Research Articles Open Access Evaluation of Pharmacist-Based Services for Type 2 Diabetes Mellitus in the Indonesian Community Health Centers Riza Alfian1,2.
Yunita Nita3.
Umi Athiyah4* Doctoral Program of Pharmaceutical Sciences.
Faculty of Pharmacy.
Universitas Airlangga.
Surabaya.
Indonesia Sekolah Tinggi Ilmu Kesehatan ISFI Banjarmasin.
Banjarmasin.
Indonesia Department of Pharmacy Practice.
Faculty of Pharmacy.
Universitas Airlangga.
Surabaya.
Indonesia Department of Pharmacy Practice.
Faculty of Pharmacy.
Universitas Airlangga.
Surabaya.
Indonesia *Corresponding Author: E-mail: umi-a@ff.
ARTICLE INFO
Manuscript Received: 05 Aug 2024 Revised: 30 Nov, 2024 Accepted: 10 Dec, 2024 Date of publication: 10 Feb, 2025 Volume: 5 Issue: 1 DOI: 10.
56338/jphp.
KEYWORDS
Pharmaceutical Care.
Pharmacist.
Community Health Centers.
Diabetes.
Indonesia
ABSTRACT
Introduction: Diabetes mellitus is a global epidemic that continues to rise, including in Indonesia, and it has significant impacts on public health.
The role of pharmacists in providing pharmaceutical care for diabetic patients in community health centers is crucial, yet challenges in its implementation persist.
However, in-depth studies on pharmacists' practice experiences in this context are still limited in Indonesia.
This study aimed to explore pharmacists' experiences in implementing pharmaceutical care for diabetic patients at community health centers in Indonesia.
Methods: The cross-sectional study was conducted in community health centers in South Kalimantan Province.
Indonesia.
Pharmacists practicing at community health centers were recruited between October and December 2023.
The survey was distributed in both paper and online (Google For.
The questionnaire used in the survey focused on the provision of assessment, care plan, and follow-up parameters regarding the medication of diabetic patients.
Results: A response rate of 60,3% .
was obtained from pharmacists involved in this survey.
Regarding the assessment parameter, the indicator of assessment patient trust was the most dominant implemented by pharmacists .
,7%) compared to other In terms of the care plan parameter, providing information on medication indications was the most dominant indicator implemented .
,9%).
Meanwhile, for the follow-up parameter, the indicator of medication adherence follow-up was the most dominantly implemented by pharmacists .
,1%).
Factor analysis revealed that assessment, care plan, and follow-up evaluation each constituted one composite.
Conclusion: The pharmaceutical care provided by pharmacists at community health centers for diabetic patients is still suboptimal.
The factors that caused the suboptimal implementation of pharmaceutical care were resource limitations, inadequate specialized training for pharmacists, and insufficient support from the healthcare system.
Publisher: Pusat Pengembangan Teknologi Informasi dan Jurnal Universitas Muhammadiyah Palu Page | 1 Evaluation of Pharmacist-Based Services for Type 2 Diabetes Mellitus in the Indonesian Community Health Centers INTRODUCTION Diabetes mellitus is a cluster of metabolic symptoms caused by elevated blood glucose levels due to disruptions in insulin secretion, insulin resistance, or both.
It is often referred to as the 'silent killer' because the disease often remains undetected for a long time .
, .
Patients with persistently high blood glucose levels above the normal range are at risk of experiencing micro- and macrovascular complications, increased healthcare costs, mortality, and decreased quality of life .
, .
Diabetes mellitus is one of the diseases with the fastest increasing prevalence in the world .
, .
In 2021, the number of people with diabetes mellitus worldwide reached 537 million.
If this increasing trend continues, it is estimated that the global number of people with diabetes mellitus will reach 783 million by 2045.
The costs incurred for managing diabetes mellitus worldwide increased from 232 billion USD in 2007 to 966 billion USD in 2021.
Indonesia, cases of diabetes mellitus rank fifth among the top ten countries with the highest number of patients, 5 million people.
The country with the highest number of sufferers worldwide is China, with 140.
9 million cases .
The goal of managing diabetes mellitus is to control blood glucose levels within the normal range, slow disease progression, reduce symptoms, and prevent complications .
, .
Management of diabetes mellitus is achieved through dietary regulation, physical activity management, and pharmacological therapy.
As part of the healthcare team, pharmacists are responsible for providing pharmaceutical care related to the pharmacological therapy .
, .
Currently, there is a shift in the pharmaceutical paradigm from a drug oriented to a patient oriented.
Formerly, the role of pharmacists was limited to providing drugs of high quality and standards.
Nowadays, pharmacists are not only expected to dispense medications but also to provide pharmaceutical care that supports the success of patient therapy .
, .
A comprehensive and intensive pharmaceutical care approach is necessary to ensure that the medication provided is appropriate, effective, safe, and adhered to by the patient .
Pharmaceutical care involves three stages: assessing the patient's medication needs, developing a pharmaceutical care plan, and following up to evaluate the implementation of that plan.
Therapeutic communication between the pharmacist and the patient facilitates discussions about the patient's medication regimen .
The implementation of pharmaceutical care has a positive impact on improving the economic, clinical, and health outcomes of patients with diabetes.
, .
Studies in various countries have reported that pharmacists provide a variety of diverse pharmaceutical care services for patients with diabetes, yet many of these services have not been implemented comprehensively.
These services include blood glucose monitoring, hypoglycemia management, pharmacotherapy, comorbid disease management, guidance on healthy living choices, and monitoring medication adherence .
One of the primary healthcare facilities accessible to diabetes patients is the community health centers (Puskesma.
Puskesmas is a government-managed health facility that provides healthcare services to the general public, including diabetes patients.
Improving the quality of pharmaceutical care for diabetes patients in community health centers settings in Indonesia is imperative.
The implementation of pharmaceutical care in Indonesia was still carried out partially and had yet to fully meet the standards established by the government.
This condition had the potential to result in suboptimal outcomes in diabetes mellitus therapy.
Comprehensive surveys on the implementation of pharmaceutical care by pharmacists in Puskesmas have not been conducted in Indonesia.
This research serves as an initial step conducted in South Kalimantan Province as a pilot study.
This study aims to assess the implementation of pharmaceutical services provided by pharmacists to diabetes patients in community health The findings of this study are expected to provide valuable information to the government, pharmacist professional organizations, and practitioners regarding the development of diabetes pharmaceutical services based in community health centers in developing countries.
METHOD
A descriptive, cross-sectional survey-based study was conducted at community health centers (Puskesma.
in South Kalimantan Province.
Indonesia.
All pharmacists working in community health centers were included in the study .
= .
Data collection was carried out between October and December 2023.
Two hundred and thirty-seven pharmacists were approached.
the questionnaires were given to those who agreed to participate, and they were completed anonymously.
Participants provided informed consent to participate in this research.
The survey Page | 2 J.
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questionnaires were distributed in both paper and online (Google For.
formats to all pharmacists .
ttps://doi.
org/10.
5281/zenodo.
The questionnaire was based on the Standards for Pharmaceutical Care in community health centers guidelines in Indonesia .
Participants expressed their implied consent by responding to and submitting the survey.
The questionnaire consisted of two sections.
Part A included demographic information of the participant.
In Part B, there were twenty-five questions about the list of pharmaceutical care indicators that had been implemented.
The questionnaire was developed for this study to assess pharmacists' experiences in implementing pharmaceutical care for patients with diabetes mellitus in community health centers settings.
The questionnaire was developed based on three theoretical pharmaceutical care domain frameworks about assessment, care plan, and follow-up evaluation.
The content validity test of the questionnaire was carried out by three experts in the field of pharmaceutical care.
The three experts serving as validators have no conflict of interest in this research.
The test results showed that the questionnaire was valid .
value for each item > 0.
n = .
and reliable with a Cronbach's Alpha value of 0.
The questionnaire consists of 25 questions related to aspects of pharmaceutical care provided by pharmacists .
ssessment, care plan, follow-up, and evaluatio.
The questions 1Ae11 relate to assessment parameters, consist of 12 .
rust indicator.
, 3-4 .
nderstanding indicator.
, 5-6 .
xpectation indicator.
, 7-8 .
oncern indicator.
, and 9-11 .
ehaviour indicator.
The questions 12Ae21 relate to care plan parameters, consist of number 12 .
erification indicato.
, 13-14 .
ndication indicator.
, 15-16 .
ffectiveness indicator.
, 17-18 .
afety indicator.
, and 19-21 .
dherence indicator.
The questions 22Ae25 relate to follow-up and evaluation parameters, consist of 22-23 .
ffectiveness indicator.
, number 24 .
afety indicato.
, and number 25 .
dherence indicato.
The response of questions used a five-point Likert scale: never, rarely, sometimes, often, and always.
Indicators of pharmaceutical care practice parameters are categorized as optimal and suboptimal.
An indicator is categorized as optimal if the score was Ou 75% (The average total score of the answers AualwaysAy and AuoftenAy from questions in 1 indicato.
The statistical package IBM SPSSA version 25.
0 was utilized to analyze the data.
Descriptive analysis was used to assess the participants' demographic characteristics and examine each pharmaceutical care indicator.
Factor analysis was conducted to identify the patterns of relationships among the indicators comprising the parameters of pharmaceutical care .
ssessment, care plan, and follow-up evaluatio.
Ethical Approval The study was approved by The Ethical Committee of Medical Research.
Medical Faculty.
University of Lambung Mangkurat Banjarmasin.
Indonesia (No.
119/KEPK-FK ULM/EC/IV/2.
RESULTS
Demographic of participants This questionnaire was completed by a total of 143 participants with fair representation of the geographic The survey response rate was 60.
Most of them were females .
3%), with the dominant age group being 25-30 years old .
0%).
The most common level of pharmacy education was general pharmacist .
6%).
The most prevalent duration of practice as a pharmacist in a community health center was 1 to 5 years .
3%).
The predominant number of diabetes medication prescriptions served at community health centers was less than 50 prescriptions per month .
1%) (Table .
Table 1.
Participant Demographic Data Demographic .
Gender Age .
Highest education Male Female Pharmacist Pharmacist & Master n (%) 41 .
Page | 3 Evaluation of Pharmacist-Based Services for Type 2 Diabetes Mellitus in the Indonesian Community Health Centers Demographic .
Gender Length of pharmacy practice .
Number of Prescriptions for Diabetic Patients Per Month
n (%) Male
Female O 50
>100
The state of pharmaceutical care implementation In the assessment parameter, the most dominant indicator implemented by pharmacists in the pharmaceutical care of diabetic patients in community health centers was the trust indicators .
ore than 75%).
The indicator with the lowest level of implementation in the assessment parameter was the expectation indicators .
In the care plan parameter, the most dominant indicator implemented by pharmacists was the indication indicators, while the lowest was the verification indicators .
In the follow-up evaluation parameter, the most dominant indicator implemented by pharmacists was the adherence indicator, while the lowest is the safety indicator .
The practice of pharmacists in the implementation of pharmaceutical care is analysed based on the performance category of each parameter and indicator.
The performance categories of pharmacist practice can be seen in Table 5.
Table 2.
Implementation of Assessment Parameter in Pharmaceutical Care Assessment Indicators I verify the completeness of the prescription, the identity of the patient with diabetes mellitus, and the identity of the prescribing doctor upon receiving the prescription I verify the name of the diabetes mellitus medication, the dosage form, the quantity, the content of active ingredients, and the instructions for use upon receiving the prescription I ask the patient with diabetes mellitus about the types and quantities of each prescribed diabetes medication I ask the patient with diabetes mellitus about the purpose of using the diabetes medication, specifically regarding the reduction in blood glucose levels desired by the prescribing doctor I ask the diabetes mellitus patient about the symptoms they experienced before visiting the doctor I ask the diabetes mellitus patient about their expectations after using the diabetes medication.
I ask the patient with diabetes mellitus about any complaints or uncomfortable symptoms, such as nausea, dizziness, or cold sweats, that they may experience while using the diabetes I ask the diabetes mellitus patient about the use of any other medications besides their diabetes medication.
I ask the diabetes mellitus patient about any difficulties they have experienced in using their diabetes medication.
I ask the patient with diabetes mellitus about their experience with prematurely discontinuing the use of diabetes medication.
I ask the diabetes mellitus patient about their dietary patterns in relation to the guidelines for using diabetes medication Always Often n (%) Sometimes Rarely Never .
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Table 3.
Implementation of Care Plan Parameter in Pharmaceutical Care Care Plan Indicators I record the assessment results of the diabetes mellitus patient, the diabetes medication, and any related issues encountered with the diabetes medication.
I provide written or verbal information to the diabetes mellitus patient regarding the name of the medication, dosage, and usage instructions for the diabetes medication received.
I explain to the diabetes mellitus patient that the purpose of using diabetes medication is to lower blood glucose levels to within normal range.
I provide information to the diabetes mellitus patient about the effects of lowering blood glucose levels after using diabetes I provide information to the diabetes mellitus patient about the effects of reducing symptoms of the disease after using diabetes I explain to the diabetes mellitus patient about the possibility of experiencing nausea symptoms while using diabetes medication.
I explain to the diabetes mellitus patient about the possibility of experiencing hypoglycemic symptoms while using diabetes I explain to the diabetes mellitus patient the actions to take to manage any unwanted effects that may occur during the use of diabetes medication.
I adjust the usage of diabetes medication based on the dietary patterns of the patient with diabetes mellitus to ensure the accuracy and comfort of medication use I remind the diabetes mellitus patient about the schedule for the next diabetes medication refill.
Always Often n (%) Sometimes Rarely Never .
Often .
n (%) Sometimes .
Rarely .
Never .
Table 4.
Implementation of Follow-up Evaluation Parameter in Pharmaceutical Care Follow-up Evaluation Indicators I confirm with the diabetes mellitus patient about the reduction in blood glucose levels after using diabetes medication.
I confirm with the diabetes mellitus patient about the reduction in symptoms of the disease after using diabetes medication.
I confirm with the diabetes mellitus patient about any adverse effects that occurred during and after the use of diabetes medication.
I confirm with the diabetes mellitus patient about their medication intake routine according to the usage instructions.
Always .
Table 5.
Pharmacist Practice Category in Implementation Pharmaceutical Care Parameters Indicators Trust Understanding Assessment Expectation Concerns Behavior Verification Indication Care plan Effectiveness Category (%) Optimal .
Suboptimal .
Suboptimal .
Suboptimal .
Suboptimal .
Suboptimal .
Optimal .
Suboptimal .
Page | 5 Evaluation of Pharmacist-Based Services for Type 2 Diabetes Mellitus in the Indonesian Community Health Centers Parameters Follow-up evaluation Indicators Safety Adherence Effectiveness Safety Adherence Category (%) Suboptimal .
Suboptimal .
Suboptimal .
Suboptimal .
Optimal .
Factor analysis of the pharmaceutical care parameters Each parameter of pharmaceutical care, consisting of several indicators, was tested using factor analysis.
The results show that the parameter assessment, consisting of 5 indicators, formed one composite.
Similarly, the parameter care plan, also consisting of 5 indicators, also formed one composite.
The analysis of the follow-up evaluation parameter, comprising three indicators, similarly revealed its formation into a singular composite.
The results are shown in table 6.
These findings indicate that each parameter is structured as a solid parameter.
Table 6.
Factor analysis of the pharmaceutical care parameters Pharmacists' practice Parameters Assessment Care plan Follow-up evaluation Number of Indicators Total composite DISCUSSION Pharmaceutical care is a crucial element in the management of chronic diseases, including diabetes mellitus.
Chronic diseases, such as diabetes mellitus, require a sustained and coordinated treatment approach to ensure patient adherence to therapy regimens, symptom management, and complication prevention .
, .
The effective implementation of pharmaceutical care can play an essential role in improving patients' quality of life and reducing the healthcare burden associated with these chronic diseases .
As integral members of the healthcare provider, pharmacists possess a unique position to implement comprehensive pharmaceutical care.
Pharmacists can facilitate the selection of appropriate medications, provide education on medication use, and monitor the effectiveness and safety of therapy.
By offering detailed consultations, pharmacists can help patients understand the importance of adherence to therapy, identify early drug side effects, and make therapy adjustments as needed.
This is particularly crucial considering that diabetes melitus is a condition that requires continuous adjustment and monitoring .
, .
The dominant parameter of assessment implemented by pharmacists in this study was solely patient trust Meanwhile, the assessment of patient understanding, expectations, concerns, and behaviors remains nondominant.
Assessment should be conducted comprehensively to identify drug therapy problems .
It can start with pharmacists building a therapeutic relationship with the patient.
A therapeutic relationship is established by learning why the patient has come to the community health centers, the patient's demographics, medication experiences, and other clinical information .
The implementation of the care plan parameter was also suboptimal in this study.
Only education regarding medication indications was predominantly implemented by pharmacists.
Pharmacists are still not optimal in documenting drug therapy problems, as well as providing education regarding effectiveness, safety, and medication Dispensing medication to patients must be accompanied by comprehensive education and information about the medication .
Patients who understand the treatment goals, effects of medication use, medication safety, and the importance of adherence to medication have a higher potential successfull treatment .
Follow-up and evaluation medication outcomes in patients with diabetes mellitus are also crucial aspects to be implemented by pharmacists .
The implementation of the follow-up and evaluation parameter was also suboptimal in this study.
Only medication adherence follow-up indicator was the most dominantly implemented by Medications are not commodities "unsupervised sale" to patients.
Medications used by patients must be monitored and their effect evaluated.
If problems arise due to medication use, it is important to identify the causes of these problems so that further care can be provided .
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effectiveness, safety, and adherence should be conducted by pharmacists for each individual patient to improve health These same results align with another study conducted in pharmacies in Indonesia.
The study revealed that implementation of pharmaceutical care for diabetes mellitus also found that only 'prepare medications' and 'provide labels with instructions for use' were 100% performed by pharmacists .
The study in Kuwait also showed that providing pharmacy services to diabetes patients is still not optimal.
Only services related to pharmacotherapy are predominantly implemented .
However, the implementation of pharmaceutical care often encounters various challenges, including resource limitations, inadequate specialized training for pharmacists, and insufficient support from the healthcare system.
Time constraints and high workloads also frequently inhibit pharmacists from providing optimal care.
This results in suboptimal medication outcomes for patients .
The factor analysis results indicate that the assessment parameter is composed into one composite factor from 5 indicators.
Similarly, the care plan and follow-up evaluation parameters each comprise one solid composite factor.
This suggests that assessment, care plan, and follow-up evaluation conducted by pharmacists must be comprehensive, encompassing all indicators, to ensure the success and quality of therapy for patients with diabetes mellitus .
Collaborative efforts among various stakeholders in the healthcare system, management support, continuous professional development, and the development of robust supporting systems to ensuring that pharmacists can improve contributions to the management of chronic diseases .
Thus, significant improvements in patient health outcomes and more effective diabetes management are expected to be achieved.
Although it makes a significant contribution, our study has several limitations that need to be acknowledged.
This research has not been able to identify the barriers that cause the suboptimal implementation of pharmaceutical Future research should aim to identify these inhibiting factors so that a more effective pharmaceutical care implementation model can be developed.
Potential bias in this study emerges from the possibility that pharmacists, as respondents, may not accurately recall the implementation of pharmaceutical care they have conducted in the past.
Such inaccuracies can lead to inconsistent reporting, either in the form of overestimation or underestimation, regarding the actual level of pharmaceutical care implementation, thereby affecting the validity and reliability of the study's results.
CONCLUSION
Pharmaceutical care has not yet been optimally implemented by pharmacists for patients with diabetes mellitus at community health centers.
It has the potential to result in suboptimal therapy outcomes for patients.
Various efforts are needed to ensure that pharmaceutical care can be comprehensively implemented for patients with diabetes AUTHORAoS CONTRIBUTION STATEMENT All authors have read and agreed to the published version of the manuscript.
CONFLICTS OF INTEREST
The authors declare no conflict of interest.
SOURCE OF FUNDING STATEMENTS
This research is independent and does not receive financial support from any party.
ACKNOWLEDGMENTS