4 DISCUSSION
This study was conducted to evaluate the KAP of CPs, which is considered an essential step to creating awareness about the safety of drugs, the hazard of dispensing banned medicine, the reporting of ADRs, and the importance of PV. Majority of our respondents were male, young age, an employee who is practicing in an independent pharmacy, having a working experience in a community pharmacy between 1 to 6 years and acquired a bachelor degree in pharmacy. The extent of the knowledge and attitude of the CPs reflected the practical aspects. In brief, the findings indicated a positive attitude towards PV with a reasonable knowledge level; however, the practical role of CPs should be encouraged and upraised. Generally, in developing countries and specifically in Yemen, pharmacists are considered health-care consultants who can be easily assessed and without payment. Most patients prefer to consult CPs about health-related problems, including ADRs. Therefore, there is a demand to involve CPs in the PV system.
The profiles of the CPs e.g. age, employment status, experience, degree, indicated that they have an adequate level of education and practice. Thus, it is supposed that they might have acceptable knowledge suitable for this study. The study also indicated that most of the CPs had good knowledge about the concept of PV and its purpose as well as the definition of ADRs and the medical products that may be the main cause of ADRs. The response rate was comparable with that in a study carried out in Lebanon [19]. Several studies have indicated that pharmacists are considered the health care professionals who have the most comprehensive knowledge of the pharmacological aspects of the drugs, so they should play an essential role in the identification, detection, prevention, and management of ADRs [20-23]. Continuous awareness campaigns should be conducted to install, enhance and increase knowledge among pharmacists. A meta-analysis study in India indicated that approximately 81% of Indian pharmacists were unaware of the PV system in their country [24] (See Table 2).
Regarding the attitude towards PV, about two-third of the pharmacists had encountered ADRs. The majority of the participants had a positive attitude about being the health-care professional who was responsible for the reporting of ADRs, and more than fourth-fifth believed that reporting should be compulsory process. In addition, close to fourth-fifth of the participants considered reporting ADRs as one of their duties. The result is similar to that from studies in India [25], Korea [26] and other Arab countries [19, 27-31]. One study in India revealed that the CPs believed that ADR reporting was the physician’s duty [32]. However, a negative attitude was detected among pharmacists in New Zealand [22]. Some studies reported that pharmacists believe that reporting disrupted drug dispensing and not was included among their main duties [33, 34]. The positive result in the current study might be due to incomplete knowledge on the ADR reporting procedure, as there is no active applied PV system in Aden. This study only reflects attitudes towards PV and ADR reporting, not the real reporting practice. However, the participants revealed that they had many challenges that made accessing the reporting system difficult, such as a lack of knowledge about ADR reporting procedures and judgments, the need for training to effectively detect ADRs and time restrictions in addition to work pressure. Similar challenges have been stated previously; several studies have revealed a positive relationship between knowledge level and reporting behavior (35-40). Furthermore, a study in Portugal showed that educational courses increased the number of ADR reports 10-fold [40]. Most of the pharmacists depended on drug leaflets to obtain ADR information, followed by the internet and books. However, the drug leaflets provide information on the most common ADRs, and some of the rarer and more serious ADRs are usually not mentioned. Additionally, obtaining information from the internet is not a good idea because not all websites are trustworthy (See Table 3).
Regarding ADR reporting practices, approximately half of the pharmacists reported having observed ADRs. They reported them to different authorities, as shown in Table 4. The outcomes also indicated the unavailability of the reporting system according to around fourth-fifth of the CPs, with slightly more than two-third of the CPs indicating that no information is provided regarding the reporting of ADRs. Most of the pharmacists felt that they did not have sufficient training, while nearly half of the CPs encouraged the reporting system and around half did not. Several problems were mentioned during the reporting procedures, including the lack of governmental reporting system and the lack of information from the patient. Additionally, some pharmacists revealed that work pressure prevents proper reporting, which is in line with the outcomes from studies in India [32, 41]. Meanwhile, the fear of legal repercussions was one of the problems that faces the reporting system in the community pharmacies in Yemen; similar results have been reported in other studies [245, 32, 41-43]. Patient safety was the prime concern of most participants. The majority of the pharmacists had a considerable awareness of the mistakes that may occur during their duties, and they learned from these mistakes to improve the quality of CP services.
Regarding the future of ADR reporting in Yemen, slight more than half of the participants encouraged the idea of self-reporting by the patients. This finding is comparable to those of previous studies in India [25], the UK [44] and the Netherlands [45]. Subsequently, the activation of a “spontaneous reporting system” might be an essential factor in the future. Approximately fourth-fifth of the participants encouraged the role of information technology in facilitating ADR reporting in the country. An identical result was found in a study carried out in India [46]. Concerning patient access to an online ADR program/website, nearly half had positive responses. Approximately three-fourth of the CPs believed that reporting procedures should be compulsory.
According to this study, more than fourth-fifth of the pharmacists believed that reporting ADRs will improve patient safety. A similar finding was reported in other studies [32, 41]. When asked if ADR reporting causes inconvenience in the working environment, around two-third of the participants responded no; some of the CPs also believed that reporting ADRs is an effort by health institutions to indicate the provision of quality care to the patients, which is a positive indication of the acceptance of the ADR reporting concept.
Based on the observation from this study, there are a few recommendations for improving ADR reporting in Yemen:
1. Every governmental or private hospital should create a PV center for reporting ADRs and save associated data in the database;
2. PV workshops should be carried out to guide pharmacists and other healthcare professionals in distinguishing and reporting ADRs;
3. Self-reporting by the patients should also be encouraged alongside reporting by healthcare professionals;
4. National PV programs should be initiated, and PV specialists should help healthcare professionals;
5. Continuous seminars and training programs should be arranged by PV professionals to enhance the reporting system;
6. There should be a periodic gathering of ADR data from health centers;
7. New technology should be incorporated to facilitate ADR reporting;
8. PV education should be introduced in pharmacy and other health-related facility curricula;
9. Pharmacists should not be subjected to legal repercussions if a mistake is made;
10. ADR reporting should be made compulsory for all pharmaceutical companies and healthcare professionals; and
11. CPs should be able to obtain the required ADR data from the hospital database.