of pharmacy staff to provide quality consultation are influenced by deficiencies in pharmacy education with respect to management and pharmaceutical consultation for self-medication.²³ Indonesian pharmacists also perceive that there is a problem with relevancy between what is taught in their pharmacy education and the knowledge required for practice, and therefore they felt that their knowledge is insufficient to provide optimal self-medication services.²³,²⁶ Similar findings have been reported in the literature from other developing countries, such as Brazil and Vietnam.²⁴,²⁷

Figure 1.  Factors related to the provision of self-medication consultation in community pharmacies in eastern Indonesia from Brata et al.23  

In Indonesia, to become a pharmacist, students are required to complete a four-year Bachelor of Pharmacy (BPharm) degree, followed by a one-year pre-registration training programme (Apothecary programme). Pharmacy curricula are regulated by the Ministry of Education and are typically based on the curriculum developed by the Indonesian Association of Higher Education of Pharmacy (Assosiasi Perguruan Tinggi Farmasi Indonesia, or APTFI).²⁸ While each pharmacy school has the freedom to design their own curriculum, APTFI suggests that the courses or units of study within the BPharm curriculum are designed to be predominantly theory based, with the addition of laboratory practice or simulation, whereas the apothecary program focuses on applied pharmacy practice.²⁸

The quality of Indonesian pharmacy education varies widely across institutions.²⁸ Therefore, from 2018 onwards, students in the apothecary programme are required to pass a national, computer-based test (CBT) examination before they can be registered as pharmacists.²⁹ In addition, students also need to take an objective structured clinical examination (OSCE) as a formative assessment.²⁹ The OSCE is intended to become a summative barrier examination; however, the transition is currently postponed as a result of the COVID pandemic.

Studies looking at the situation of Indonesian pharmacy education are limited. A study conducted at the University of Gadjah Mada, has evaluated their 422 apothecary students' performance using an OSCE.³⁰ The authors reported that approximately 85% of the 422 students were able to pass the minor ailment station.³⁰ However, the study aim was to measure students' experience and perception of the OSCE and not to measure the competence of students in responding to patients with minor illness.

This study is conducted to measure the competency of Indonesian pharmacy students in providing self-medication consultations for patients with a cough. In this study, the competency of pharmacy students in providing self-medication consultation is defined as a combination of students asking/gathering essential information such as information related to patient identity, symptoms (nature, duration, action taken to alleviate symptoms, associated symptoms, etc.), medical conditions, medications used, and allergies during patient assessment and students subsequently providing appropriate advice to the patient. Therefore, the specific objectives are to: (1) describe the type and amount of information gathered; (2) describe the type and amount of advice provided, (3) measure the overall proportion of students providing appropriate advice, and (4) identify factors associated with the provision of appropriate advice.

METHODS

RESULTS

Based on the faculty registration data, the population of third year students who had completed COMM-PHARM 1 in 2018 was 304. Of these, 183 agreed to participate in this study, resulting in a response rate of 60.2%. Details related to participants' characteristics are presented in Table 1.

All students (100%) asked questions before providing advice. The average number of questions asked for product and symptom-based requests for cough due to worsening asthma scenarios were 5 and 6 with the standard deviation of 1.5 and 1.4 respectively. Information related to patient identity, and the nature and duration of cough were the most common types of information gathered in both scenarios (≥ 80% of the participating students). In contrast, accompanying symptoms, medications, and allergies were the least frequently gathered types of information; they were gathered in less than 60% of the participating students. Details related to the types and amount of information gathered can be seen in Figure 2 and Table 2.

Figure 2.  The number of questions asked by students 

The types and amount of advice provided by participants are outlined in Table 3. In the product-based request scenario, medical referral was advised by 99 students (54% of the 183 participants). Of these 99 students, 21 and 26 students also recommended cough medicines and non-pharmacological/follow-up advice, respectively. In the symptom-based request scenario, 102 students (56% of the 183 participants) recommended direct medical referral. Fifteen and 23 of these 102 students also recommended cough medicines and non-pharmacological/follow up advice, respectively.

Appropriate advice, which was defined as advice that contained direct medical referral, was provided in 99 (54%), and 102 (56%) of 183 participating students in the product-based requests and symptom-based requests, respectively.

From the univariate analysis, significant variables for providing appropriate advice comprised of asking about action taken and duration of cough in the product-based request scenario (Table 4). Meanwhile, significant variables for providing appropriate advice in the symptom-based request scenario consisted of: GPA, number of questions asked, asking about duration of cough, action taken, and other medical conditions (Table 5).

After inputting these significant variables into the multivariate analysis, we determined that the nature of the information gathering by students is associated with the provision of appropriate advice. In the product-based request scenario, students who asked about the duration of cough were more likely to provide appropriate advice than students who did not ask this question (OR 4.8, 95%CI 1.68-13.57). Meanwhile, in the symptom-based request scenario, students who asked about other medical conditions were more likely to provide appropriate advice than students who did not (OR 2.1, 95%CI 1.05-4.19). Demographic characteristics of participating students (i.e. age, gender, previous education, have working/training experience in community pharmacies, GPA, mark for COMM PHARM 1 course) were not associated with the provision of appropriate advice.

DISCUSSION

This is the first study in Indonesia that examined the ability of pharmacy students in gathering information and providing appropriate advice for a simulated patient with chronic cough. All students participated in this study were novice learners, which describes that they just learnt about self-medication consultation during their undergraduate pharmacy curriculum.

This study indicates that the information-gathering process among students in this school, needs to be improved. The lecture notes and laboratory practice module of COMM-PHARM1 class indicated that topics related to information-gathering have been provided. However, this study showed that students did not gather appropriate information when encountering our simulated patients. Important information such as medical conditions, medications used, and accompanying symptoms that are needed to enable students to identify the root of the problems were asked in 40% to 75% of the encounters. This contrasts with the results from an Australian study, in which most of their novice students perform well during the information-gathering process.³² While it is argued that complete information is not always necessary to be gathered in order to provide appropriate advice, it is safer for novice students to gather complete information for assessing patients correctly and hence appropriate advice.³³

In this case, advice was considered appropriate when students recommended direct medical referral. However, in both scenarios, only about 55% of them were able to do so. This figure is about similar to findings from an Australian study, which stated that appropriate advice was provided in 52% of their novice students in the case of childhood fever.³² Other than incomplete information gathered as explained above, these participating students may also have limited knowledge of disease and therapy and inability to analyse the information gathered; and hence inappropriate advice.¹⁷,³² The syllabus in this pharmacy school shows that during semester 1 to 4, students only learn about basic sciences (human anatomy & physiology, pathophysiology, and pharmacology). Topics related to diseases and drug therapy, drug related problems, and patient counselling are provided in semester 5 and above. It could be that these students may not know that the case is cough due to worsening of asthma since they haven't learnt much about asthma, and therefore they did not know that direct medical referral was needed.

A potential factor to sub-optimal student performance is the teacher-student ratio. A review of the COMM PHARM1 classroom student list and tutor schedule identified that the teacher-student ratio was 1:20 during laboratory practices and 1:80 during lectures. Such ratios may be insufficient for students to receive adequate supervised practice and feedback during simulated role-plays. As the effectiveness of simulation learning relies on practice and feedback for each learner, measures should be undertaken to optimised the teacher-student ratio.³⁴ Furthermore, with the current curriculum design, students are expected to be ready for supervised provision of minor ailment care to the public in the apothecary programme after completing the COMM PHARM1 course. This indicates that this one semester course carries a lot of weight in the curriculum. Redesigning the BPharm curriculum, such as by adopting the spiral curriculum in which key concepts are revisited and reinforced throughout the curriculum with increasing levels of complexity, could be more appropriate than a stand-alone course.³⁵,³⁶ Further qualitative research looking at the design of the current curriculum, students and teachers' perceptions, the teaching-learning process including the mode of delivery is required for designing interventions for the optimisation of student performance.

Simulated patient technique has been used widely in pharmacy education, including for training in consultation for self-medication requests.³⁴ Using simulated patient technique as an educational tool may improve training since it can reinforce knowledge, integrate between knowledge and practice, and improve professional skills and attitudes (e.g., communication skills, decision making, emphaty, teamwork, social and cultural competency, and confidence).³⁴,³⁷ In addition as an educational tool, simulated patient technique can also be an assessment tool for evaluating the effectiveness of the training provided. Indeed, simulated patients in the form of OSCE is planned to be a compulsory element of the Indonesian national pharmacist registration examination.³⁰ Evidence suggests that examinations using simulated patient technique challenges students to think critically and indicates student performance in real clinical encounters.³⁷ Indonesian pharmacy schools, therefore, should use this technique in the teaching and evaluation of pharmacy students.

The multivariate analysis identified that asking a particular type of question (i.e., duration of cough and medical conditions) are factors positively associated with the provision of appropriate advice (Tables 4 and 5). This finding is in keeping with a previous Australian study in pharmacy staff responding to a very similar scenario.²¹ It could be that by asking such questions, students were able to discern that the patient had a contraindication for self-medication and recommend medical referral. It is important to train students to be able to ask key questions according to the clinical situation to improve the appropriateness of advice for minor ailments. Further, as there is a current lack of formal guidance on information-gathering when responding to patients with self-medication requests in Indonesia, policy makers such as the Indonesian Pharmacists Association (IAI), the Ministry of Health, and the APTFI may need to develop and promote a national protocol to improve appropriate information-gathering and to optimise the provision of care.

Research evaluating the competence of pharmacy students providing self-medication consultation in Indonesia is limited. Kristina et.al reported that 85% of 422 apothecary students from the University of Gadjah Mada, passed the the minor ailment station in their OSCE assessment.³⁰ However, detailed aspects assessed in this minor illness station were not provided in the article and the population used were different with this study's population (apothecary students vs third year students in this study); thus making direct comparison difficult. It could be hypothesized that final year/apothecary programme students may have superior outcomes compared to students at an earlier stage in their education, as found in an Australian study.³²

Despite the students in this study only being halfway through their pharmacist training, their performance was superior to Indonesian pharmacy staff, as reported in previous research.²⁰,³⁸ When responding to a simulated patient asking for a particular product for chronic cough, all of these students conducted information gathering and 54% of them were able to provide appropriate advice. In contrast, only 1% of pharmacy staff performed information gathering and none provided appropriate advice in the previous articles.²⁰,³⁸ Although the cases of chronic cough used between this study and the previous studies were not exactly the same, the essence and complexity of the cases are similar; and therefore we think they can be compared.

Better performance of these students compared to pharmacy staff as reported in the previous article may be due to several reasons. As stated in the theory of the Efficiency-Thoroughness Trade-Off (the ETTO principle), there is a balance or tradeoff between being efficient and being thorough.³⁹ If demands to productivity are high, thoroughness is usually reduced. On the other hand, if demands to safety are high, efficiency is reduced. Following this theory, it could be that pharmacy staff were being efficient due to demands of high productivity, whereas students were being thorough because they knew that they were being assessed and therefore they will try harder to show their best performance. Another possible reason of why Indonesian pharmacy staff performed more poorly than students might be that the person that typically handles patients with self-medication requests in pharmacies is a non-pharmacist, as has been reported in Indonesian and other developing countries' literature.⁴⁰-⁴² This being the case, measures should be taken to ensure that pharmacists are able to provide self-medication services when they are on duty. Further research on why students perform better than pharmacy staff is required.

CONCLUSIONS

The performance of novice students in responding appropriately to a simulated patient with a self-medication request for cough is sub-optimal. Appropriate information-gathering is a predictor of appropriate provision of advice. Measures to improve student performance, such as curriculum restructuring, optimising teacher-student ratio, and developing a protocol for appropriate information-gathering may be required. Further qualitative research to identify factors affecting student performance is required to develop strategies to improve student response to self-medication requests.