Drug Dispensing and Counselling: Challenges and Practices in Patient-Pharmacist Communication

The role of communication in healthcare is crucial, particularly when dealing with patients. Effective communication ensures that healthcare personnel can approach and deliver information to patients with the aim of improving their medical conditions. This study aimed to explore the practices and challenges encountered in patient-pharmacist communication and factors affecting it among pharmacists and Provisional Registered Pharmacists (PRPs) in a public hospital in Malaysia. A cross-sectional study was conducted, and a self-administered questionnaire was distributed to the pharmacists and PRPs working in various pharmacy departments in a district hospital in Peninsula Malaysia. The questionnaire consists of demographic information, challenges faced during patient-pharmacist communication, types of resources used to overcome communication barriers, communication difficulties and their communication practices. Descriptive statistics were used to analyse the data. The study found that most of the participants were young adults (21-30 years old), Malay, and held a bachelor’s degree in pharmacy. Most of them worked in the outpatient department and had between 2 to 5 years of work experience. The self-rated communication skills of most of the participants were good, and the majority expressed interest in attending communication-related workshops, seminars, or training. However, the study also identified some limitations, including language barriers and communication difficulties faced by the pharmacists and PRPs when dealing with patients with communication disabilities. Effective communication between pharmacists and patients is essential for providing pharmaceutical care and improving medication adherence. Therefore, efforts should be made to enhance communication skills among pharmacists and PRPs, including


Patient-Pharmacist Communication Approaches
Pharmacists use various communication approaches to overcome the challenges they face when communicating with patients. For instance, using visual aids, such as pictures or videos, can be helpful in overcoming language barriers and low health literacy levels among patients (Mbanda et al., 2020;Park & Zuniga, 2016). In addition, pharmacists can use patient-centred communication techniques, such as motivational interviewing and open-ended questions, to facilitate patient engagement and improve medication adherence (Aubeeluck et al., 2021). One of the most common approaches used by pharmacists in communicating with patients is the use of plain language. This is the use of simple and clear language that is easy for patients to understand (Odegard and Capoccia, 2007). Studies have shown that the use of plain language improves patient understanding and adherence to medication regimens (Quesenberry, 2017). Pharmacists also use active listening and empathy to establish rapport with patients and understand their concerns and needs (Roche et al., 2014). Active listening involves giving patients full attention, asking open-ended questions, and repeating back what they have said to ensure understanding.

Methodology
A cross-sectional study was conducted at a district hospital in Peninsula Malaysia from April until June 2022 (due to confidentiality agreement, the name and locality of the hospital will not be mentioned). The study sample included all 87 pharmacists and PRPs, of which 59 completed and returned the questionnaire. The study used a convenient sampling technique, and participants were invited to complete the questionnaire either through printed copies or an online Google form. The questionnaire consisted of three sections covering background information, challenges in patient communication, and practices in patient communication.
Section A of the questionnaire gathered information on respondents' socio-demographic background, such as age, gender, ethnicity, education level, and working status. In Section B, participants were asked to provide multiple-choice answers to questions about the challenges faced by them when communicating with the patients. Respondents were allowed to select more than one answer per question. Section C of the questionnaire focused on the practices of pharmacists and PRPs in patient communication (as detailed in Table 6). The data were analysed using IBM SPSS Statistics for Windows, version 26. Descriptive statistics such as frequency (N) and percentage (%) were used to analyse respondents' demographic characteristics and responses.

Results and Discussion
Our findings showed that most of the pharmacists were between 21-30 years old (74.6%) and female (83.1%). The most common ethnicity was Malay (74.6%), and the majority held a bachelor's degree (98.3%). The most common position was pharmacist (79.7%), and most worked in the outpatient department (55.9%). Almost half of them had 2-5 years of work experience (47.5%), and most rated their communication skills as good (67.8%). Twelve pharmacists (20.3%) had attended a workshop, seminar, or training related to patientpharmacist communication in the past 12 months, and seven pharmacists (11.9%) had attended sign language classes. Most pharmacists (88.1%) were interested in attending future seminars on patient-pharmacist communication (Table 1).

Patient-pharmacist Communication Challenges
There were several challenges in communicating with patients during medication dispensing or counselling ( Table 2). The most reported challenge was the use of language that the pharmacists were not familiar with, which was reported by 43 respondents (19.6%). This was followed using jargons or unfamiliar terms, and/or slang/dialect that the pharmacists did not understand, which was reported by 32 respondents (14.5%). Patients with low health literacy level were also identified as a significant challenge in communication, reported by 31 respondents (14.1%). Other challenges encountered by the pharmacists and PRPs during patient communication included elderly patients with poor hearing (20.9%), patients with speaking disabilities (15%), and patients with poor cooperation (15.9%). These findings suggest that there are several challenges in communicating with patients during medication dispensing or counselling, and it is important for the pharmacists and PRPs to be aware of these challenges to address them effectively.
Previously, Sevinc et al (2005) recognised the use of medical terms or jargons as a barrier to effective communication between doctors and patients whilst De Young (1996) pointed out that unfamiliar language and jargons caused patient-pharmacist communication difficulties. Meanwhile, Ngoh (2009) stated that low health literacy was a barrier to communication between patients and pharmacists that could lead to various consequences including medication errors, medication non-adherence and many unfavourable health outcomes (Hironaka & Paasche-Orlow, 2007). Therefore, improving communication with patients is essential for improving medication adherence and ultimately leading to better health outcomes. Next, poor health literacy was common among elderly patients (Williams et al., 2002) and they were more easily overwhelmed by health and medical information.
Moreover, Holmes (2014); Cohen et al (2017) pointed out that hearing loss was common and unusually prevalent in the elderly. Findings from Ferguson and Shan (2016) showed that nearly 70% of the pharmacists interacted with at least 1 to 5 deaf patients in a month. Hence, specific measures such as staff education and training are needed to raise awareness on patients (Ferguson & Liu, 2015) with impaired hearing and speaking disabilities alike. In our study, a few of the pharmacists attended sign language classes that might benefit them in their communication with such patients. The use of assistive technology in providing visually stimulating environment could facilitate interactions with patients with hearing disabilities (Blakely et al., 2020). Kengar et al (2022) stated that patient's health literacy, the amount of clear information provided, mutual listening and tone of voice were among the challenges that affected communication between patients and pharmacists.  Table 3 shows that the frequency of pharmacists encountering communication difficulties or problems with patients that varied among the respondents. The highest reported frequency was "at least once a day," which was reported by 17 respondents (28.8%). This was followed by "more than once a week," reported by 14 respondents (23.7%), and "more than once a month," reported by 18 respondents (30.5%). Ten respondents (17%) reported that they face communication problems with patients only once every 6 months.

Experience of Communication Difficulties
The study also identified the experiences of the respondents during communication with patients (Table 4). Among the experiences reported, the most common challenge encountered by the respondents was "difficulty in counselling patients regarding the proper use of medications," reported by 40 respondents (18.5%). This was followed by "patient has poor/limited understanding of his/her health condition," reported by 35 respondents (16.2%), and "difficulty in collecting personal details (e.g., name, address etc.)," reported by 32 respondents (14.8%). Other challenges reported by the respondents were "difficulty in taking medical history (e.g., medical/health conditions, current medications etc.)" (13.4%), "patient has poor adherence to drug regimens/therapy" (14.3%), "patient defaults the prescribed drug therapy" (11.6%), "patient opts for traditional or complementary treatments" (5.6%), and "patient resist from treatment/therapy and/or counselling" (5.6%). Hence, our findings suggest that pharmacists and PRPs encounter various challenges when communicating with patients during medication dispensing or counselling sessions.

Resources Used to Overcome Communication Barriers
Our study also investigated the resources utilised by the respondents to overcome communication barriers (Table 5). The most utilised resource was "refer to colleague or staff who understand patient's native language," reported by 52 respondents (36.9%). This was followed by "use pictograms/infographics/sketches" and "translate patient information sheets available in the department," both reported by 28 respondents (19.9%). Other resources reported by the respondents were "print medication labels in patient's native language" (8.5%), "play or show video clips from YouTube" (8.5%), "have a copy of patient information sheets from the internet" (4.2%), and "others" (6.3%). Therefore, these finding show that they use a variety of resources to overcome communication barriers during pharmacist-patient communication and interaction. Among the resources utilized, referring to colleagues or staff who understand the patient's native language was the most used.
In one study, an animated medication information video with a special focus on patients with limited health literacy was used to provide drug information (Visscher et al., 2021). Dowse (2020) pointed out that pictograms are a valuable tool to disseminate drug information, urging pharmacists to consider their adoption in practice. Likewise, infographics have gained popularity as an innovative tool to communicate easy and quick drug information visually in a colourful and attractive way (McCrorie et al., 2016). Furthermore, in their review, Samaranayake et al (2018) found that simple and straight forward instructions written legibly were better understood by patients. Hence, our findings highlight the importance of having resources available to overcome communication barriers and improve pharmacist-patient communication.

Patient-pharmacist Communication Practices
The results of the study (Table 6) show that the majority of the participants agree or strongly agree with the following practices: introducing oneself to patients before starting any conversation (77.9%), speaking clearly (89.9%), using simplified language (91.6%), avoiding medical jargon (84.8%), speaking in a respectful and courteous manner (88.2%), allowing patients to express their religious/cultural beliefs (76.2%), asking open-ended questions (74.5%), listening actively (83.1%), observing non-verbal cues (76.2%), avoiding distractions (77.9%), showing empathy (86.4%), explaining how medication works in a way patients can easily understand (86.4%), encouraging patients to take responsibility for managing their own health (89.8%), allowing patients enough time to ask questions (84.7%), allowing patients to interrupt with questions (74.5%), making patients feel at ease (88.1%), encouraging patients to talk to their doctors about treatment options (88.1%), and checking patients' understanding at the end of the counseling session (91.5%).
Greenhill et al (2011) stated that pharmacists may need more training to improve the use of specific communication skills such as listening effectively and creating patient-centred consultations. Moreover, Delli et al (2022) found that pharmacists used self-repair practices, such as replacement, clarification, verbatim repeat, and repetition with an elaboration to increase patient understanding. Next, Fesharaki (2019) stated that expressing the correct non-verbal cues is exceptionally important for the pharmacists and PRPs to practice while communicating with patients. Non-verbal communication is expressed by facial expressions, gestures, posture, and physical barriers such as distance from the speaker (Evans, 2003). Findings from Stevenson (2014) indicated the use of non-verbal communication between patients and pharmacists that do not share a common language despite having a multilingual interpreter. Likewise, by having the right management of health communication with patients, it is possible that the patients would take responsibility in self-care for their health (Kourkouta & Papathanasiou, 2014).
On the other hand, a significant portion of participants disagreed or strongly disagreed with the practice of choosing not to deal with patients from other races than one's own (64.4%). Additionally, a minority of participants agreed with the practice of using sign language to communicate with special needs patients (44.1%), which may indicate a need for further training or resources for healthcare professionals in this area. Finally, most participants agreed with the practice of abiding by a code of ethics and professionalism when communicating with patients (89.8%), which is a positive finding. This is important since pharmacists will assist patients in making the best use of their medications (Vottero, 1995)  Nevertheless, there are several limitations to this study. First, the sample size was relatively small and limited to a single hospital in a specific geographic region, which may limit the findings from being generalised to a greater population. Additionally, the study relied on selfreported data, which may be subject to biases or inaccuracies. Moreover, the study only focused on pharmacists and PRPs and did not include other healthcare professionals, such as physicians and nurses, who may also play a role in patient-pharmacist communication.
Suggestion for future studies is to increase the sample size to obtain a more accurate representation of pharmacist-patient communication practices and challenges. The study setting could also be expanded to include multiple hospitals in different regions of the country. Additionally, other healthcare professionals such as doctors or nurses could be incorporated to provide a more comprehensive understanding of communication practices and challenges in healthcare. Qualitative research methods such as interviews or focus groups could be utilised to gather more in-depth and nuanced information on pharmacist-patient communication. It is also recommended to include patient perspectives to obtain a more complete understanding of the challenges faced in pharmacist-patient communication.
knowledge on the importance of effective communication in providing pharmaceutical care and improving medication adherence.
In the context of the Malaysian healthcare system, this research plays an essential role in highlighting the need to improve patient-pharmacist communication. The study's findings can inform the development of communication-related interventions to enhance the quality of pharmaceutical care in public hospitals in Malaysia. The study's recommendations for organizing communication-related workshops, seminars, or training can be implemented to enhance the communication skills of pharmacists and PRPs in public hospitals. Overall, this research can help improve the quality of healthcare services provided to patients in public hospitals in Malaysia by enhancing communication between healthcare personnel and patients.