Pharmacists and Travel Advice for Tropics in Lisbon (Portugal)

Authors


  • Some aspects of this research were presented as poster presentation at the 8th Conference of the International Society of Travel Medicine, May 2003, New York, USA.

Rosa Teodósio, MD, PhD, Tropical Medicine Unit Institute of Hygiene and Tropical Medicine, Rua da Junqueira, 96, 1349-008 Lisboa, Portugal. E-mail: rosateo@ihmt.unl.pt

Abstract

Background In Portugal, little is known about the quality of advice given to international travelers by pharmacists. The aim of this study was to determine pharmacists’ training, experience, and interest in travel medicine and to assess the technical quality of the information given.

Methods We sent a postal questionnaire to all pharmacies in the Lisbon area. The technical director or another graduate pharmacist was asked to complete the questionnaire.

Results A total of 251 pharmacists participated in the study. Most of them (93.2%) did not have any training in travel medicine, and most of them expressed a wish to be informed and/or updated on this subject. The number of advised travelers was low. The use of repellent, protective clothes, and mosquito bed nets was the most frequent advice on protection against mosquito bites. From a subgroup of 170 pharmacists, 43.5% indicated mefloquine and 44.1% indicated chloroquine as malaria chemoprophylaxis to African countries. A significant association existed between the variables “to indicate mefloquine” and “seeks to be informed/updated on travel medicine.” Those who indicated chloroquine tended to like travel medicine less. Concerning diarrhea prevention and treatment, the consumption of bottled and/or treated water and the administration of antibiotics during the episode were the most reported advice. Concerning vaccination against yellow fever, only 8 of 91 pharmacists correctly indicated all Portuguese-speaking countries with and without the risk of this disease.

Conclusions Studied pharmacists need training in travel medicine. Travel advice was incomplete and/or incorrect and must be improved.

In Portugal, the number of persons who travel to tropical countries is in the tens and hundreds of thousands.1,2 According to the Direcção Geral do Turismo—Portugal (General Management of Tourism), in 2001 the number of Portuguese older than 15 years who went on holiday to Brazil was 91,000, to Africa, 56,000, and to Asia, 16,000;3 a bigger group went on holiday to Africa and to Asia during 2002 to 2003.4 However, the characteristics of these travelers and any health advice given to them were relatively unknown. In Portugal, studies on travelers’ health problems began recently.

In the Pharmacists’ Deontological Code, these healthcare professionals should perform educational health promotion activities, as well as carry out tasks concerning medication.5 Documents on Good Pharmaceutical Practice indicate that pharmacists should interpret each prescription with professionalism, noting therapeutic aspects, suitability to the patient, counter-indications, and interactions, and should give advice to patients to guarantee the correct, safe, and effective use of the medication.6

Pharmacists have been pointed out as a possible counseling source for travelers.7 In a study carried out on travelers to Portuguese-speaking countries in Africa (Angola, Mozambique, Sao Tome and Principe, Guinea-Bissau, and Cape Verde), 2.3% of those inquired turned to their pharmacist as a counseling source.8,9 Although the prescription of medication is a medical competency, often the pharmacists sell the drugs without medical prescription.

Studies of Swiss and French pharmacists revealed that most of them advised travelers regularly.10,11 However, authors noted that the advice given was sometimes insufficient or incorrect and concluded that pharmacists needed training and periodic updating of information, as well as cooperation with doctors.

In Portugal, little is known about the quality of advice given to international travelers by pharmacists. In this study, we intended (1) to determine pharmacists’ training, experience, and interest in travel medicine and (2) to assess the technical quality of the information given regarding malaria, diarrhea, and yellow fever.

Study population and methods

We sent a postal questionnaire to all pharmacies in the Lisbon area (a total of 628 pharmacies). Either the technical director or another graduate pharmacist was asked to complete the questionnaire, on the condition that he/she had at least 1 year’s experience of public attendance in that pharmacy. The questionnaire was anonymous and not of an obligatory nature. With the intention of increasing the response rate, about 1 month later, the questionnaire was resent to all the pharmacies, reminding them of the need to return it if they still had not. The study took place from November 2001 until January 2002 after ethics approval. It was previously pretested with another group of pharmacists.

The questionnaire had closed questions and open questions. Closed questions were dichotomized, single-choice answer lists or multiple response with an “other” category, or scaled. The questions requested information on sociodemographic and training data, work experience in travel medicine, the search for information and updating, usual sources of information, personal preference for travel medicine, themes broached when giving travel advice, what they do in case of doubt, and the frequency of information exchange with other entities in the travel health area. The open questions were about what advice pharmacists would give to a healthy adult who intended to travel to tropical Africa. The answers to these questions were analyzed by content analysis through comparison with a list of eligible items to each answer that had been previously defined. All the quality criteria with which the answers were compared were drawn from World Health Organization publications.12

Data were analyzed using the SPSS package (version 7.5; SPSS Inc., Chicago, IL, USA). We considered the significance level of 5%. The statistical tests used were as follows: chi-square test, Mann–Whitney test (M-W test), and Spearman’s correlation test.

Results

A total of 251 pharmacists participated in this study (39.96% of the total questionnaires), 20.1% were male and 79.9% female. The average age was 43.55 years (n= 238, SD = 13.75 years, minimum = 24 years, and maximum = 84 years), and the average time since graduation was 17.66 years (n= 216, SD = 13.25 years, minimum = 1 year, and maximum = 60 years).

Training, experience, and interest in travel medicine

In 5.2% (13/248) of the pharmacies, travelers were never advised about health care. In a group of 218 pharmacies, it was noted that in 87.6%, advice was sought by up to three travelers a month, and only in 2.9% (n= 6) of the pharmacies, advice was sought by 10 or more travelers a month.

Most of the pharmacists who participated in the study (93.2%) did not have any training in travel medicine. However, 77.9% (187/240) of these professionals attempted to stay informed and/or updated on this subject. The main information sources used were Centros de Informação do Medicamento in Portugal (Medication Information Centers) (77.9%), the Internet (32.6%), tourist destination magazines (33.2%), and doctors (32.1%) in a group of 190 respondents. Only 86.5% of the pharmacists (147/170) reported a need for specific training to advise travelers to the tropics. Only a small percentage (2.9%) of these professionals indicated that they “did not like” this area of medicine, while more than half expressed a great interest on this subject (Figure 1).

Figure 1.

Pharmacists’ personal liking for travel medicine (n= 244).

Table 1 shows that the pharmacists who had been in tropical countries tended to have more interest in this thematic area (p= 0.001). A positive correlation existed between the variables “personal liking for travel medicine” and “number of travelers advised in the pharmacy” (p < 0.001). In spite of no correlation with the variable “age” (p= 0.402), it was noted that the pharmacists who reported not liking travel medicine were essentially of a higher age group (Figure 2).

Table 1.  Pharmacists’ interest in travel medicine—statistical differences, associations, or correlations between variables
Variables nStatisticsp value
  • *

    Seek to be informed/updated in travel medicine.

  • Mann–Whitney test.

  • Spearman correlation test.

  • §

    Chi-squared test.

Personal liking for travel medicineSex Mean rank 
 Male49127.470.483
 Female193119.98
Had been in tropics Mean rank 
 Yes167130.130.001
 No7398.47
Informed/updated* Mean rank 
 Yes184130.08<0.001
 No5174.43
Age231rs=−0.0550.402
Number of travelers advised  in the pharmacy213rs= 0.278<0.001
Seek to be informed/updated in travel medicineSex238χ2= 0.0010.973§
Had been in tropicsInformed/updated*236χ2= 1.1180.290§
Need training in travel medicineInformed/updated*165χ2= 0.2580.611§
Time since graduationInformed/updated* Mean rank 
 Yes161102.500.501
 No46109.24
Number of travelers advised in the pharmacyInformed/updated* Mean rank 
 Yes169111.030.003
 No4079.53
Figure 2.

Variation of pharmacists’ age according to categories of the variable “personal liking for travel medicine.”

Pharmacists who sought to be informed/updated in travel medicine had, as a tendency, a greater personal preference for these subjects (p < 0.001) and worked in pharmacies where more travelers were advised (p= 0.003). There was no statistical relation between other studied variables (Table 1).

Advice to travelers

In the pharmacies that provided advice to travelers (n= 236), it was found that 89.8% advised about malaria prevention, 97.0% on prevention/treatment of diarrhea, and 64.4% advised the travelers to have a vaccination. Of the remaining subjects, the advice on solar protection (90.7%) and recommended medication (75.4%) stand out.

Statistical differences/associations were sought between the variables that characterized the advice given to travelers and the variables “time since graduation,”“training in travel medicine,”“have been to the tropics,” personal liking for travel medicine, “frequency of information exchange with travel medicine consultations,”“contact with travel medicine clinics in case of doubt,” and “seeks to be informed/updated in travel medicine.”

Malaria transmission

In the group of pharmacies where travelers were advised on malaria prevention, 41.0% of the respondent pharmacists did not indicate that transmission of this disease is by mosquito bite, and nearly all pharmacists (90.8%) failed to mention the biting habits of Anopheles spp.

Statistical differences/associations were sought out between the variable “indicates malaria transmission by mosquito bite” and the variables listed above. Pharmacists who indicated malaria transmission by mosquito bite graduated, as a tendency, a shorter time ago (M-W test: p= 0.006). There was no statistical relation between other studied variables.

Protection against mosquito bites

In the group of pharmacies where travelers were advised on malaria prevention, the use of repellent, protective clothes, and mosquito bed nets was the most frequently transmitted advice (Figure 3). We sought out possible differences/associations between each one of the variables “indicates the use of repellent,”“indicates the use of protective clothes,” and “indicates the use of mosquito bed nets” and the variables in the study listed above.

Figure 3.

Advice on antimosquito measures—pharmacies where travelers were advised on malaria (n= 180).

Pharmacists who indicated the use of repellent tended to have graduated a shorter time ago (M-W test: p= 0.006). Those who indicated the use of mosquito bed nets tended to have graduated a shorter time ago (M-W test: p= 0.021) and to be more interested in travel medicine (M-W test: p= 0.007). A significant association existed, in a positive sense, between each one of the variables that indicates the use of mosquito bed nets and indicates the use of protective clothes and the variable seeks to be informed/updated in travel medicine (n= 193, χ2= 7.305, p= 0.007 and n= 193, χ2= 8.418, p= 0.004, respectively). There was no statistical relation between other studied variables.

Malaria chemoprophylaxis

In the group of pharmacists working in pharmacies where advice on malaria prevention was given, more than a half (55.9%) tended not to indicate any chemoprophylactic drug. From the remaining pharmacists, 44.1% indicated chloroquine and 43.5% indicated mefloquine to a healthy adult who intended to travel to tropical Africa, with a significant association between the variables “indicating chloroquine” and “indicating mefloquine” (n= 170, χ2= 10.404, p= 0.001); 2.9% indicated doxycycline and 2.4% indicated the chloroquine–proguanil combination. It is important to mention that 12.9% of pharmacists indicated a drug not used in prophylaxis (halofantrine, primaquine, or quinine). At the time of the study, the atovaquone–proguanil combination was not available in our country. Regarding the chemoprophylactic dosage regimen, only 14.8% (11/74) of pharmacists who indicated mefloquine advised on dosage and chemoprophylactic period correctly.

We sought out a statistical relation between the variables indicating mefloquine and indicating chloroquine and the variables reported in the previous points. Pharmacists who indicated chloroquine tended to like travel medicine less (M-W test: p= 0.038). The association between the variables indicating mefloquine and seeks to be informed/updated in travel medicine was significant (n= 181, χ2= 6.432, p= 0.011). There was no statistical relation between other studied variables.

Prevention and treatment of travellers’ diarrhea

Figure 4 shows the advice given on prevention of diarrhea by pharmacists who worked in pharmacies where advice on prevention/treatment of diarrhea was given. No significant relation was found between the variable “indicates the consumption of bottled and/or treated water” and the variables listed above.

Figure 4.

Advice on prevention of diarrhea—pharmacies where travelers were advised on prevention/treatment of diarrhea (n= 196).

Concerning diarrhea treatment, the administration of probiotics, antibiotics, or loperamide was the most reported advice, suggested by more than half the pharmacists, while the need to prevent dehydration with available fluids was indicated by one third of the respondents (Figure 5).

Figure 5.

Advice on treatment of travelers diarrhea—pharmacies where travelers were advised on prevention/treatment of diarrhea (n= 191). ORS = oral rehydration solution.

Protection against yellow fever

In the group of pharmacists who worked in pharmacies where travelers were advised to have a vaccination, 21.2% (22/104) did not indicate vaccination as the protection against yellow fever. The variable “seeks to be informed/updated in travel medicine” was significantly associated with the variable “indicates vaccine against yellow fever” (n= 150, χ2= 6.034, p= 0.014). There was no significant relation with the other variables referred to in the previous items.

Questioned on which Portuguese-speaking countries advised to vaccinate against yellow fever (Angola, Mozambique, Sao Tome and Principe, Guinea-Bissau, Cape Verde, Brazil, and Timor-Leste), 26.8% of the respondents (48/183) reported they were unfamiliar with this. The proportion of pharmacists who correctly indicated all Portuguese-speaking countries with and without the risk of yellow fever was 8.8% (8/91).

Discussion

The answer rate of 39.96% obtained with this questionnaire was lower than that obtained in similar studies performed with Swiss pharmacists (about 80%)10 but higher than the answer rate pointed out by specialist literature in this kind of questionnaire (about 10%).13

A certain “ageing” of the study population was noted because a quarter of the respondents were older than 50 years and more than 26 years had passed since their graduation. This aspect was useful, as it could test if these two characteristics were related to variations found in other variables in the study.

In almost all the pharmacies, advice was given to travelers with the exception of only 5.2%. Advice was given on a relatively regular basis, but the number of travelers advised was low. The indicated values result from an appreciation of the respondent pharmacists, certainly approaching the real values—this study did not consider local registration of those travelers who sought advice.

Almost all the pharmacists did not have any training on travel medicine or on a related area. Such a fact should reflect the curricula of the pharmacists’ degrees and postgraduate training opportunities. It seems that they wish to increase their knowledge in this area because about three quarters of pharmacists sought to be informed/updated and a superior percentage referred their need for specific training to advise travelers.

The fact that only a small percentage of pharmacists (13%) reported “frequently or always” to consult information sources before advising a traveler was probably because most of these professionals believed they had enough knowledge on specific themes, as in other studies.11 It was noted that a personal liking for travel medicine tended to be greater in pharmacists who sought to be regularly informed/updated, in those who exchanged information with travel clinics more frequently, and in those who recommended consulting a travel clinic when in doubt about what advice to give. As in many other situations, this subjective aspect certainly influences attitudes and behavior. In addition, those who sought to be informed/updated and those who frequently exchanged information with travel clinics worked in pharmacies where, as a tendency, a larger number of travelers sought advice, suggesting professionalism and concern for clients.

“To work in a pharmacy where travelers have been advised” was not statistically associated with “to advise correctly” for respondents of the questionnaire. This suggests that the exchange of knowledge among pharmacists was not effective or that individual factors were more related to the advice given. Repellents are sold without prescription in the pharmacies. The high percentage of advice on the use of repellent to avoid mosquito bites reflects this situation.

Concerning chemoprophylaxis, the values achieved were substantially different from the ones found in a study of Swiss pharmacists10 in which almost the total indicated accurate advice for Kenya. We noted a significant association between indicating mefloquine and indicating chloroquine in the group of pharmacists who worked in pharmacies where information about malaria was given. This suggests that these pharmacists tended to consider both medications as equivalents for chemoprophylaxis. Concerning the dosage regimen, a greater part of the pharmacists who indicated mefloquine seem to ignore the proper dosage for prophylaxis, with the possibility of risks for the health of the traveler.

Pharmacists who graduated a shorter time ago and those who sought to be informed/updated tended to give correct information on malaria. This aspect suggests that the curricula of the most recent degrees have included subjects in the area of travel or tropical medicine or that the importance of health education was more recognized within this group of pharmacists. The variables “experience of previous stays in the tropics,”“to have training in travel medicine,” and “to exchange information with travel clinics” were not related, in this sample, with malaria advice.

There were no statistical differences/associations between the variable indicates the consumption of bottled and/or treated water and other pertinent variables. However, those who indicated this kind of care tended to have finished university a shorter time ago.

The group of pharmacists who worked in pharmacies where travelers were advised on prevention/treatment of diarrhea indicated mainly the medicinal treatment (probiotics, antibiotics, or loperamide) in case of diarrhea during the trip. This aspect, allied with the fact of there being a significant association between “to have travel medicine training” and “advise to increase consumption of potable water and/or oral rehydration salt solutions during the episode,” led us to believe that the professional predisposition to deal with drugs was enhanced, while other treatments like rehydration, that are simple and effective in most of the cases, were not mentioned.

The percentage of pharmacists who correctly pointed out all Portuguese-speaking countries with and without indication to vaccinate against yellow fever was very low (8.8%). This aspect shows a great unfamiliarity with this vaccine and the insufficient specific training of these professionals.

Measures are needed to improve the quality of the advice given by pharmacists. We believe that specific training, credible information sources, and more exchange of information with travel clinics are good ways to improve the advice given by these professionals.

Declaration of Interests

The authors state that they have no conflicts of interest.

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