Community pharmacists' management of minor ailments in developing countries: A systematic review of types, recommendations, information gathering and counselling practices

To conduct a systematic review of the management of minor ailments by community pharmacists in developing countries, and to identify the specific minor ailments encountered, the medications recommended or requested and the information gathering and counselling practices.


| INTRODUC TI ON
William Ostler (1891) stated that 'a desire to take medicine is, perhaps, the great feature which distinguishes man from other animals'. 1 This aphorism seems appropriately captured by the phenomenon of self-medication for the management of medical conditions that are perceived as minor by patients. Minor ailments are common, selflimiting and uncomplicated conditions that are often diagnosed and treated without the intervention of a medical doctor, and they remain the centrepiece of self-care practices worldwide. [2][3][4] However, minor ailments have become a major source of clinical and financial burden especially in high-cost settings, and these are related mainly to service delivery and cost of care. 5 For instance, about 13% of the 340 million visits to general practitioners (GPs) in United Kingdom (UK) were related to minor ailments that were considered suitable for management by nonmedical professionals including community pharmacists. 6 It has also been reported that up to 18% of the workload of GPs are related to minor ailments and cost the UK about 2 billion pounds annually, while about 8% of Emergency Department (ED) visits related to minor ailments cost about 136 million pounds per annum. 7,8 Hence, the cost and service delivery burden associated with minor ailments are clearly substantial and appear to place enormous strain on the health care system. However, the clinical and financial burden currently associated the management of minor ailments can be mitigated with the use of other primary care professionals including community pharmacists to deliver minor ailment services. 5,9,10 Community pharmacists are healthcare professionals with medicine-related and clinical skillsets that uniquely placed them to manage minor ailments. The geographic and social access to community pharmacists, the impressive rates of symptoms resolution of minor ailments managed by community pharmacists, and patients' trust in and satisfaction with the recommendations and counselling services provided are well documented. [10][11][12][13][14] Furthermore, the outcomes of minor ailments managed by community pharmacists equate that obtained at the high-cost settings such as ED and GPs and were substantially lower in cost. 5,9,12 In addition, the ceding of the tasks of managing minor ailments to community pharmacists appeared well received by physicians as this could enable them to focus more effectively on complex medical cases, reduce waiting time and improve the efficiency. 7,15,16,17 Published evidence from developed countries such as UK, Canada, Australia and New Zealand showed that the use of specific protocols or frameworks for the management of minor ailments by community pharmacists achieved positive clinical outcomes at relatively lower cost. [18][19][20][21][22][23][24] However, no such published evidence from developing settings exist. Although, the information gathering and counselling activities of community pharmacists and nonpharmacist staff during the management of self-medication requests involving chronic medical conditions and minor ailments have been reported. 25,26 In addition, some studies have also documented self-medication practices involving prescription-only medicines for communicable and noncommunicable diseases and its handling by community pharmacists and other staff members in developing countries. 27,28 However, no systematic review exists that is focused specifically on the community pharmacists' management of minor ailments in developing countries. In addition, the evidence is unclear regarding the information gathering and counselling practices associated with the community pharmacists' management of minor ailments in developing countries. Yet, minor ailment-induced encounters by patients with community pharmacists is a major component of health-seeking behaviour and self-care practices in developing countries. 29,30 Hence, the current systematic review is warranted and will probably provide significant perspectives from developing countries that potentially adds to the published knowledge in the research area. The aim of the systematic review was to assess the protocol and vary in the quality of recommendations, information gathering and counselling practices.

What's known?
• Minor ailments remain a major source of clinical and financial burden especially in high-cost settings in both developed and developing countries, but this can be reduced with ceding the task of managing minor ailments to community pharmacists.
• Published evidence from developed countries showed that the use of specific protocols for the management of minor ailments by community pharmacists is associated with positive clinical outcomes at relatively lower cost.

What's new?
• Management of minor ailments by community pharmacists in developing countries is unstructured and not guided by a specific standard protocol.
• The absence of a specific standard protocol appeared responsible for the wide variation in information gathering and counselling practices by community pharmacists during the management of minor ailments in developing countries.
• There is dearth of published data related to the assessment of the outcomes of the management of minor ailments by community pharmacists in developing countries.
• There is a clear need for a standard protocol to guide the planning, delivery and evaluation of minor ailment services by community pharmacists in developing countries. management of minor ailment by community pharmacists in developing countries, the types of minor ailments encountered, the medications recommended or requested and information gathering and counselling practices. In addition, the study also assessed the availability and/or the use of a protocol or guideline specifically for the management of minor ailments by community pharmacists in developing countries.

| ME THODS
A systematic review was conducted to synthesise evidence about the management of minor ailments by community pharmacists in developing countries. The search was specifically focused on the types of minor ailments and medications recommended by community pharmacists or requested for by patients and on the associated information gathering and counselling practices. A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and reviewed for clarity and focus by the authors. 31

| Literature retrieval
Three electronic databases (PubMed, ScienceDirect and Cochrane Library) were searched to identify relevant studies. The number of databases used for systematic literature search was in compliance with PRISMA statement 2009 and AMSTAR guidelines, which recommend full electronic search strategy for at least one database or at least two bibliographic databases, respectively. 32,33 The key search terms used include 'community pharmacy', 'community pharmacies', 'community pharmacist', 'community pharmacists', 'pharmacist', 'pharmacists', 'minor ailments', 'minor illness', 'self-care',

| Inclusion criteria
The systematic review covered studies published in English language from inception up until 2019. The criteria for inclusion are as follows: studies conducted in developing countries that surveyed community pharmacists and/or consumers about encounters associated with minor ailments, self-medication practices associated with minor ailments and managed by community pharmacists, and information gathering and counselling practices of community pharmacists related to the management of minor ailments in developing countries.
The United Nations' World Economic Situation and Prospects (WESP) classification was used to identify the developing countries included in the systematic search, and this classification was based on a model developed by the Department of Economic and Social Affairs of the United Nations Secretariat. The WESP classified countries essentially on the basic economic country indices into three major categories including developed, developing and in transition. 38

| Exclusion criteria
Studies were excluded if they were conducted in countries not classified by WESP as developing, focused on self-medication with prescription-only medicines or for medical conditions that are chronic or severe. In addition, studies that addressed activities or interventions not related to minor ailments among community pharmacists, interventions or practices related to minor ailments by nonpharmacist staff members in community pharmacies, or activities by clinical pharmacists or hospital pharmacists, systematic reviews, editorials, and commentaries were also excluded.

| Data extraction
The identified studies were uploaded to a citation management soft-  (Table 1), and the minor ailments encountered, medications recommended and the community pharmacists' information gathering and counselling practices ( Table 2). The processes of screening, data extraction and presentation of results were guided with items recommended in the PRISMA statement and PRISMA checklist.

| Quality assessment of the included articles
The included articles were assessed for quality with the Crowe Critical Appraisal Tool (CCAT). 69 The tool focuses on eight domains for quality assessment, and these include preliminaries (title, abstract and text), introduction (background and objective), design (research design, intervention, treatment, exposure, outcome, output, predictor, measure and bias), sampling (sampling method, sample size, sampling protocol), data collection (collection method,

TA B L E 2 (Continued)
ethics), Results (analysis, integration, interpretation method, essential analysis, outcome, output, predictor analysis), and discussion (interpretation, generalisation and concluding remarks). The CCAT tool was used to assess the quality of all the included articles in all the eight domains, and a total score was calculated and converted into a percentage for each article. The percentage scores were classified into three categories: High quality (≥80%), medium-quality (60%-79%), and poor-quality (<60%). The quality assessment was done independently by the authors, and disagreements were resolved with consensus.

| Systematic search and screening
The preliminary searches of the three electronic databases produced 7808 studies. Additional 56 studies were identified from grey literature and hand searches ( Figure 1). Hence, 7867 studies were identified after the initial search, and 1975 duplicates were removed. Five thousand eight hundred ninety-two studies were included for the title/abstract screening, out of which 5744 were excluded due to ineligibility. In total, 148

F I G U R E 1 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart of literature search and study selection
studies were subjected to full-text reading, out of which 118 were excluded: systematic review (10), prescription-only medicines (41), pharmaceutical care (32), and general attitude to pharmacists' roles (35). Hence, 30 full-text studies were used for the systematic review ( Figure 1).

| Study characteristics
The methodological and participant characteristics of all the included studies are as shown in Table 1

| Information gathering and counselling practices by community pharmacists and the protocol/framework used to guide the management of minor ailments
The information gathering and counselling practices of community pharmacists during the management of minor ailments in developing countries is as shown in Table 2. None of the studies reported the availability and/or use of a specific protocol or framework for the management of minor ailments.  The type and depth of information gathered and used for the planning and recommenda-

| Impact assessment of minor ailment services provided by community pharmacists
Only one of the studies from developing countries reported outcome assessment of the clinical, economic impact of the management of minor ailments by community pharmacists. 56 However, a study reported that a majority of customers (90%) were satisfied with the management of minor ailments by community pharmacists. 51

| D ISCUSS I ON
Evidence from this systematic review generally suggests that minor ailment-induced encounters is widespread and seems to present a good opportunity for community pharmacists to contribute significantly to reducing disease burden in developing countries. Indeed, the fact that most of the minor ailments-related encounters reported were unguided and involved mostly verbal requests for specific medicines strongly warrants the involvement of a primary health care professional with medicine-related and direct patient care competencies such as community pharmacists. Such interventions by community pharmacist may enhance the achievement of positive outcomes and potentially improve public health. 26,27 The extent of minor ailments-induced patients' requests encountered by community pharmacists in developing countries seem consistent with trends in developed countries. In addition, the range of minor ailments and medicines recommended by community pharmacists in developing settings also appear consistent but not as comprehensive relative to developed settings. 5,6,9,10,11,12 This suggests that minor ailments probably continue to be a critical driver of clinical burden in both developed and developing settings. However, the lack of published evidence about the availability and/or use of a specific protocol to guide the management of minor ailments by community pharmacists is inconsistent with trends in developed countries. [19][20][21][22][23][24][25][26][27][28][29] Hence, it is unsurprising that the management of minor ailments by community pharmacists in developing settings is unstructured and seems based on individual preferences or initiatives. The absence and/or non-usage of a specific protocol may also be responsible for the wide variation observed in the frequency and depth of patient information gathered during the planning phase; and the counselling information provided to consumers. In fact, the observation that the counselling on side effects, drug interactions and contraindication were the least provided clearly underscores the need for a specific minor ailmentspecific standard protocol to serve as a guide and reminder to community pharmacists. Indeed, the development and use of such a minor ailments-specific standard protocol may potentially reduce variation in the quality of service delivery by community pharmacists during the management of minor ailments and ensure a more efficient use of available healthcare resources at the primary care level.
The lack of documentation of the interventions and referrals made by community pharmacists during the management of minor ailments is probably connected to the non-availability or non-usage of a minor ailments-specific protocol that should specify a priori the standards that must be met during service delivery. Hence, there is no incentive or mandate for community pharmacists to document their activities. Therefore, there is a clear need for the development and use of a minor ailments-specific standard protocol to serve as guide and reminder to community pharmacists. This may potentially reduce variation in service delivery and improve effectiveness.
However, it is important to ensure that community pharmacists are actively involved in the development of such a standard protocol from the start. This is more likely to create a sense of ownership among community pharmacists and enhance the prospect of the use of such a protocol to guide their management of minor ailments. Finally, the lack of sufficient published evidence related to the assessment of the outcome of the management of minor ailments by community pharmacists in developing countries is inconsistent with trends in developed settings. 5,9,10 This is because only one study reported a limited outcome assessment for minor ailments managed by community pharmacists in Thailand. The Thailand study showed that two-third of the patients with minor ailments (77.9%, 539/692) managed by community pharmacists reported complete recovery at lower unit cost relative to physicians and nurses. 58 The findings of this single study is consistent with those reported in developed settings, 5,9,10 and this is probably expected as community pharmacists, irrespective of settings, are expected to guide the effective and safe management of minor ailments based on the entry-level knowledge, skills and competences acquired during the undergraduate pharmacy training.

| Strengths and limitations
The synthesis of evidence from the eligible studies was conducted

| CON CLUS ION
Community pharmacists' encounter with and management of minor ailments appear extensive in developing countries and probably present an opportunity to contribute significantly to reduce disease burden and enhance public health. However, the management process is currently unstructured, unguided by a specific protocol and vary in the quality of recommendations, information gathering and counselling practices. There is a clear need for a standard framework to guide the planning, delivery and outcome assessment of minor ailment-related services provided by community pharmacists in developing countries.

D I SCLOS U R E
No potential conflict of interest was reported by the authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.