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INTRODUCTION
Community pharmacists have the main role in the health system to provide care to different kind of patients. Academic literature confirms the benefits of pharmaceutical care to the patients1,2,3,4,5. However, in spite of the evidence of positive outcomes, the implementation of PCare is still a hard task, specifically when all aspects related to the health system, patients, other health professionals and, the performance of pharmacists are not reviewed. Factors of development in few countries also have been described in the literature, and it can be recognized that the factors are not the same between different countries. Studies developed previously found some factors to the provision of PCare such as poor prescription6, the need for pharmaceutical care teaching7, discrepant attitudes of physician/ nurses8 between others. It is important to analyze what is the real situation of a healthcare system to create innovative strategies for PCare implementation9. The present work used a modeling to establish what is the effect size of each factor (instead of just describing what they are) because in this way those factors that have a greater influence can be prioritized in the implementation strategies that are formulated in the future.
It was used PLS due to some specific reasons10:
a. PLS is particularly suitable for data analysis during the early stage of theory development where the theoretical model and its measures are not well-formed.
b. The objective of PLS is an explanation of the relationships and prediction of the criterion variables of the model.
c. PLS is a more rigorous approach compared to correlation and regression analyses.
d. PLS is more appropriate for the exploratory nature of a study.
e. The PLS method is more robust since its does not require either a large sample or normally distributed data.
In Argentina, there is the Law of Pharmacies11, which is the normative document ruling to pharmaceutical activity and that was approved on 1987. More currently was realeased the Good Practice in Community Pharmacies12. developed for Argentinian regulatoty agency (Administración Nacional de Medicamentos, Alimentos y Tecnología Médica - ANMAT). The most important issues that influence the community pharmacy practice in Argentina is the Integral Program of Medical Assitance (Programa de Asistencia Médica Integral - PAMI in Spanish), created in 1971 and focused to provide medicines to veterans population.
Aim of the study
To describe the factors for the development of pharmaceutical care (PCare) in community pharmacies in Buenos Aires, Argentina, through the model of structural equations through partial least squares, using information from community pharmacists.
Current study question established was: which are the factors of development of PCare in community pharmacist in Buenos Aires, Argentina are? Also, it is proposed the following set of hypotheses:
Main hypothesis
The training of pharmacists in PCare, mediated by the skills of pharmacists in PCare for PCare practice, has a positive correlation on PCare practice.
Specific hypothesis
H1. The training of pharmacists in PCare has a positive correlation to the skills of pharmacists in PCare.
H2. The skills in PCare of pharmacists has a positive correlation to PCare practice.
H3. The sources in community pharmacies for PCare has a positive correlation to PCare practice.
The term “positive correlation” is used in statistic measurement to describe the direct relation between two variables (it means when the first variable increase, the second variable increase too and vice versa. It must not be confused with good impact in the clinical outcomes of the patients).
METHOD
Setting
Data in this cross-sectional study were derived from a pharmacist survey conducted in community pharmacies in Buenos Aires. It was a descriptive study because the study explains the characteristics of the sample; the study is correlational because it is established the relations between factors. The study was prospective because the information was not available in any database o report so current study obtained new information.
Sample selection
It was planned to collect the data of 300 pharmacists who work in community pharmacies to conduct face-to-face surveys with a questionnaire elaborated by the authors. The selection criteria were to evaluate the community pharmacies which the pharmacist was working during the visit to collect information. At the time of the study, the population of Buenos Aires was 2.89 million, and there were 1897 community pharmacies. Approximately 55% of pharmacists work in community pharmacies. The sample size was estimated for 95% of confident and 5% of error. Formula calculation mentioned 320 pharmacists but we obtained data from 350 community pharmacies for a 4.8% of error. The pharmacists surveyed self-completed the questionnaires in the presence of the interviewer.
Questionnaire development
For the current study, it was used adaptation of the questionnaire developed by Megralian et al.13. The instrument comprised two sections. The first section captured demographic information as sex, age, education level, year of experience and their position in the pharmacy. The second part included a 5-point Likert scale, where 1=strongly agree and 5=strongly disagree. It was tested 10 items, distributed in their independent variables: Training, skills and sources and one dependent variable: PCare practice.
Training
The clinical training towards pharmacotherapy follow-up.
The training towards communication.
The training towards social pharmacy.
Skills
The skills for the evaluation of pharmacotherapy.
The pharmacists' documentation skills.
The of management skills.
Sources
Money to pay for the service.
The space in the community pharmacies.
PCare practice
I usually give information about the use of medications.
I usually report the adverse reactions found.
For the scale validation, internal consistency was measured using Cronbach's alpha which values are considered adequate when a dimension has a factor loading greater than 0.707 as expressed by Carmines & Zeller10. At this stage, during the development of the questionnaire, the Cronbach's alpha values of each dimension were 0.781, 0.883, 0.774 and 0.865, so it did not need changes in items of questionnaire.
Research model
For the current study, it was designed a research model to be evaluated. Figure 1 shows the research model. The present model was used to analyze a multivariate relationship of factors because of this mod we can know the influence that the independent variable has, through the mediating variables, on the dependent variable.
Validation with PLS-SEM10
Using partial least squares structural equation modeling (PLS-SEM) was evaluated the validity of construct and discriminant and, internal consistency by the composite reliability. SmartPLS statistical package is used to calculate the factorial structure of the indicators, using partial least squares. PLS-SEM aims to predict the latent variables by estimating partial least squares (PLS) and principal component analysis (PCA). In a PLS model, the individual reliability of the indicators is assessed by examining the load between each indicator and dimension, accepting as reliable those above 0.40 loads for exploratory studies. For internal consistency reliability composite reliability should be 0.7 or higher. If it is an exploratory research, 0.6 or higher is acceptable.
Data collection
Between March and April 2018, 350 self- administered questionnaires were delivered to community pharmacists in Buenos Aires city. Questionnaires anonymous were delivered which included an informed consent for each participant. The pharmacists surveyed self-completed the questionnaires in the presence of the interviewer.
RESULTS
350 questionnaires were fulfilled. Regarding the pharmacists who answered the survey, 71.72% were women. The average age of the pharmacists was 42.77 years (SD: 11.95). Most of the participating pharmacists had on average more than 12.1 years (SD: 8.46) of experience as community pharmacists.
More than 50% of the participants chose the "strongly agree" and "agree" alternative for items that included:
a. Money to pay for the service.
b. The space in the community pharmacy.
c. The training in PCare.
d. The training towards communication.
Evaluation of hypotheses
Considering the relation showed in figure 2, we evaluated the hypotheses proposed.
H1: The training of pharmacists in PCare has a positive correlation to the skills in PCare of pharmacists
The training in PCare have a positive correlation of 0.356 to the skills of pharmacists. The training in PCare explains 12.7% de the skills in PCare of pharmacists (p<0.01).
H2. The skills in PCare of pharmacists has a positive correlation to PCare practice
The skills in PCare have a positive correlation of 0.129 to PCare practice in the community pharmacies (p<0.01). The skills in PCare explains 11.1% de the skills in PCare of pharmacists (p<0.01).
H3. The sources in community pharmacies for PCare has a positive correlation to PCare practice
The sources of the community pharmacies have a positive correlation of 0.285 to PCare practice in the community pharmacies. The skills together with sources explains 11.1% of the PCare Practice (p<0.01).
The training of pharmacists in PCare, mediated by the skills of pharmacists in PCare for PCare practice, has a positive correlation on PCare practice.
The training of pharmacists in PCare, mediated by the skills in PCare of pharmacists has a positive correlation on PCare practice. The skills together with the sources explain 11.1% of the PCare practice (p<0.01).
DISCUSSION
Previous outcomes found different factors to the provision of PCare, as in the case of the study developed in Belgium by Binakaj y Stojkov14 who found the need of mental health training to provide pharmaceutical care in patients with depression. El Hajj et al.15 in Qatar show that the main factors are the difficulty in accessing the patient's medical information, as well as the lack of staff and time. The research of Ibrahim & Scott16 in community pharmacies in Sudan shows among the main factors to performance of PCare the lack of support of physicians, lack of qualified personnel, lack of professional standards, lack of specific training and lack of remuneration. In the case of the current research, reviewing each dimension in detail, it can be evidenced that in the resource domain, both the payment for the service and the space are the main factors. The training of the public towards pharmaceutical services is the biggest factor that has been reported, not surprising because the activities of pharmacists are usually not promoted compared to other professionals, for which the population is fully aware of their functions. Communication limitations were also reported, but with less importance, from a professional orientation towards patients and clinical training. The communication experience for the implementation of PCare has been reviewed as well as the improvement strategies17. The service inspiration of pharmacists is an issue to be evaluated since it is possible that, despite working in a community pharmacy, pharmacists may be only focused on the products they sell and not to the patients they serve. Educational gaps are a constant in several countries since undergraduate training often lacks hours of practical training to solve patients' clinical problems. Although pharmacists are in charge of pharmacy management, the incorporation of a specialized service such as PCare implies a greater responsibility and a more detailed control of the management of the patients that we are quoting and who are following up. One aspect that is striking is that the communicational skills of pharmacists are not considered important, implying that there is good communication with the patients. The communication skills of the pharmacists can be used to communicate to patients about personalized services to optimize the use of medications. Inappropriate evaluation and promotion to develop pharmaceutical care, national health structure and legal limitations were identified as important limitations to the provision of PCare.
The use of the technique of structural equation analysis allows us to establish an effect size that makes it possible to show which variables are more important to explain the dependent variable. As shown in the results, the training of pharmacists has an important influence on skills (0.356) and these skills have an influence (0.129) on the practice of pharmaceutical care. This leads to raise the urgent need to increase and improve the training of pharmacy students (future pharmacists) and pharmacists who are already working, in order to optimize the clinical services that are required to provide patients. It is also important to mention that resources have an influence (0.285) on the practice of pharmaceutical care, since physical spaces and access to data sources are fundamental for the service to patients.
This result explains that it is perceived among the pharmacists surveyed that although it is an individual issue for the development of services towards patients, aspects at the level of the health structure, as well as the absence of specific norms that support clinical services, are crucial to improve clinical outcomes in patients.
All the information that has been evaluated in the research serves to know what are the reasons why pharmacists do not provide pharmaceutical care services. Policymakers need to know the barriers and at the same time they need to know the advantages offered by pharmaceutical care, which is widely described in the literature on different diseases such as diabetes18, COPD19, dermititis20, HIV/AIDS21, hepatitis C22 and others. Also, there are evidences for type of patients in relation to age as neonatal23 and older people24.
CONCLUSION
Pharmacists in community pharmacies in Buenos Aires, Argentina, estimated that lack of money (payment for the service), lack of enough space in the community pharmacy, lack of PCare training and lack of training to communicate to patients were the main barriers reported. These aspects should be addressed by both health system regulators and pharmacy faculties to generate changes that, although they will take years to be perceived in the system, need to be initiated in the short term to optimize clinical outcomes in the patients using medication.
