
==== Front
Explor Res Clin Soc Pharm
Explor Res Clin Soc Pharm
Exploratory Research in Clinical and Social Pharmacy
2667-2766
Elsevier

S2667-2766(24)00091-X
10.1016/j.rcsop.2024.100494
100494
Article
Nonsteroidal anti-inflammatory drug use by patients: Impact of modular educational training on pharmacists' questioning, counselling and risk assessments
Showande Segun Johnson sj.showande@gmail.com
sj.showande@ui.edu.ng
⁎
Akinbode Tolulope Eunice
University of Ibadan, Department of Clinical Pharmacy and Pharmacy Administration, Ibadan, Nigeria
⁎ Corresponding author. sj.showande@gmail.comsj.showande@ui.edu.ng
20 8 2024
9 2024
20 8 2024
15 10049418 6 2024
15 8 2024
17 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Nonsteroidal anti-inflammatory drugs (NSAIDs)-related morbidity and mortality can be reduced through medication counselling and risk reduction.

Objectives

This study evaluated the impact of short online modular NSAID training on the type and quality of questions asked, risk factors assessed, and counselling offered by community pharmacists to NSAID users.

Methods

A cross-sectional questionnaire-guided survey conducted in Ibadan, Nigeria, among 87 pharmacists evaluated the frequency of counselling, NSAID risk factor assessment and barriers to risk assessment. Additionally, a before-and-after RCT was used to evaluate the impact of short online modular NSAID training for the intervention group (IG) on the type and quality of the questions asked, counselling provided, and risk assessed by the pharmacists. Eight standardised patients, aged 25–43 years, four at pre- and postintervention, presented four standardised scenarios at community pharmacies [IG, n = 22, control group (CG, n = 30)] to assess these outcomes. The quality of each outcome (questions asked, counselling offered and risk assessed) was classified as poor (0–≤20%), fair (>20–≤40%), moderate (>40 – ≤60%), or optimal (>60–100%). The data are presented with descriptive statistics.

Results

The community pharmacists reported counselling patients on NSAID precautions (80–86%) and dosages (51–69%). Gastrointestinal bleeding risk was assessed by 61–89% of the pharmacists, and time constraints (39–42%) and patient impatience (47–75%) were some barriers to risk assessment. Online modular educational intervention significantly improved the types and quality of questions asked by pharmacists (CG: poor to fair, 16%–21%; IG: poor to moderate, 14%–45%), NSAID risk factors assessed (CG: poor to poor, 10%–9%; IG: poor to fair, 11%–27%) and counselling offered (CG: poor to poor, 6%–7%; IG: poor to fair, 6%–22%).

Conclusions

Short online modular educational training on NSAIDs improved the types and quality of the questions asked, NSAID risk factors assessed, and counselling provided by community pharmacists to patients during consultations.

Highlights

• Pharmacists displayed poor questioning, counselling and risk assessment skills.

• Short on-the-go online modular educational intervention improved pharmacists' skills.

• Standardised patients are useful in evaluating pharmacy practice.

• Short on-the-go online modules can be employed in continuing professional education.

Keywords

Nonsteroidal anti-inflammatory drug
Community pharmacist
Standardised patient
Educational intervention
Patient counselling
NSAID risk factor assessment
Abbreviations

NSAID Nonsteroidal anti-inflammatory drug

IG Intervention group

CG Control group

ADR Adverse drug reaction

RCT Randomised controlled trial

WWHAM Who? What? How long?Actions taken? What Medication
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pmc1 Introduction

Over a decade ago, Singh1 reported that approximately 30 million individuals took nonsteroidal anti-inflammatory drugs (NSAIDs) daily, and NSAIDs represented 5–10% of global prescriptions.2 These drugs are antipyretic agents and can be used as analgesic and anti-inflammatory agents, especially in the treatment of arthritis3,4 but have led to >100,000 hospital admissions, 16,500 fatalities, and 2 billion dollars in medical expenses annually in the United States5 due to complications, including cardiovascular, gastrointestinal, and renal toxicity.6, 7, 8 Similar trends in NSAID-induced adverse drug reactions (ADRs), leading to hospital admissions ranging from 5.2% to 30%, have been observed in countries such as Thailand, the United Kingdom, Italy, and Slovenia.9., 10, 11, 12, 13, 14

Prior research has underscored the cautionary aspects of using NSAIDs, with chronic use predisposing patients to an increased risk of cardiovascular events15 and acute or chronic kidney injury in high-risk patients.16 Risk factors such as patient age, comorbid conditions, significant drug interactions, hypertension, kidney disease, and peptic ulcers increase the likelihood of NSAID-induced ADRs in chronic users.17,18

Patient education and counselling on the potential side effects and risks of NSAIDs are crucial for minimising ADRs and achieving therapeutic outcomes.19 Nurses, physicians, and pharmacists play significant roles in providing this service, with pharmacists, in particular, being in a strategic position due to their accessibility and frequent interactions with the public and patients using NSAIDs.20,21 Pharmacists are equipped to assess NSAID use risk factors and provide patients at high risk of experiencing ADRs with safety information.19,22,23 This is important in places like Nigeria, where NSAIDs are widely used for pain management and where pharmaceutical care varies greatly.24,25

In a study conducted in both rural and urban settings in Nigeria, 28.3% of the participants used NSAIDs daily. Among these participants, 52.9% reported taking more than one type of NSAID at the same time.24 Two other studies, one conducted in an outpatient department and the other in a geriatric department of two teaching hospitals, revealed that 22% of prescriptions included NSAIDs25 and that 75% of elderly hypertensive patients used NSAIDs.26 A significant portion of NSAID users in Nigeria obtain their medications from unregistered premises,24 leading to a gap in proper patient medication counselling and risk assessment. Unlike Australia, Britain, and the U.S.A., Nigeria, a developing nation similar to Thailand, has no national or state guidelines for providing patient medication counselling and NSAID risk assessment.24,27, 28, 29., 30 This has led to a lack of patient awareness and understanding of NSAID-induced adverse drug reactions. This could engender patients' lack of knowledge and awareness of NSAID risk factors and NSAID-induced ADRs.31,32 By implementing thorough questioning and screenings for risk factors during consultations, pharmacists can determine the necessity for NSAID use and provide targeted counselling, enhancing patient safety and care outcomes. Comparatively, in Australia,28 Thailand,33 and Nigeria,34,35 screenings for NSAID risk factors by community pharmacists and physicians are often inadequate.28,36, 37, 38

There are several studies on the questioning skills of pharmacists39, 40, 41. but there seems to be no intervention aimed at improving quality. With respect to NSAID risk factors, two studies utilising pharmacist medication therapy management in a multidisciplinary team and pharmacist-led medicine review interventions reported reduced NSAID usage rates in pre-end-stage renal disease patients and the number of side effects experienced in patients using NSAIDs for knee pain.42,43 Likewise, interventions to improve pharmacist counselling in sexually transmitted diseases,44,45 nonprescription analgesics46 and oral anticoagulants34 have shown mixed results with the use of educational meetings and educational material interventions. Other interventions like the use guidelines, local opinion leaders,34,47 educational packages, and continuing medical education,32,48,49 have been employed to enhance the questioning skills of pharmacists, improve NSAID counselling, and increase NSAID risk factor screening. However, the successes of these interventions in making significant changes have been variable, indicating the need for continued effort and potentially new strategies to improve the safe use of NSAIDs across different populations. However, none of these interventions targeted improving the questions asked, counselling provided, or NSAID risk factors assessed as a composite skill among community pharmacists.

Given the peculiarity of pharmacy practice in Nigeria and the paucity of data on such interventions among pharmacists, there is a need to fill this gap by providing composite skills to community pharmacists. This study investigates the impact of short online modular NSAID training on the type and quality of questions asked, NSAID risk factors assessed, and counselling provided by community pharmacists for NSAID users using self-reported and standardised patient models.

2 Materials and methods

2.1 Ethics approval and consent to participate

The study was approved by the University of Ibadan/University College Hospital Ethics Committee (UI/EC/21/0725) and the Pan African Clinical Trials Registry (PACTR202208586601902). Written informed consent was obtained from the owners of the selected community pharmacies and their pharmacists through a letter detailing the purpose of the study and the use of impromptu standardised patient visits with audio recording. This study adhered to the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

2.2 Study site, design, and sample size

The study was conducted in selected community pharmacies in Ibadan, a city in southwest Nigeria, from May 2022 to April 2023 among community pharmacists, with the pharmacist as the unit of analysis. A mixed-methods design comprising a cross-sectional, self-administered questionnaire-based survey and a before and after single-blind, randomised controlled trial (RCT) was employed.

For the survey, a complete sample of pharmacists from the eligible community pharmacies who had a record of four complete standardised patient visits to the pharmacies at the end of the preintervention phase was used, as detailed in Fig. 1. For the trial, Student's t-test was used to determine the required sample size for each group, resulting in 32 pharmacists per group for both the intervention and control groups.50 A standard deviation of 0.9 for changes in counselling and questioning scores on the basis of findings from previous studies34,51,52 was anticipated. To achieve 80% power at a 5% significance level, equal allocation and an effect size of 0.5 were chosen. The effect size was chosen to obtain the minimum sample size that would provide clinically meaningful or practically important differences in the outcomes of interest between the study groups.Fig. 1 CONSORT flow diagram for the study.

Fig. 1

2.3 Sampling technique

According to the 2021 Pharmacy Council of Nigeria's (PCN) register, there were 171 operational community pharmacies in Ibadan. Each pharmacy is registered and overseen by a superintendent pharmacist, although busier pharmacies often employ additional pharmacists. Based on similar previous studies using simulated patients with appreciable fallouts,34,53 consent was sought from the owners of the 171 pharmacies. Among the 171 pharmacies, 132 pharmacies (with their pharmacists) agreed to participate. They were randomly divided into a control group (CG, n = 66) and an intervention group (IG, n = 66) through computer-generated random numbers facilitated by a neutral postgraduate clinical pharmacy student.

A further selection of the community pharmacies was performed based on those successfully visited by four standardised patients in both groups (Fig. 1). This group of pharmacies, with their pharmacists, formed the baseline (preintervention). The study groups were only known to the authors and the postgraduate student who performed the randomisation. The community pharmacists were unaware of their group assignment, and the standardised patients were also unaware of the existence of the CG and IG throughout the pre- and postintervention periods.

2.4 Inclusion and exclusion criteria

All pharmacists and locum pharmacists in community pharmacies who participated in four audio-recorded standardised patient consultations at the end of the preintervention phase were included. Pharmacists on internships and pharmacists in community pharmacies with fewer than four recorded consultations and other pharmacy staff were excluded (see Fig. 1 and the sections on the pre- and postintervention phases).

2.5 Questionnaire

The authors developed a structured questionnaire to evaluate pharmacy practice by pharmacists in control and intervention groups, following a literature review.27,54,55 This questionnaire included sections on sociodemographics, counselling frequency (7 items), NSAID risk factors assessment (17 items), and barriers to risk assessment (17 items) and utilised a 3-point graded responses Likert scale. The graded responses for the counselling and risk assessment were never = 1, sometimes = 2, and always = 3, and those for the barrier assessment were disagree = 1, neutral = 2, and agree = 3. Six clinical pharmacy lecturers assessed the questionnaire's content validity, and its face validity was pretested in ten community pharmacies, leading to further adjustments. The reliability of the scales in the questionnaire, as measured by Cronbach's alpha coefficient, ranged from 0.760 to 0.810.

Before the modular educational intervention and the postintervention standardised patient evaluations, all the pharmacists in the control and IGs selected after the preintervention phase were administered the questionnaire by one of the authors. The completed questionnaire was returned immediately. If a pharmacist was not available, the author revisited the pharmacy to administer the questionnaire to the pharmacist when on duty.

2.6 Standardised patient descriptions and scenarios

The standardised patient model was chosen as an objective evaluation of pharmacy practice to lessen the limitations of self-reports. A standardised patient is a pseudopatient, and the model has been used to assess pharmacists' clinical and counselling skills,56 and dispensing practices [5739] and to identify factors hindering effective counselling56 successfully.

Eight standardised patients (4 male and 4 female) aged 25–43 years were recruited, including five experienced graduates and two inexperienced undergraduates, to evaluate community pharmacists' questioning, assessment of NSAID risk factors, and counselling, pre- and postintervention. The standardised patients were given four scripted scenarios designed by the authors from prior practice experiences to present at pharmacies. The scenarios involved a range of situations, including a symptom-based complaint by a 43-year-old man with back pain, a product-based request for ibuprofen by a 25-year-old woman with peptic ulcers, an ADR-based scenario involving the use of diclofenac by a 27-year-old man with a complaint of a week-old passage of black, foul-smelling stool, and a drug interaction scenario with a 42-year-old woman on medication for hypertension and diabetes seeking celecoxib for joint pain. The scenarios are outlined in detail in Table 1.Table 1 Case presentation of standardised patients at pharmacies with brief history of illness and medications.

Table 1Scenario 1: Standardised patient with back
pain (symptom-based request)
A male standardised patient (aged 43 years) visited each community pharmacy and asked to see the pharmacist in charge. Once the pharmacist was identified, the standardised patient said, “I have back pain; please, what can I take for it?”
History of illness and medications
He has had back pain for 2-weeks and used 2 tablets of paracetamol three times daily with little relief and worsening back pain. He is a tailor, and the pain is aggravated when he sits for long. No history of allergies or chronic diseases

Scenario 2: Standardised patient who requested for ibuprofen (product-based request)
A female standardised patient (25 years) visited each community pharmacy and asked to see the pharmacist in charge. On identifying the pharmacist, the standardised patient said “Do you have Ibuprofen?”
History of illness and medications
She requested ibuprofen for her 3-day-old toothache, which got worse with cold drinks or chewing on that side of the mouth. She has stomach pain and a burning sensation at the upper part of the abdomen and has taken a Mixture of Magnesium Trisilicate for her ulcer. She is currently self-medicating with piroxicam for her dysmenorrhea. She takes at least a bottle of beer per week and has no history of any other disease.

Scenario 3: Standardised patient who had black, foul-smelling stool (ADR-based scenario)
A male standardised patient (27 years) visited each community pharmacy and asked to see the pharmacist in charge. On identifying the pharmacist, the standardised patient stated: “I noticed my stool is back in colour and foul smelling. I don't know what is happening”.
History of illness and medication
He noticed these symptoms a week ago, along with tiredness. Had used antibiotics and taken Rufenac® (diclofenac) 100 mg twice daily for a week. He does not know if he has an ulcer but smokes.

Scenario 4: Hypertensive standardised patient who sought advice on using celecoxib with her antihypertensive (Drug interaction-based scenario)
A female standardised patient (42 years) visited each community pharmacy and asked to see the pharmacist in charge. On identifying the pharmacist, she opened the dialogue with: “Please, do you have Celecoxib? I have joint pain, and a friend recommended it to me. I, however, have hypertension, and these are the drugs I am taking for it. The standardised patient brought out a blister pack of incomplete tablets of Zestoretic® 10/12.5 mg tablets and asked the pharmacist if she could use the drugs together.
History of illness and medications
She has had joint pain for a week and has been on the antihypertensive for 5 years. She also takes Metformin 1 g and Daonil® 5 mg daily, paracetamol 1 g three times daily. The BP and blood glucose readings this morning were 128/72 mmHg and 110 mg/dL, respectively. No other known illness.	
Felvin® (Piroxicam), Rufenac® (diclofenac 100 mg), Zestoretic® (lisinopril 10 mg + hydrochlothiazide 25 mg); Daonil® (glibenclamide 5 mg).

2.7 Expert panel recommendations

A panel of 13 experts (10 community pharmacists, 1 hospital pharmacist, and 2 clinical pharmacy lecturers) drawn from Ibadan and not included in the study, was tasked with evaluating lists of potential questions that the pharmacists should ask the standardised patients (ranging from 9 to 15), NSAID risk factors to assess (ranging from 9 to 12), and counselling to offer (ranging from 3 to 8) based on each scenario. The relevance of each item was assessed using a 7-point Likert scale from totally irrelevant = 1 to totally relevant = 7, with those items garnering a moderate to total relevance rating from at least 80% consensus. The types of questions the pharmacists were to ask, NSAID risk factors to assess, and counselling to provide are displayed in Table 2.Table 2 Expert panel suggested questions the pharmacist should ask, NSAID risk factors to assess, and minimum counselling to offer to the standardised patients.

Table 2Scenario 1: Standardised patient with back pain	
Questions that the pharmacist should ask (n = 8)	Risk factors to assess (n = 6)	Minimum counselling to offer (n = 8)	
Where exactly is the pain?	Do you have any history of ulcers?	Name of drug	
How long have you had the pain?	Do you have any history of high blood pressure?	Drug dosing	
Have you used any medication for the pain?	Do you have any history of asthma?	Missed doses	
Did it relieve the pain?	Do you smoke?	Side effect/ADR	
Has the back pain worsened?	Do you take alcohol?	When the drug will start working	
What aggravates the pain?	Are you on any corticosteroid?	Precautions	
Does it radiate to other parts of the body?		Drug interaction	
What other symptoms do you have aside from the back pain?		Storage	


	
Scenario 2: Standardised patient who requested for ibuprofen	
Questions that the pharmacist should ask (n = 9)	Risk factors to assess (n = 6)	Minimum counselling to offer (n = 8)	
Who needs the Ibuprofen?	Do you have any history of ulcers?	Name of drug	
What do you need it for?	Do you have any history of asthma?	Drug dosing	
How long have you had the toothache?	Are you on any medication?	Missed doses	
Is there a hole in the affected tooth?	Do you smoke?	Side effect/ADR	
What have you used for the pain?	Do you take alcohol?	When the drug will start working	
Has the pain worsened since it started?	Are you on any corticosteroid?	Precautions	
What makes the pain worse?		Drug interaction	
What do you do to relieve the pain?		Storage	
Do you have any other symptoms?			


	
Scenario 3: Standardised patient who had black, foul-smelling stool	
Questions that the pharmacist should ask (n = 8)	Risk factors to assess (n = 3)	Minimum counselling to offer (n = 3)	
When did you first notice the black stool?	Have you used any pain relievers like Ibuprofen (NSAIDs) before?	Stop Diclofenac	
Did you notice any abdominal pain?	Do you smoke?	May recommend Omeprazole	
Do you feel tired?	Do you have any history of ulcer or GIT bleeding?	Refer to Physician	
Have you used any medication for the condition?			
Do you take any iron supplements or haematinics?			
Did you change your diet or start eating something different recently?			
Are you on any medication for any other condition?			
How did you take the diclofenac tablet?			


	
Scenario 4: Hypertensive and type 2 diabetes standardised patient who sought advice on using celecoxib with her antihypertensive	
Questions that the pharmacist should ask (n = 3)	Risk factors to assess (n = 4)	Minimum counselling to offer (n = 3)	
For how long have you had the joint pain?	Do you have any history of asthma?	Advise against the use of celecoxib	
Have you taken any medication for the joint pain?	Do you have any history of kidney disease?	Suggest an alternative	
Any other symptoms aside the joint pain?	Are you pregnant?	Give reasons for possible drug-drug interaction.	
	Are you breastfeeding?		
n = number of questions, risk factors, or counselling.

2.8 Standardised patient training

The authors trained the standardised patients with the scripted scenarios, a list of expert panel expected pharmacist questions, NSAID risk assessment, and counselling provision for each standardised patient using a 2–4 h role-play. One of the authors acted as a pharmacist. The conversations were recorded and played back for corrections until standardisation was achieved. The training was conducted for two groups of four standardised patients prior to the pre- and postintervention visits.

The standardised patient visits were pretested at five different community pharmacies (not part of the study) immediately after each training before and after the intervention phases. These visits were recorded and used to assess the standardised patients' preparedness and further standardisations. The pretest data were not included in the final analysis.

2.9 Preintervention phase

Each of the four standardised patients visited the 132 pharmacies over a period lasting 2–3 weeks. During these visits, the standardised patients sequentially presented the four different scenarios to pharmacists in the intervention and CGs, deliberately avoiding weekend visits to prevent actors' fatigue and allocate time for additional training. Their approach involved identifying the on-duty pharmacist upon each visit, re-enacting prescripted and rehearsed scenarios, and secretly recording the consultations for later analysis. At each pharmacy, each of the four standardised patients spoke with only one pharmacist during the visit, regardless of the number of pharmacists in the pharmacy. The standardised patients could have consulted with the same pharmacist where there was only one pharmacist in the community pharmacy or with different pharmacists where there was more than one pharmacist on duty. Only pharmacies with complete records of the four pharmacist-standardised patient consultations were selected for the postintervention phase for adequate and logical comparison of pharmacists' performance, as illustrated in Fig. 1. The pharmacists in these pharmacies formed the baseline. The standardised patients received compensation for their contributions.

2.10 Intervention

The intervention provided community pharmacists in the IG with skills in questioning, counselling, and understanding NSAIDs and their risks via a short online modular training program hosted at www.moodle.com. This program, developed by the authors based on a thorough literature review,23,33,47,57,58 included topics such as NSAID pharmacology, counselling practices, and risk assessment, supported by 2–3 case studies and quizzes in each module (see doi: 10.17632/yv4w93hnwv.1 at Mendeley Data). Pharmacists needed to achieve a 70% minimum on each quiz to advance to the next module and had to complete the training within a month, with the possibility of finishing in two weeks at a rate of one hour a day. Noncompletion led to the disqualification of the pharmacy from the study to ensure comprehensive training, as any pharmacist on duty could have encountered the standardised patient. The successful participants received certificates, and the average completion time was one week. After the study, the pharmacists in the CG received similar training to maintain skill equity across groups.

2.11 Postintervention phase

Another four standardised patients visited the pharmacists in the control and IGs one month after the IG pharmacists' training. The same protocol was followed for the preintervention standardised patient visits to the pharmacies. Each standardised patient completed the visit to all the pharmacies within a week.

Independent personnel transcribed the standardised patient-pharmacist conversations, which were then verified for accuracy by the two authors. The authors analysed these transcripts to assess the pharmacists' performance based on the type and quality of the questions asked, the risk factors evaluated, and the counselling provided, aligning them with the recommendations from the expert panel. These were itemised for each scenario.

2.12 Scoring rubric

Pharmacists' performance was evaluated by assigning a score of 1 for every accurately addressed item and 0 for unaddressed ones. Discrepancies were resolved by author consensus. The global scores for the questions asked, risk assessed, and counsel provided were compiled across the scenarios, with high scores reflecting superior performance. The quality of the performance was analysed on the basis of the percentage of total achievable scores, leading to classifications: poor (0–20%), fair (>20–40%), moderate (>40–60%), and high (>60–100%), in line with the expert recommendations and consistent with prior studies.34,53,59

2.13 Data analysis

The results are presented as proportions and means with standard deviations. Differences in the sociodemographic characteristics of the pharmacists in the intervention and CGs were explored with either an independent sample t-test or the Fisher-Freeman-Halton test. Between-group differences in the individual mean, and global scores (a composite of each score for the four scenarios, whether questioning, risk assessment, or counselling) were similarly assessed pre- and postintervention with independent sample t-tests. All inferential statistical analyses were conducted at p < 0.05 using the Statistical Package for Social Sciences version 27 (IBM Corp, New York, U.S.A.).

3 Results

At the completion of the preintervention phase, only 32 community pharmacies (with 53 pharmacists) in the CG and 23 community pharmacies (with 38 pharmacists) in the IG had four standardised patient visits recorded. Thirty-six pharmacists from 22 community pharmacies in the IG and 51 pharmacists from 30 community pharmacies completed the study (Fig. 1). Four pharmacists from three community pharmacies in both groups failed to complete the study (the reasons are shown in Fig. 1).

3.1 Demographics of the community pharmacists

Most of the pharmacists in both groups were male [IG = 19 (52.8%), CG = 33 (64.7%)], and the mean ages of the pharmacists were IG = 30.00 ± 4.84 and CG = 33.31 ± 8.85 years, p = 0.028. Most community pharmacies in both groups had one branch, and the pharmacists were mostly superintendent or staff pharmacists (Table 3). The consultation time differed significantly between the two groups (IG = 436.96 ± 130.96 s., CG = 307.63 ± 127.93 s., p < 0.001).Table 3 Demographics of the pharmacists in the intervention and control groups at the community pharmacies (N = 87).

Table 3Variables	Category	Control group
N = 51	Intervention group N = 36	p-value	
		N (%)	N (%)		
Gender	Male	33 (64.7)	19 (52.8)	0.277b	
Female	18 (35.3)	17 (47.2)	
Age, years Mean ± SD		33.31 ± 8.85	30.00 ± 4.84	0.028a⁎	
Age group, years	≤ 24	3 (5.9)	2 (5.6)	0.170b	
25–32	28 (54.9)	25 (69.4)	
33–40	14 (27.5)	9 (25.0)	
≥ 41	6 (11.8)	0 (0.0)	
Marital status	Single	26 (51.0)	21 (58.3)	0.802b	
Married	24 (47.1)	15 (41.7)	
Separated	1 (2.0)	0 (0.0)	
Divorced	0 (0.0)	0 (0.0)	
Highest Educational level after B. Pharm	Pharm D	7 (13.7)	9 (25.0)	0.180b	
MPharm/MScPharm	9 (17.6)	10 (27.8)	
Ph.D	0 (0.0)	0 (0.0)	
FPC Pharm	2 (3.9)	1 (2.8)	
M.BA	2 (3.9)	3 (8.3)	
None	31 (60.8)	13 (36.1)	
Year of community pharmacy experience,
Mean ± SD	6.04 ± 6.08	3.89 ± 2.85	0.030a	
Years of community pharmacy experience	≤ 3	18 (35.3)	20 (55.6)	0.141	
4–12	29 (56.9)	16 (44.4)	
13–21	2 93.9)	–	
22+	2 (3.9)	–	
Type of pharmacy	One branch	17 (56.7)	14 (63.6)		
	2–4 branches	9 (30.0)	4 (18.2)	
	>4 branches	4 (13.3)	4 (18.2)	
Position in the pharmacy	Owner	8 (15.7)	2 (5.6)	0.073b	
Pharmacy manager	2 (3.9)	6 (16.7)	
Supt pharmacist	22 (43.1)	13 (36.1)	
Staff pharmacist/full time pharmacist	19 (37.3)	13 (36.1)	
Post NYSC locum pharmacist	0 (0.0)	2 (5.6)	
No of pharmacist in the pharmacy, Mean ± SD	2.33 ± 1.49	2.53 ± 1.38	0.534a	
Working hours, Mean ± SD	8.69 ± 1.36	7.42 ± 1.90	0.001a	
Consultation time (min.)	5.13 ± 2.13	7.28 ± 2.18	< 0.001a	
a Independent sample t-test, bFisher-Freeman-Halton exact test, *P < 0.05, PhD – Doctor of Philosophy, MBA – Master of Business Administration, FPCPharm – Fellow, West African Postgraduate College of Pharmacists, M.Sc – Masters of Sciences, M.Pharm – Master of Science in Pharmacy, N – total number of pharmacists in all the community pharmacies in each study group, NYSC – National Youth Service Corp, a mandatory one-year national youth service for all graduates in Nigeria.

3.2 Pharmacists' self-reports on counselling, NSAID risk factor assessment, and barriers to risk assessment

The response rate for the survey was 95.60%. The community pharmacists in both study groups claimed to frequently counsel pharmacy clients or patients on the precautions to take when on NSAID (IG = 86%, CG = 80%) and review dosing parameters (IG 75%, CG = 39%) among others (Appendix Fig. A1). The pharmacists also assessed the patients or pharmacy clients for a history of gastrointestinal bleeding (IG = 89%, CG = 61%), the use of other medications (IG = 83%, CG = 61%), and the presence of asthma (IG = 39%, CG = 12%) (Appendix Fig. A 2). Some of the barriers to NSAID risk factor assessment were time constraints (IG = 42%, CG = 39%), patient impatience (IG = 75%, CG = 47%), and lack of patient or pharmacy-client cooperation (IG = 61%, CG = 45%) (Appendix Fig. A3). Ten (19.6%) pharmacists from the CG and 9 (25.0%) from the IG had attended a seminar on NSAID risk factor assessment.

3.3 Types and quality of the questions asked

Prior to the intervention, the pharmacists in both IG and CG asked the standardised patients similar questions. Postintervention, the IG pharmacists asked the standardised patient with back pain significantly more detailed questions about symptom duration (CG = 0.43 ± 0.50; IG = 0.91 ± 0.29, p < 0.001) and other medication use (CG = 0.47 ± 0.51; IG = 0.91 ± 0.29, p < 0.001) Also, more relevant questions were asked by IG pharmacists of the standardised patient who requested ibuprofen at postintervention (CG vs. IG: who needs it? = 0.07 ± 0.25 vs. 1.00 ± 0.00; purpose = 0.17 ± 0.38 vs. 0.91 ± 0.29; toothache duration = 0.00 ± 0.00 vs. 0.45 ± 0.51; p < 0.001 for all). For the patient with black foul-smelling stool, significant postintervention differences arose only in questions about iron supplement intake or haematinics use and the manner of diclofenac usage. Postintervention, the IG pharmacists improved significantly in inquiring about symptom duration, current medications, and other symptoms from the standardised patient who asked about the use of celecoxib with antihypertensives. Overall, the quality of the pharmacists' questions was initially poor (CG = 15.61%, IG = 13.79%) but improved to fair in CG (21.43%) and moderate in IG (45.29%) after the intervention.

Despite the intervention, questions addressing the medications used, what aggravates or relieves symptoms, and any other symptoms showed no significant improvement among the pharmacists in either group (Table 4).Table 4 Types and quality of the questions asked by community pharmacists.

Table 4	Preintervention	Postintervention	
	Control group
N = 30
(n) Mean ± SD	Intervention group
N = 22
(n) Mean ± SD	P-valuea	Control group
N = 30
(n) Mean ± SD	Intervention group
N = 22
(n) Mean ± SD	P-valuea	
Scenario 1 (Back pain)							
 Where exactly is the pain?	(9) 0.30 ± 0.47	(5) 0.23 ± 0.43	0.568	(19) 0.63 ± 0.49	(19) 0.86 ± 0.35	0.054	
 How long have you had the pain?	(19) 0.63 ± 0.49	(16) 0.73 ± 0.46	0.485	(13) 0.43 ± 0.50	(20) 0.91 ± 0.29	<0.001*	
 Have you used any medication for the pain?	(9) 0.30 ± 0.47	(8) 0.36 ± 0.49	0.637	(14) 0.47 ± 0.51	(20) 0.91 ± 0.29	<0.001*	
 Did it relieve the pain?	(6) 0.20 ± 0.41	(5) 0.23 ± 0.43	0.816	(5) 0.17 ± 0.38	(10) 0.45 ± 0.51	0.032*	
 Has the back pain worsened?	(1) 0.03 ± 0.18	(0) 0.00 ± 0.00	0.397	(1) 0.03 ± 0.18	(5) 0.23 ± 0.43	0.057	
 What aggravates the pain?	(2) 0.07 ± 0.25	(0) 0.00 ± 0.00	0.161	(12) 0.40 ± 0.50	(9) 0.41 ± 0.50	0.949	
 Does it radiate to other parts of the body?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(1) 0.03 ± 0.18	(4) 0.18 ± 0.39	0.112	
 What other symptoms do you have aside from the back pain?	(1) 0.03 ± 0.18	(0) 0.00 ± 0.00	0.397	(2) 0.07 ± 0.25	(2) 0.09 ± 0.29	0.752	
Mean questioning score	1.57 ± 1.38	1.55 ± 1.14	0.953	2.23 ± 1.76	4.05 ± 1.09	<0.001*	
Scenario 2 (Request for Ibuprofen)							
 Who needs the Ibuprofen?	(2) 0.67 ± 0.25	(2) 0.90 ± 0.29	0.752	(2) 0.07 ± 0.25	(22) 1.00 ± 0.00	<0.001*	
 What do you need it for?	(3) 0.10 ± 0.31	(3) 0.14 ± 0.35	0.692	(6) 0.17 ± 0.38	(20) 0.91 ± 0.29	<0.001*	
 How long have you had the toothache?	(0) 0.00 ± 0.00	(3) 0.14 ± 0.35	0.083	(0) 0.00 ± 0.00	(10) 0.45 ± 0.51	<0.001*	
 Is there a hole in the affected tooth?	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	(0) 0.00 ± 0.00	(12) 0.54 ± 0.51	<0.001*	
 What have you used for the pain?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(5) 0.23 ± 0.43	0.021*	
 Has the pain worsened since it started?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 What makes the pain worse?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 What do you do to relieve the pain?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Do you have any other symptoms?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(3) 0.14 ± 0.35	0.083	
Mean questioning score	0.10 ± 0.31	0.32 ± 0.84	0.211	0.23 ± 0.43	3.36 ± 1.40	<0.001*	
Scenario 3 (Black foul-smelling stool)							
 When did you first notice the black stool?	(19) 0.63 ± 0.49	(15) 0.68 ± 0.48	0.723	(28) 0.93 ± 0.25	(22) 1.00 ± 0.00	0.161	
 Did you notice any abdominal pain?	(14) 0.47 ± 0.51	(11) 0.50 ± 0.51	0.817	(23) 0.77 ± 0.43	(17) 0.77 ± 0.43	0.960	
 Do you feel tired?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(1) 0.03 ± 0.18	(0) 0.00 ± 0.00	0.397	
 Have you used any medication for the condition?	(6) 0.20 ± 0.41	(3) 0.14 ± 0.35	0.558	(3) 0.10 ± 0.31	(4) 0.18 ± 0.39	0.403	
 Do you take Iron supplements or haematinics?	(15) 0.50 ± 0.51	(5) 0.23 ± 0.43	0.420	(15) 0.50 ± 0.51	(17) 0.77 ± 0.43	0.042*	
 Did you change your diet or start eating something different recently?	(14) 0.47 ± 0.51	(6) 0.27 ± 0.46	0.155	(22) 0.73 ± 0.45	(20) 0.91 ± 0.29	0.095	
 Are you on any medications for any other condition?	(6) 0.20 ± 0.40	(1) 0.05 ± 0.21	0.083	(7) 0.23 ± 0.43	(5) 0.23 ± 0.43	0.960	
 How did you take the diclofenac tablet?	(5) 0.17 ± 0.38	(1) 0.05 ± 0.21	0.150	(2) 0.07 ± 0.25	(8) 0.36 ± 0.49	0.015*	
Mean questioning score	2.63 ± 1.33	1.91 ± 1.02	0.037	3.37 ± 1.07	4.23 ± 1.31	0.012*	
Scenario 4 (the use of celecoxib with anti-hypertensive drugs)							
 For how long have you had the joint pain?	(2) 0.07 ± 0.25	(1) 0.05 ± 0.21	0.752	(3) 0.10 ± 0.31	(12) 0.55 ± 0.51	0.001*	
 Have you taken any medication for the joint pain?	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	(2) 0.07 ± 0.25	(7) 0.32 ± 0.48	0.032*	
 Any other symptoms aside from the joint pain?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(4) 0.18 ± 0.39	0.042*	
Mean questioning score	0.07 ± 0.25	0.09 ± 0.43	0.799	0.17 ± 0.53	1.05 ± 1.09	0.002*	
Mean global questioning score	4.37 ± 1.81	3.86 ± 1.73		6.00 ± 2.20	12.68 ± 2.85	<0.001*	
Mean % questioning score	15.61%	13.79%		21.43%	45.29%		
Quality of questions asked	Poor	Poor		Fair	Moderate		
N – Total number of pharmacists in the group, ND – Not determined, *P < 0.05, aIndependent sample t-test, n – number of pharmacists who asked the question, SD – standard deviation. Classification of the quality of questions asked: Poor (0 – ≤20%); Fair - >20 - ≤40%; Moderate - >40 – ≤60% and Optimal. > 60–100%.

3.4 Types and quality of NSAID risk factors assessed

Table 5 shows that the pharmacists in both groups screened for a history of ulcer or gastrointestinal bleeding at preintervention. Postintervention, more pharmacists in the IG than in the CG screened for the same risk factor in three of the four standardised patients. Other NSAID risk factors assessed at postintervention, mostly by the IG pharmacists, were high blood pressure (CG = 0.00 ± 0.00, IG = 0.45 ± 0.51, p < 0.001), asthma (CG = 0.00 ± 0.00, IG = 0.32 ± 0.48; p = 0.005), and smoking (CG = 0.00 ± 0.00, IG = 0.27 ± 0.46; p = 0.011). The overall quality of NSAID risk factor assessment was still poor in the CG (6.65%) but fairly (22.05%) improved in the IG at postintervention (Table 5).Table 5 Types of NSAID risk factors assessed by community pharmacists and risk assessment scores.

Table 5	Preintervention	Postintervention	
	Control group
N = 30
(n) Mean ± SD	Intervention group
N = 22
(n) Mean ± SD	P-valuea	Control group
N = 30
(n) Mean ± SD	Intervention group
N = 22
(n) Mean ± SD	P-valuea	
NSAIDs risks assessed by pharmacists							
 Do you have any history of ulcer? or GIT bleeding	(23) 0.77 ± 0.43	(15) 0.68 ± 0.48	0.512	(25) 0.83 ± 0.38	(22) 1.00 ± 0.00	0.023*	
 Do you have any history of high blood pressure?	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	(0) 0.00 ± 0.00	(10) 0.45 ± 0.51	<0.001*	
 Do you have any history of Asthma?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(7) 0.32 ± 0.48	0.005*	
 Are you on any medication?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(2) 0.09 ± 0.29	0.162	
 Do you smoke?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(6) 0.27 ± 0.46	0.011*	
 Do you take alcohol?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(8) 0.36 ± 0.49	0.002*	
 Are you on any corticosteroid?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(1) 0.03 ± 0.18	(0) 0.00 ± 0.00	0.397	
Mean risk assessment score	0.77 ± 0.43	0.73 ± 0.46	0.752	0.83 ± 0.38	2.55 ± 1.18	<0.001*	
Scenario 2 (Request for Ibuprofen)							
 Do you have any history of ulcer or GIT bleeding?	(1) 0.03 ± 0.18	(1) 0.04 ± 0.21	0.827	(4) 0.14 ± 0.35	(14) 0.64 ± 0.49	<0.001*	
 Do you have any history of Asthma?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 Are you on any medication?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Do you smoke?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Do you take alcohol?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Are you on any corticosteroid?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
Mean risk assessment score	0.03 ± 0.18	0.05 ± 0.21	0.831	0.07 ± 0.25	0.68 ± 0.57	<0.001*	
Scenario 3 (Black foul-smelling stool)							
 Have you used any pain relievers like Ibuprofen (NSAIDs) before?	(0) 0.00 ± 0.00	(2) 0.09 ± 0.29	0.162	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 Do you smoke?	(1) 0.03 ± 0.18	(1) 0.05 ± 0.21	0.827	(1) 0.03 ± 0.18	(1) 0.05 ± 0.21	0.827	
 Do you have any history of ulcer or gastrointestinal bleeding?	(10) 0.36 ± 0.49	(8) 0.36 ± 0.49	0.963	(12) 0.40 ± 0.50	(17) 0.77 ± 0.43	0.006*	
Mean risk assessment score	0.39 ± 0.57	0.50 ± 0.60	0.374	0.43 ± 0.57	0.86 ± 0.47	0.006*	
Scenario 4 (the use of celecoxib with anti-hypertensive drugs)							
 Do you have any history of asthma?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Do you have any history of kidney?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Are you pregnant?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(1) 0.03 ± 0.18	(7) 0.32 ± 0.48	0.013*	
 Are you breastfeeding?	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
Mean risk assessment score	0.00 ± 0.00	0.00 ± 0.00	ND	0.00 ± 0.00	0.32 ± 0.48	0.005*	
Mean global risk assessment score	1.23 ± 0.82	1.27 ± 0.77	0.708	1.35 ± 0.80	4.41 ± 1.44	<0.001*	
Mean % NSAID risk assessment score	6.15%	6.35%		6.65%	22.05%		
Quality of NSAID risk assessment	Poor	Poor		Poor	Fair		
N – Total number of pharmacists in the group, ND – Not determined, *P < 0.05, aIndependent sample t-test, n – number of pharmacists who assessed the risk factor, SD – standard deviation. Classification of the quality of questions asked: Poor (0 – ≤20%); Fair - >20 - ≤40%; Moderate - >40 – ≤60% and Optimal. > 60–100%.

3.5 Types and quality of counselling offered

As shown in Table 6, the pharmacists informed the standardised patients with back pain of the name of the drug and the dose before and after the intervention. This information was only provided to standardised patients who requested a drug product after the intervention. There was a significant difference in the mean scores between the IG and CG for the latter. For the standardised patient with ADR (foul-smelling black stool), at postintervention, the pharmacists informed the standardised patient to stop taking diclofenac (CG = 0.07 ± 0.25, IG = 0.36 + 0.49, p = 0.015) and referred the patient to the physician (CG = 0.07 ± 0.25, IG = 0.48 ± 0.51; p = 0.002). As shown in Table 6, the mean score of the pharmacists' counsel against the use of celecoxib by the standardised patient was significantly different only at postintervention (CG = 0.00 ± 0.00, IG = 0.32 ± 0.48, p = 0.005).Table 6 Types of counselling offered by community pharmacists and counselling scores.

Table 6	Preintervention	Postintervention	
	Control group
N = 30
(n) Mean ± SD	Intervention group
N = 22
(n) Mean ± SD	P-valuea	Control group
N = 30
(n) Mean ± SD	Intervention group
N = 22
(n) Mean ± SD	P-valuea	
Minimum counselling offered by pharmacists on the use of an NSAID	
Scenario 1 (back pain)	
 Name of drug	(28) 0.93 ± 0.25	(22) 1.00 ± 0.00	0.161	(29) 0.97 ± 0.18	(22) 1.00 ± 0.00	0.397	
 Drug dosing	(28) 0.93 ± 0.25	(22) 1.00 ± 0.00	0.161	(28) 0.93 ± 0.25	(22) 1.00 ± 0.00	0.161	
 Missed doses	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Side effect/ADR	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 When the drug will start working	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 Precautions	(2) 0.07 ± 0.25	(3) 0.14 ± 0.35	0.410	(2) 0.07 ± 0.25	(6) 0.27 ± 0.46	0.065	
 Drug interaction	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Storage	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
Mean counselling skill score	1.93 ± 0.58	2.14 ± 0.35	0.468	1.97 ± 0.49	2.32 ± 0.48	0.020*	
Scenario 2 (Request for Ibuprofen)							
 Name of drug	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(1) 0.03 ± 0.18	(19) 0.86 ± 0.35	<0.001*	
 Drug dosing	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(18) 0.82 ± 0.39	<0.001*	
 Missed doses	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 Side effect/ADR	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	–	–	ND	
 When the drug will start working	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	
 Precautions	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(5) 0.23 ± 0.43	0.021*	
 Drug interaction	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 Storage	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
Mean counselling score	0.00 ± 0.00	0.00 ± 0.00	ND	0.03 ± 0.18	2.00 ± 0.87	<0.001*	
Scenario 3 (Black foul-smelling stool)							
 Stop diclofenac	(5) 0.17 ± 0.38	(1) 0.04 ± 0.21	0.150	(2) 0.07 ± 0.25	(8) 0.36 ± 0.49	0.015*	
 Smoking cessation plan	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	(0) 0.00 ± 0.00	(0) 0.00 ± 0.00	ND	
 May recommend Omeprazole	(2) 0.07 ± 0.25	(0) 0.00 ± 0.00	0.161	(1) 0.03 ± 0.18	(8) 0.36 ± 0.49	0.006*	
 Refer to physician	(0) 0.00 ± 0.00	(1) 0.05 ± 0.21	0.329	(2) 0.07 ± 0.25	(10) 0.48 ± 0.51	0.002*	
Mean counselling score	0.23 ± 0.50	0.10 ± 0.30	0.442	0.17 ± 0.38	1.24 ± 0.83	<0.001*	
Scenario 4 (the use of celecoxib with anti-hypertensive drugs)							
 Advise against the use of celecoxib	(2) 0.07 ± 0.25	(2) 0.09 ± 0.29	0.752	(0) 0.00 ± 0.00	(7) 0.32 ± 0.48	0.005*	
 Suggest an alternative	(0) 0.00 ± 0.00	(2) 0.09 ± 0.29	0.162	(0) 0.00 ± 0.00	(3) 0.14 ± 0.35	0.083	
 Give reasons for possible drug-drug interaction	(0) 0.00 ± 0.00	(2) 0.09 ± 0.29	0.162	(0) 0.00 ± 0.00	(3) 0.14 ± 0.35	0.083	
Mean counselling score	0.07 ± 0.25	0.27 ± 0.88	0.223	0.00 ± 0.00	0.59 ± 0.96	0.016*	
Mean global counselling score	2.24 ± 0.91	2.52 ± 0.93	0.341	2.17 ± 0.60	6.14 ± 1.82	<0.001*	
% counselling score	9.74%	10.96%		9.44%	26.70%		
Quality of counselling	Poor	Poor		Poor	Fair		
N – Total number of pharmacists in the group, ND – Not determined, *P < 0.05, aIndependent sample t-test, n – number of pharmacists who provided the counselling, SD – standard deviation. Classification of the quality of questions asked: Poor (0 – ≤20%); Fair - >20 - ≤40%; Moderate - >40 – ≤60% and Optimal. > 60–100%.

The quality of counselling offered by the pharmacists in the CG was poor at preintervention (9.74%) and postintervention (9.44%), whereas it improved from poor (10.96%) at preintervention to fair (26.70%) at postintervention in the IG (Table 6).

4 Discussion

The study revealed that online training in NSAIDs enhanced the quality of community pharmacists' consultations. Although the counselling and risk assessments, self-reported by pharmacists, were slightly exaggerated compared with observations from standardised patient visits, the training improved the types of questions asked and provided more thorough NSAID risk evaluations. However, the effectiveness of the training varied among different patient scenarios. This variation underscores the importance of adapting questions, counselling, and risk assessments to each unique pharmacist-patient interaction. The use of standardised patients provided a robust method to capture the breadth of pharmacy practices, offering valuable insights into pharmacists' behaviours and decision-making.

Initially, community pharmacists did not ask adequate questions during the presentation of the three scenarios (symptom-based, product-based, and drug interaction) before the intervention. Studies by Rutter et al. in the UK58 and Showande and Adelakun41 in Nigeria reported similar findings. However, at postintervention, there was a notable improvement in the type and quality of the questions the pharmacists asked in the IG. These questions covered symptom duration, the medication used, the requestor, the intent behind product requests, concomitant medications, and the specific regimen related to the drug-causing issues.

The postintervention enhancement in questioning skills may be attributed to the incorporation of the WWHAM mnemonic (Who, What, How long, Actions taken, Medication used) in the consultation, which highlights its value in pharmacy practices. Despite its ease of use, there have been arguments against WWHAM's sufficiency for gathering medication information,60., 61., 62 prompting a recommendation for diversified training in questioning techniques to bolster pharmacy practice.

The quality of the questions posed by the pharmacists in both study groups at preintervention was poor, which aligns with previous research, indicating a lack of thorough questioning by community pharmacists in consultations.58,63,64 Notably, many pharmacists fail to inquire about detailed medication history, missing potential drug interactions or adverse drug reactions (ADRs). This finding is consistent with a study by Al-Aqeel and Abanmy.65 Factors such as limited consultation times (<7 min in this study) and poor pharmacist and patient communication skills were highlighted as contributing factors. Rutter et al. stated that a poor medication history is mainly responsible for poor pharmacy practices in resource-limited nations.58 Nonetheless, the findings also revealed a significant improvement in the quality and appropriateness of the questions following the intervention.

Improvement in the quality of questions asked by pharmacists in the control group (CG) after the intervention is noteworthy. This change from poor to fair aligns with the observations in the intervention group (IG). Interestingly, various factors could have contributed to this improvement in the questions asked by CG pharmacists, such as length of experience and attendance at seminars focused on NSAID risk assessment. It is equally important to consider the broader context in which these pharmacists work and how external factors may also impact their professional development. The scenario of a standardised patient with black foul-smelling stool calls for attention and hence, it is not surprising that both the IG and CG pharmacists asked similar questions pre- and postintervention. This could lead to better patient care and outcomes. There is a positive and strong correlation between appropriate decisions made by pharmacists and the type of questions asked during patient consultations.66,67 This improvement is linked to better decision-making during patient consultations. The study underscores the importance of adopting various questioning techniques among community pharmacists in Nigeria to improve patient care, suggesting that reliance solely on mnemonics is not enough for effective consultation.

During the study, while pharmacists claimed to assess NSAID users for various risk factors such as high blood pressure, gastrointestinal bleeding history, and concurrent medication use, actual assessment rates (through standardised patients) were low prior to the intervention. Healthcare professionals regularly screen for gastrointestinal risk,19,38,68,69 as reflected in this study. This intervention, a modular training program, led to improvements in screening not only for the aforementioned risk factors but also for chronic diseases, lifestyle factors, and pregnancy. Despite these improvements, the study revealed gaps in screening for cardiovascular risks and the usage of corticosteroids, other medications, and kidney disease, even postintervention. These findings have been corroborated by other studies.22,27,38,65 These consistent deficiencies in screening for NSAID-linked risks could be attributed to various barriers, including time constraints, patient impatience, work overload, stereotypes, and insufficient training, as mentioned by community pharmacists. Continuous professional education should be provided to improve pharmacists' screening practices and reduce NSAID-associated adverse drug reactions (ADRs). Furthermore, proper patient education and vigilant prescription monitoring are recommended to mitigate the risks of NSAID usage effectively.

After the modular training program on NSAIDs, the pharmacists showed enhanced performance in counselling standardised patients. The pharmacists effectively provided essential information like drug names, dosages, and precautions, including advice on when to stop taking the drug and when to seek further medical advice. However, there was no noticeable improvement in advising standardised patients on side effects, potential drug interactions, or appropriate storage methods for NSAIDs. While pharmacists self-reported offering counselling on NSAID use precautions, effect monitoring, and dosage reviews, some studies65,70 aligned with these claims, indicating that pharmacists often discuss dosages and drug names. However, there are discrepancies with reports of patients not receiving comprehensive information about their NSAID treatments, including precautionary measures.71 In addition, other self-reported outcomes suggest that pharmacists usually provide counselling on side effects, contraindications,70 adverse effects,33,37,72 drug interactions, and alternative medications.71 These variances in the present study could stem from self-reporting limitations, such as the tendencies for overreporting, underreporting, and bias toward socially desirable answers.

The use of standardised patient evaluation methods in this study identified significant shortfalls in NSAID counselling by pharmacists, which improved markedly after a targeted modular educational intervention. Previous research has consistently demonstrated the poor quality of counselling in community pharmacies.73, 74, 75, 76. The findings in this study support this assertion. Initially, both the IG and CG exhibited poor counselling quality, but postintervention, the IG showed noticeable enhancement. The complexity of community pharmacy counselling underlines the necessity for well-designed interventions targeting pharmacists' cognitive service behaviours. Educational initiatives specifically meetings, materials, and outreach, have been effective,47 but often focus more on the quantity rather than the quality of counselling. This intervention, centred on educational training, successfully enhanced both aspects, suggesting that brief, online training can be an efficient strategy to bolster the quality of pharmacists' cognitive services amidst the pressurised environment of community pharmacy practices.

Notably, the demographics of the pharmacists in the IG and CG significantly differed in terms of age and years of experience, with the IG pharmacists being younger and having fewer years of experience. Age and years of experience may positively affect pharmacists' performance. Nevertheless, studies have shown that age does not influence patient counselling77 but affects the provision of pharmaceutical care services.78 In contrast, years of experience influence the pharmacist's knowledge of oral anticoagulants79 but fails to affect patient counselling.77 Despite the differences in age and years of experience between the pharmacists in the IG and the CG, the outcomes measured at preintervention were not significantly different between the groups. Thus, it may be inferred that the improvements noted in the outcomes of interest by the pharmacists in the IG were most likely due to the educational intervention.

The type of training employed in this study could enhance patient care, medicine use safety in general and specifically safety related to NSAID use in community pharmacy settings. Modular educational training could also be employed in other parts of Nigeria and in countries with similar practice settings where community pharmacists are often busy with pharmacy clients and have minimal time to engage in educational training. It could also be adapted to enhance other areas of pharmaceutical care practice or may be used by other health professionals as a training model to improve practice. This type of short online module can be done on-the-go and completed in a few hours, which may make it appealing to pharmacists who are not interested in lengthy courses or training. The only limitation to the applicability of the training model is that it is hosted on a learning platform or course management system such as www.moodle.com.

4.1 Strengths and limitations of the study

This study assessed the type and quality of questions asked, NSAID risk factors assessed, and counselling practices of community pharmacists through a single-blind, randomised, controlled trial using standardised patient methods. This marks the first instance where these three outcomes were evaluated simultaneously in research. Multiple standardised patients were also used to broaden the remit of the pharmacy practice assessed. Additionally, it compared self-reported practices by pharmacists against their actual practices.

Limitations of the study included the small sample size of community pharmacists, excluding those from pharmacies with fewer than four standardised patient encounters and omitting hospital pharmacists. The incomplete records of pharmacist-standardised patient encounters in some community pharmacies resulted primarily from the absence of pharmacists during two consecutive visits by standardised patients. Consequently, these pharmacies were excluded from the final analysis to prevent potential discrepancies in the comparison of outcomes among the study groups. This study focused on community pharmacists in one of the largest cities in Nigeria. This might limit the applicability of the results to community pharmacists in other cities across Nigeria. However, by using a single-blind RCT with a representative sample size to identify differences in group outcomes, the results could potentially be applied to other community pharmacists in different states in Nigeria and other countries with similar pharmacy practice settings. The use of RCT and objective assessment of outcomes with standardised patients prevented selection bias and the Hawthorne effect, thereby improving the external validity of the findings. Nevertheless, the external validity of the study may be limited by the use of the same scenarios delivered by different standardised patients for evaluation before and after the intervention. There was a 2-month gap between the end of the preintervention evaluation and the beginning of the postintervention evaluation reducing the chances of the pharmacists recollecting the encounter with such scenarios. Therefore, this is unlikely to impact postintervention outcomes. The research methodology did not pinpoint specific pharmacists who attended to the standardised patients during multiple visits, leading to a blanket training approach for all pharmacists in the IG during the intervention. Thus, pre-postintervention analysis was performed on the premise of one pharmacist per pharmacy. Thus, individual pharmacists' demographic impact on their service quality could not be determined.

5 Conclusion

Online modular training on NSAIDs significantly improved community pharmacists' consultation quality, including the questions asked, counselling offered, and assessment of NSAID risk factors with standardised patients. The Pharmacy Council of Nigeria (PSN) and other pharmacy education regulatory bodies should consider incorporating this training as an on-the-go learning module into continued professional education programs to improve medicine use safety and other pharmaceutical care services. The PSN should also consider establishing guidelines for screening NSAID use risk factors. It is recommended that large-scale studies in real patient consultations and various pharmaceutical services within community pharmacies, utilise this training model.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Segun Johnson Showande: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Tolulope Eunice Akinbode: Writing – review & editing, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used Grammarly generative AI to improve the language and readability of the manuscript. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

Counselling offered to pharmacy clients or patients by community pharmacists during consultations.

Image 1

Nonsteroidal anti-inflammatory drug risk factors assessed by community pharmacists during consultations with pharmacy clients or patients.

Image 4

Perceive barriers to nonsteroidal anti-inflammatory drug risk factors assessments by community pharmacists during consultations with pharmacy clients or patients

Image 6

Data availability

The datasets used and/or analysed during the current study are available at Mendeley data (doi: 10.17632/yv4w93hnwv.1).

Acknowledgements

The authors express their gratitude to all the participating pharmacies and the pharmacists who contributed to the study.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.rcsop.2024.100494.
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