This study investigated knowledge and practice related to antihypertensive (alpha methyldopa, labetalol, nifedipine and hydralazine) and anticonvulsant (MgSO4 and its antidote, calcium gluconate) drugs among pharmacy workers in selected areas of Bangladesh, particularly at the district and lower level public (i.e. government) facilities as well as private pharmacies and drug stores. It reveals complexities for the prescription of antihypertensive and anticonvulsant drugs and their dispensing staff, particularly due to the lack of availability of authorized, qualified pharmacists in public PHC facilities (e.g. government-run pharmacies). Clinical service providers are often compelled to assume pharmacist duties when registered pharmacists might not be available; they have demonstrated competencies in this capacity. Staff of private drug stores are also prescribing and dispensing the same drugs, completely unregulated, without sufficient knowledge nor any counseling capabilities [27]. To safely and appropriately dispense drugs for pregnancy complications and prevent adverse outcomes, pharmacy workers, particularly those in private pharmacies, must have specific knowledge and skills, including contraindications for medicines, and their use and risks [33, 34]. If pharmacy staffs are to effectively dispense antihypertensive or anticonvulsant drugs for management of hypertensive disorders during pregnancy, they must know which drugs are safe and effective, and what to do in case of adverse events [35,36,37,38,39, 41,42,43,44,45,46,47,48,49]. Unfortunately, information supporting antihypertensive drug use during pregnancy, including benefits and risks, is frequently lacking and contradictory among pharmacy staff in Bangladesh.
Although there is a wide range of training, skills, and experience among pharmacy workers surveyed in this study, particularly among public system health care providers, more than three-fourths of pharmacy staff interviewed demonstrated poor knowledge of antihypertensive and anticonvulsant drugs, primarily due to the number of untrained providers in private pharmacies. Except for accredited medical service providers, pharmacy staff should not diagnose nor prescribe any drugs to patients, but they do [21]. Results indicate that clients who seek medications for hypertension and convulsions during pregnancy from private pharmacies can receive limited or inappropriate counseling, and receive contraindicated drugs. Our findings are similar to other studies in retail drug shops in Bangladesh [13, 39]. A previous study reported that informal allopathic providers commonly prescribe sedatives or sleeping pills, antidepressants, and beta blockers to patients with hypertension in both rural and urban areas [27]. Another study reported that pharmacy workers not only prescribed hypertension medications [40] but menstrual regulation medications as well, and that significant numbers of private pharmacy staff had deficient knowledge in routes of administration, recommend doses, and regimens of mifepristone–misoprostol [41]. Patients seek medications for PE/E from private pharmacies instead of public facility (i.e. government) pharmacies often due to periodic stock outs at government pharmacies. This study found that only 3% of public pharmacies had a loading dose of MgSO4 injection for PE/E management [19].
While most pharmacy staff surveyed in this study’s four districts work in private pharmacies or drug stores, there were significant disparities between public and private pharmacy workers’ knowledge of antihypertensive drugs. Only one-fourth of the pharmacy staff in this study demonstrated correct knowledge for dispensing drugs such as alpha methyldopa, labetalol, nifedipine, and hydralazine that are safe for controlling pregnant women’s high blood pressure during severe PE/E, in addition to providing correct prescribing information for these drugs. Among those surveyed who demonstrated correct knowledge of antihypertensive drugs, only one in 10 correctly dispense MgSO4 injection for women with severe PE/E, usually in public facilities. Those correctly dispensing (as well as prescribing) antihypertensives are primarily service providers (FWVs or SACMOs) who are also practicing pharmacists. These service providers’ superior knowledge may be due to their training on eclampsia and hypertension from the Ending Eclampsia project. Some public pharmacy staff (mostly service providers) prescribe and dispense MgSO4- a safe drug for convulsions, while others prescribe diazepam, and phenobarbitone, two drugs not recommended by WHO and not approved for this use in Bangladesh [26].
This study reveals that private pharmacies and drug shops are mostly unregulated, without any formal accreditation. This demands urgent attention. In LMICs such as Bangladesh, pharmacies are often a primary means of access to health care, but pharmacy workers frequently lack essential information and necessary resources to fulfill complex challenges and needs at the nexus of patient care and safe and effective use of medications.
Public sector pharmacy workers demonstrate greater knowledge of antihypertensive medications likely because of their formal training and accreditation processes that private pharmacy and drug store staff are not provided [39]. This study’s multivariate model found that FWVs and SACMOs with correct knowledge of anticonvulsant drugs were also more likely to correctly prescribe MgSO4 injection for convulsions. Except for FWVs and SACMOs who also work at public pharmacies, pharmacy workers do not prescribe MgSO4 for convulsions but instead dispense the drug, but these pharmacy workers are prescribing as well as dispensing antihypertensive drugs, despite their lack of authorization. Similar findings were reported by John Parr et al. in 2012 in a study of informal allopathic doctors in Bangladesh [27].
A larger challenge for volunteer and community health workers, along with pharmacy workers, is their limited knowledge of PHC beyond drug distribution [42]. Although officially prohibited, many drug sellers provide prescription medications in addition to diagnostic and therapeutic medical advice. One study in Bangladesh found informal practitioners as immediate, essential health care providers among the poor, but with a majority lacking essential training, knowledge, or other capacities to provide basic curative services, and thus contributing to contraindicative drug use [43]. SACMOs and FWVs are associated in this study with significantly better knowledge of antihypertensive and anticonvulsant drugs than all other health care cadres, even pharmacists, likely due to their broad, basic training of 3 years and 18 months, respectively, and clinical practice covering obstetric complications. General pharmacy staff—store clerks, managers, and proprietors—receives no form of medical training and receive no kind of accreditation. Given the unregulated dispensing of drugs in Bangladesh, including prescriptions, it is imperative to reconsider the country’s pharmacy accreditation process and include private proprietors in official drug policy and a comprehensive regulatory process.
While pharmacy staff should not prescribe any drug, it practices it is a common occurrence, and we recommend significant, effective measures to regulate private pharmacies’ dispensation of medications much more closely. Not merely developing pharmacy workers’ health care knowledge beyond medicine dispensing, but integrating them within the formal system as PHC providers with specified responsibilities and formal support should be considered in future policy and programming [44]. Officials in Bangladesh should also implement regulatory policy with routine processes to strengthen the capacities of private pharmacy staffs, particularly their knowledge of prescription medication indications. The public health system should strongly consider adopting, and adapting, innovative education programs already implemented in the country. One private organization, The Vennue Foundation, is implementing a pharmacy workforce education program that equips local staff with the knowledge and skills for effective provision of quality, patient-centered pharmaceutical care [45].
Generally, pharmacy workers in Bangladesh are male, reflected in this study sample as well as others [27]. The female pharmacy workers in this sample are primarily service providers (e.g. FWVs) with other public health responsibilities. Bangladesh’s private and public pharmacy staffing gender disparity differs markedly from the greater South East Asia region, where the majority—54%--of staff is female in independently operated community pharmacies [46]. Bangladesh’s rural female community health workforce, with the exception of family planning programs, is small due to cultural and familial restrictions on women’s employment outside the home [47]. One study has shown that cultural and religious beliefs also create barriers to women’s care during pregnancy, especially when services are only available from male health care workers [48]. To establish an equitable workforce that can provide the most efficacious services for women, who prefer health care services from women, pharmacy owners should endeavor to create more opportunities for female employees. The higher proportion of male pharmacy staff demonstrating correct knowledge of antihypertensive and anticonvulsant drugs than female staff in this study is, at least in part, likely an effect of the proportionally smaller sample of female pharmacists (FWVs with additional responsibilities), exacerbated by women’s limited opportunities for education, training, and equitable employment as pharmacy workers [49, 50]. Although the proportion of female pharmacy workers in South East Asia has increased over the last few decades [51], such a scenario is unlikely in Bangladesh until greater political will is manifested.
Although course curricula for pharmacist diplomas and certificates include various drug categories, practical training for general pharmacy staff including antihypertensive and anticonvulsant drugs for PE/E management, along with other drugs used by pregnant and postpartum women, needs to be developed, officially adopted, implemented, and sustained. The results of this study demonstrate the need for training and continuing education for all pharmacy staff. Job aids and simple instructions, for ready reference by pharmacy staff at all levels, throughout Bangladesh, would also be both useful and beneficial. If Bangladesh’s regulatory authorities incorporate practical information on antihypertensive and anticonvulsant drugs in current and future training modules for all cadres of pharmacy staff, with universal monitoring and support to all pharmacy workers, it can result in improved use and maternal health outcomes for antihypertensive and anticonvulsant drugs.
Limitation
This study should be considered with some limitations, particularly its comparability with other studies and the ability to make causal inferences due to a cross-sectional design. Similar studies, particularly of pharmacy workers’ knowledge of antihypertensive and anticonvulsant drugs, are not available, so we were unable to directly compare findings. Future research should consider longitudinal designs and explore the roles of pharmacy workers in other contexts, such as poor urban settings, where density and patronage of private drug sellers, as initial points of health care, are high.