Malaysia_journal_of_pharmacy.pdf

Malaysian Journal of PharmacyVolume 1 Number 1 May 2001

The Official Journal of the Malaysian Pharmaceutical Society

Editor-in-Chief: Dr. Yew Su Fong

Associate Editors: Assoc. Prof. Dr. Abas bin Hj Hussin

Dr. Ab Fatah bin Haji Ab Rahman

Dr. Abu Bakar Abdul Majeed

Assoc. Prof. Dr. Aishah bte Adam

Assoc. Prof. Dr. Chung Lip Yong

Assoc. Prof. Dr. Hadida bte Hashim

Prof. Dr. Mohd. Isa bin Abdul Majid

Mr. John Chang

Dr. Mohamed Izham bin Mohamed Ibrahim

Assoc. Prof. Dr. Mustafa Ali Mohd.

Assoc. Prof. Dr. Paraidathathu Thomas a/l P.G. Thomas

Mr. Wong Kok Thong

Mr. Wong Sie Sing

Prof. Yuen Kah Hay

Publisher: Malaysian Pharmaceutical Society

P.O. Box 158 Jalan Sultan

46710 Petaling Jaya

Selangor

Malaysia

Tel: 03-77291409

Fax: 03-77263749

Homepage: www.mps.org.my

Email:[email protected]

The Malaysian Journal of Pharmacy is a bi-annual publication of the Malaysian Pharmaceutical Society.Enquiries are to be directed to the Publisher at the above address or the Editor-in-Chief at the PharmacyDepartment, Faculty of Allied Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda AbdulAziz, 53100 Kuala Lumpur. The Publisher reserves copyright and renewal on all published materials, andsuch material may not be reproduced in any form without the written permission of the Publisher.

Editorial

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Table of Contents

EditorialPublish and disseminateSF Yew

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General ArticlePharmacy practice in MalaysiaSS Wong

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Continuing Pharmacy EducationBioethicsA B A Majeed

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Research PapersCareer choice of Malaysian pharmacystudents: A preliminary studyAR Ab Fatah, MI Mohamed Izham, MY Zuraidah, BMohd Baidi & I Rusli

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Public awareness of community pharmacyand pharmacistsH Hadida, M Ahmad, WH Lim, PY Lum, MYNatasha, YB Tang

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Development of a high-performance liquidchromatographic method for analysis ofglibenclamide from dissolution studiesWI Wan Azman, N Mohamed Ibrahim, H Hadida, AKumar

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Book ReviewFarmakologi Perubatan Sekali Imbas: M.J.Neal, Edisi Ketiga. Terjemahandikendalikan oleh Unit Terjemahan MelaluiKomputer. Penyunting Terjemahan: AbasHj. Hussin.A Adam

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Instructions to Authors 37

Editorial

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Editorial

Publish and disseminateResearch in pharmacy-related areas within this country is growing. If not for anything

else, the job promotion tied to research publications should serve as a carrot to

academicians, and yet many useful local research findings have ended up as

dissertations kept in the darkest corners of the library. While research is normally

associated with academicians, it is not confined to that group. Practising pharmacists

also play an important role. For example, the Malaysian Pharmaceutical Society has

supported studies such as Survey on Diabetic Care Management, that was presented

by the Pharmacy Practice Chapter at the Societys Project 2003 Workshop II held at

Kuala Lumpur in 1999. The findings however were only shared among the group of

pharmacists who were able to attend. Many hospital pharmacists also do carry out

small research projects, but presentation of the results is often limited to members of

that department. All these highlight the need for proper documentation, where

valuable findings can be widely disseminated and discussed, and help reduce

repetitions in research.

So, for a long time now, it has been the aim of the Malaysian Pharmaceutical Society

to publish its own journal. As well as to encourage research and publication, this

journal intends to keep local pharmacists, academicians and others in the related areas

in touch with the profession. This bi-annual nationally peer-reviewed journal covers

areas related to Pharmacy in the form of General Articles, Invited Reviews, Research

Papers and Book Reviews. In addition, the Continuing Pharmacy Education section

allows members to earn CPE points. The editors would like to invite you to submit

manuscripts for the areas above, which will be reviewed year round. Please refer to

the Instructions for Authors on page 36 for more information. Feedback on articles in

each issue is welcomed, and these will be published in the Letters to the Editor section

in the following issue.

In order for the widest readership possible, this journal will be distributed to members

of the Society throughout the country, and later on, to allied health professional

organizations, universities and relevant government agencies. We hope that for now,

this journal will be the avenue for pharmacy publications within the country, and that

our boundaries will expand regionally in the future.

Yew Su Fong

Malaysian Journal of Pharmacy 2001 1:2-8 General article

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Pharmacy Practice in MalaysiaWong Sie Sing

8 Jalan Court House, 93000 Kuching, Sarawak, Malaysia

ABSTRACT

Pharmacists in Malaysia practise their profession in rugged terrains which demandboth professional skills and pioneering spirits. Many of the current pharmaceuticalstandards, practices, and legislations need overhauling in order to meet theaspiration of the nation in this new millennium. The Malaysian PharmaceuticalSociety has a vital role to play. The profession requires the greatest understandingof the Malaysian Medical Association and the Government in this transition period.

Keywords: pharmacy practice, pharmacy standards, legislations, healthcare, Malaysia

INTRODUCTION

Pharmacy is a learned profession. It is a well-established science-based profession whichpossesses all the essential characteristics of aprofessional group. Four main characteristicsreflect the professions distinctiveness: the specialsphere of knowledge and intellectual discipline,well defined functions, professional ethics andconduct, and practitioners representative body.Persons who desire to partake in the professionneed to master the pharmaceutical sciences.

The first distinctive characteristic concerns thespecial sphere of knowledge and intellectualdiscipline. Knowledge in the pharmaceuticalsciences may be acquired through undergraduatepharmacy degree courses presently availablelocally in Universiti Sains Malaysia, UniversitiMalaya, Universiti Kebangsaan Malaysia,International Medical University, Sepang Instituteof Technology and Sedaya College. In addition tothese six institutions of higher education,Universiti Teknologi Mara and InternationalIslamic University are expected to offer pharmacydegree course soon. Pharmacy graduates from 56other overseas universities, in 13 countries, are alsorecognized by the Pharmacy Board (1). Only pharmacystudents who have satisfactorily completed theprescribed course are permitted to embark upon

the compulsory twelve months of pre-registrationtraining in an establishment recognized by thePharmacy Board. Currently a pre-registrationpharmacy graduate has a choice to receive trainingin either hospital pharmacy, community pharmacy,manufacturing pharmacy or wholesale tradingpharmacy.

The second feature is the presence of a nationalbody representing all the pharmacy practitioners.Malaysian Pharmaceutical Society (MPS) wasformed and incorporated under the Society Act in1965. It promotes pharmaceutical practice, protectsthe interests of the practitioners and end-users, andencourages the advancement of the pharmaceuticalsciences. It is interesting to add here that anothertwo pharmaceutical societies, namely SabahPharmaceutical Society and SarawakPharmaceutical Society also co-exist to championthe pharmacy profession in the states of Sabah andSarawak, respectively.

The third feature relates to the professional ethicsand conduct which guide all members. TheCouncil of MPS had issued a guideline on thematter. Uniquely the Pharmacy Board had alsoissued the Code of Conduct For Pharmacists andBody Corporates. By virtue of the power given to

General article: Pharmacy practice in Malaysia

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the Pharmacy Board under Section 22(1)(e) and (j)of the Registration of Pharmacists Act 1951, thisdocument may be legally binding upon thepharmacists.

The fourth feature of a learned profession is theprovision by its practitioners of uniformprofessional services and advice to the public. Thisrefers to the supply of medicines to the public,accompanied by appropriate advice (that is, patientmedication counseling) during the dispensingprocess.

Pharmacy, as a learned profession, was rarelychallenged since time immemorial. The inherentdynamism has brought it through several rounds ofprofessional metamorphosis. As a result, thepractice of pharmacy has been described in avariety of ways.

WHAT IS PHARMACY PRACTICE?

Differing views have been presented on thismatter. Some consider it a profession, others lookat it as a trade albeit a professional one. There isno concise and precise description on whatpharmacy practice should be. Perhaps thedifficulty is due to the co-existence of bothspecialized and generalized professional serviceswhich the profession offers.

Nonetheless, pharmacy practitioners all agree thatpharmacists ought to know the properties (whichinclude pharmacodynamics, pharmacokinetics,mechanisms of drug action, side-effects, adversedrug-drug reactions, adverse drug-food reactions,and drug toxicity) of all the medicines, theirformulation processes, proper storage conditions,and appropriate usage. Such knowledge should beapplied primarily towards public interests duringthe course of our profession activities. Theseprofessional activities pertain to the supply ofmedicines for humans, supply of veterinarymedicines, infant and enriched formulas for adults,sick-room appliances, agricultural, horticulturaland industrial chemicals, scientific apparatus (suchas stethoscopes and clinical thermometers),surgical appliances and instruments, electro-medical therapeutic apparatus (such as bloodpressure meters and blood glucose or cholesterolmonitors). But many pharmacies also offer non-professional activities which are often closelyassociated with pharmacy, such as the supply ofperfumes, cosmetics, toilet requisites andphotographic materials.

Pharmacy practice in Malaysia varies from onepharmacy to another. Chain-store pharmaciesusually offer a significant proportion of non-professional services and activities alongside thetraditional professional services. Smallerindependent pharmacies normally focus onprofessional pharmacy services. Both types arerepresentative of private pharmacy practice inMalaysia. On the other hand, pharmacy practice inthe government sector is quite different.Government pharmacists enjoy a more favourablelegal environment which permits them completecontrol over the supply of medicines. Governmentdoctors do not provide pharmacy services topatients, unlike their counterparts in privatepractice. Consequently, private pharmacies operateunder very harsh and unfavourable conditionsimposed by legal and historical limits. Manycommunity pharmacies do not even receive oneprescription chit a day! This unhealthy scenarioshould be rectified by the government, with thefull understanding of the Malaysian medicalprofession. It is hoped that the pharmacyprofession will be granted a new lease of life inthis new millennium.

PHARMACY PRACTICE IN THE NEWMILLENNIUM

Malaysia is one of the front-runners amonstdeveloping countries in this high technologyinformation era through the creation andimplementation of the world renowned MultimediaSuper Corridor. Our nation ranks 16th as a worldtrading nation, and we are a signatory to almost allinternational treaties including global tradeliberalization related to the World TradeOrganization. Global trade liberation willinevitably be accompanied by a free flow ofprofessionals (such as lawyers, accountants,pharmacists and doctors). With a relatively lowerpharmacist to population ratio coupled with acomparatively higher salary in our country,neighbouring foreign pharmacists will flow intoMalaysia to fill up any shortage. We may not beprepared sufficiently to handle the situation to thenational advantage. The interests of localpractitioners may be damaged. In this context, thepharmacy profession in Malaysia needs to workdoubly hard so as not to be caught unprepared.

Against such a background, MPS has risen to theoccasion by examining the various professionalissues and putting in place necessary strategies toenhance professionalism in every aspect of the


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pharmacy practice. The undersigned feels stronglythat Malaysian pharmacists need to address thefollowing matters in order to be able to contributemore meaningfully, as an important primaryhealthcare team member, to the overall health ofthe nation:

(a) Control over the supply of medicines

As mentioned earlier, private medical doctorscontrol a large percentage of medicines supplied topatients. It is high time that this control beexclusively given to pharmacists who, after all, arethe only professionals properly trained for the job.In 1984, the Malaysian Medical Association(MMA) had agreed, in principle, that the presentsystem should change for the better. Physiciansshould focus on diagnosis and prescribing. Thedispensing of medicines had been mutually agreedto be the professional role of pharmacists andshould, therefore, be implemented for both thepublic, as well as the private sector.

Many brainstorming sessions have been held onthis matter. Finally, MPS launched in 1998 Project2003 to spearhead this professional activity. Sevensub-committees (namely Pharmacy PracticeStandards Committee, Professional CompetenceCommittee, Professional Image and PublicEducation Committee, Telepharmacy Committee,Pharmacy Legislation Committee, ManpowerProjection Committee, and National Drug Policyand National Healthcare System Committee) wereestablished to examine and prepare reports onvarious important aspects of the profession. It ishoped that a formal official recommendation willbe ready for submission to the Government by themiddle of 2001.

(b) National Healthcare Fund

National healthcare bills have risen sharply inrecent years. Health expenses in 1999 werereported at about four and a half billion ringgit.There is a need to cap and control the bill and toinvolve citizens in this important matter. As acaring and well-planned nation, it seems anexcellent idea to introduce a National HealthcareFund to finance all future needs of the people inour medication-treatment. It should be by and forthe people. The government also needs to budgetfor it because about one-third of the populationwill require subsidy.

Indeed, Malaysia cannot afford not to plan aheadfor a National Healthcare Fund or a similar scheme

because in about 10 years time, a fifth of ourpopulation would have aged beyond 65 years. Thegeriatric population requires a bigger budget forhealth matters. And it will not get cheaper as theyears go by.

The National Healthcare Fund should finance allmedicines supplied. Pharmacists should be paid aprofessional fee for services rendered to the public.This will enhance the professional image ofpharmacists, and place us at par with otherprofessionals in Malaysia. MPS needs tocontribute proactively, through seminars andpublic talks, singularly as well as collectively, withother stakeholders (namely MMA, allied healthbodies, consumer groups, Insurance and ManagedCare Organizations) to work out a win-winformula for all the health service providers andusers.

(c) Even distribution of pharmacy services

The present 3000-plus registered pharmacists isexpected to increase to about 5000 by the year2004. MPS needs to ensure an even distribution ofpharmacies throughout the country. Some sort ofpharmacy zoning system may be necessary. Thepopulace should be entitled to receive similarstandards of pharmacy services to that in the bigcities. A duty roster will ensure round-the clockavailability of medicines to needy patients.

In cities such as Kuala Lumpur, Kota Kinabalu,Kuching, Johore Bahru and Penang, there areprobably too many private community pharmaciescatering to the needs of city dwellers. Perhapsnewcomers should be given incentives orlegislated to set up pharmacies in small towns andrural areas. In rural places where there are noprivate clinics, private community pharmacies canstill complement the services provided by thegovernment's rural clinics. A town of 30,000people requires about three private communitypharmacies to work side by side with thepublic/hospital pharmacies. Distribution ofpharmacies should be worked out on a districtbasis.

It was reported that there are about 350pharmacists working in government hospitals,clinics, laboratories and stores (MMA pressrelease, 24th August 2000). This represents about13% of all practising pharmacists. However, 45%of the medical practitioners work in the publicsector. Obviously the national pharmacist shortagelies in the public sector. Urgent action needs to be


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taken by the government to rectify this problem.

The Health Minister announced, on 9th December2000, the requirement for a compulsory three-yeargovernment service for all newly qualifieddentists, effective from 1st January 2001. It is timethat pharmacists join the doctors and dentists incompulsory national government service. This is inline with the present global paradigm shift inhealthcare delivery.

(d) Self-regulation in pharmacy standards andpractice

There is a need for a paradigm shift in allowing thelearned profession to be self-regulated in matterspertaining to pharmacy standards and practice.These refer to ethics and conduct of pharmacists,the continuing competence of members to practise,and assessment of new entrants into the profession.

Some other professional groups in Malaysia (suchas the MMA and Malaysian Advocates Society)have been self-regulating in these matters. It is astep forward which will inevitably bring muchbenefit to the people.

Continuing Pharmacy Education (CPE) for thepractising pharmacists is a universal trend carriedout by most advanced nations. The United Statesof America and the United Kingdom adoptdifferent CPE systems. Perhaps the MPS-CPEpioneering project can form the basic frameworkto build upon. Seminars, conferences and certainwrite-ups can be a basis for assessment. To captureall CPE efforts, it may be reasonable and feasibleto adopt the American Log-Book system where theonus to maintain records lies with the practitioners.The Royal Pharmaceutical Society of Great Britain(RPSGB) had introduced the ContinuingEducation Logbook in 1995 (2). The RPSGB arein the process of consulting its 40,000 members inworking out a new framework for professionalregulation with measures to ensure professionalcompetence and lifelong learning (3).

Our present pre-registration training programmehas its form but lacks mechanisms for monitoringthe actual progress of students. Visual assessmentmay not be sufficient and objective enough.Regular intervals of written assessments arepreferable. The pharmacist-supervisors input willdepend on his/her experience and knowledge. Asystematic write-up on what to impart and astandard list of reference books/materials shouldstandardize the supervision. Wholesale trading

pharmacy and manufacturing pharmacy do notexpose the pre-registration students to adequatepatient counseling. Many students are left to learnon their own. It is vital for the profession toacertain whether it is important for all students toattain the same breath and depth ofprofessionalism in the different disciplines.

The undersigned recommends the New Zealandsystem that was recently implemented. Since 1997,all newly qualified pharmacy graduates in NewZealand undergo a twelve-month pharmacy pre-registration training program which defines sevenprofessional competency standards expected of aregistered pharmacist. A combination of on-the-jobassessment, submission of assignments,performance at training days, completion of alearning record, and attendance at a finalassessment centre determines the standardsachieved (4). Australia is likely to follow a similarcompetence-based accreditation for pharmacists(5).

(e) Education and research

Pharmacy has been designated as one of thepriority development areas in our knowledge based new economy which our government is verydetermined to nurture. Pharmacy educationistsneed to ensure that our profession is wellpositioned to derive optimal growth. The choice ofsubjects in undergraduate pharmacy degreeprogrammes ought to provide wide coverage andsufficient depth in all the pharmaceutical sciences.Postgraduate studies should produce specialists invarious disciplines such as pharmaceutics,pharmacognosy, synthetic-medicinal chemistry,clinical pharmacy and pharmaceuticalbiotechnology. Our educational system needs toproduce both generalists as well as specialists whowill contribute to the further advancement of theprofession.

The local pharmaceutical industry may form asymbiotic partnership with academicians. Thelatter can generate the much needed input in basicpharmaceutical science research. The former cancommercialize useful products or applications formutual benefit. This modulus of operation is anorm in many advanced countries.

A sound pharmacy education system withemphasis and smart partnership in research anddevelopment will surely bring forth tremendousprogress to the pharmacy profession in Malaysia.Greater and closer co-operation between


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pharmaceutical scientists in universities and thepharmaceutical industry in areas such asproduction of raw material for pharmaceuticals,synthesis of new and useful chemical entities,biotechnology in manufacturing, design of newand better methods in extraction of activeingredients from local medicinal plants,formulation, and general transfer of technologyfrom the academic scientists to the pharmaceuticalindustry should be encouraged.

(f) National Formulary and Pharmacopoeia:

A hallmark of a learned profession is a systematicaccumulation and compilation of new knowledgeinto reference standards or specifications whichposterity can build upon for greater advancement.The legal profession has unmatched achievementin this matter. All advanced western nations havebuilt up their own wealth of knowledge andtechnology over a long period of time. After beingindependent for four and a half decades, Malaysiashould begin to build its own Pharmacopoeia andNational Formulary.

It is a matter of grave concern that many locallyconcocted medicinal preparations are not properlydocumented. Many rural folks ("village doctors")have been using selected plants as medicines forgenerations. This knowledge of traditionalmedicine needs to be preserved in writing (intoFormulary or Pharmacopoeia) before these oldfolks leave us for good.

Even worse still is the fact that we may lose a largerange of indigenous plants during our rapideconomic development. Malaysia is blessed withabout 12,500 species of medicinal plants (6) whichcan be a valuable source of new drugs. As much as50% of modern medicines have been derived fromplants, the majority of them from the tropicalforest (7). The Malaysian forest represents one ofthe richest of the region's tropical forest but is alsoin serious danger of over-exploitation.

Much research has been initiated by local scientistsin the fields of natural product chemistry but thescientific impact these efforts has generated isminimal. Much of the activities are confined todetecting and identifying the chemical constituentsthat possess biological activity and are oftendiscontinued at the juncture where critical animalor human testing is required further (8).

The Malaysian Herbal Products Blueprint waslaunched in September 2000 by the Malaysian

Industry-Government Group for High Technology(MIGHT). It is hoped that MIGHT will give equalemphasis to research and development andproduce monographs on Malaysian herbs, inaddition to developing and promoting the localherbal industry (9).

Perhaps it is the right time for all the six localinstitutions of higher learning where pharmacy istaught to jointly initiate and spearhead a nationalproject in establishing an Institute ofPharmaceutical Research, parallel to the Instituteof Medical Research.

It is also high time for MPS to work side by sidewith MMA in recommending to the government ofa permanent committee, comprising of expertsfrom various medical and pharmaceuticalspecialities, to bring into being a NationalPharmacopoeia and Formulary.

(g) Pharmacy legislation:

The Poisons Act 1952 (Revised 1989) andRegistration of Pharmacists Act 1951 (Revised1989) are the two main pillars of pharmacy law inMalaysia. Other pieces of legislation such as theDangerous Drugs Act 1952 (Revised 1980), Saleof Drugs Act 1952 (Revised 1989), and Medicines(Advertisement and Sale) Act 1956 (Revised1983) are built upon these two laws. It is quiteapparent that these acts were first formulated withstrong British Colonial characteristics. Althoughthese laws have been reviewed during the lastdecade, much of the reviews were piecemeal innature without much forward vision and strategy indeveloping the pharmacy profession. With theadvent of the Information Technology Era, ourpresent pharmacy legislations are obviously notequipped to deal with matters such as electronicprescribing, digital signature, Telemedicine andTelepharmacy. Significant overhauls are the orderof the day.

It is imperative that Telepharmacy and Internetpharmacy should also comply completely with allpharmacy legislations. Professional ethics and highstandards should be maintained. Medicines shouldonly be delivered to patients in person. Systemsand mechanisms to detect and to verify theprescribers signature that come with electronicprescribing should be in place. Malaysiancyberspace legislations for pharmacy practice needto be incorporated.

A paradigm shift and legislation overhaul are


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suggested for the following areas of pharmacypractice:(i) exclusive control over the supply of

medicines by the pharmacists;(ii) re-classification Group D Poisons as Group

C Poisons;(iii) pharmacists control over the supply of

herbal and traditional medicines/products;(iv) introduction of an annual practising

certificate to replace the present annualretention certificate and Type A Licence;

(v) self-regulation in professional matters suchas ethics and conduct, practice standards,and continuing education;

(vi) introduction of a compulsory three-yearnational service for all new pharmacists;and

(vii) introduction of pharmacy cyberspacelegislation to deal with Telepharmacy andInternet-Pharmacy.

CONCLUSION

Pharmacists in Malaysia practise under twodifferent sets of legal-historical framework.Government employed pharmacists enjoycomplete control over the supply of medicines.They are even exempted from many pharmacyregulation provisions. On the other hand, privatepharmacists do not have full control over thesupply of medicines. Medical doctors, in theprivate clinics and private hospitals, still dispensemedicines to their own patients. This doctor-dispensing practice has been allowed since theColonial era when Malaysia suffered from acuteshortage of all professionals. This outdated andunhealthy situation must change in the near future.The government needs to legislate such a change.As a developing country, Malaysia has alreadybeen served with a reasonable ratio of pharmacists

to doctors per given population. The national ratioof private pharmacists to private doctors is 1 to2.4. There are 5400 private practising doctors and2300 private practising pharmacists. We havealready achieved the optimal ratio of one doctor tothree pharmacists in the urban places. With theannual increase of about 450 new pharmacistsfrom now on, there is a serious threat ofunemployment for the pharmacists in a few years'time.

On the other hand, there are insufficient numbersof pharmacists working in the public sector.Urgent measures must be worked out to rectify thesituation. The acute shortage of pharmacists in thepublic sector may be overcome with the newentrants. The government's 118 hospitals, 772health clinics and 1992 rural clinics (StatisticsDept. Bulletin-1999) certainly need to employmany more pharmacists in order to render qualityservices to the people.

MPS needs to work hand-in-hand with theGovernment Planning Unit to map out a thoroughmanpower projection for pharmacists and thesupporting staff over the next decade.

The pharmacy profession needs the greatestunderstanding of the medical profession and theconsumer groups in working out the mostappropriate healthcare delivery system in theinterests of the people in this country. MPS has avital role in leading pharmacists through thistransition period into a new type of pharmacypractice. This new kind of pharmacy professionenvisaged will be more fitting for a fast developingcountry like Malaysia. Vision 2020 will certainlybe incomplete if pharmacists fail to rise to theoccasion in building a professional and caringpharmacy practice for the nation.

*****REFERENCES

1. Kelayakan Farmasi Dari Institusi PengajianTinggi. Malaysian Pharmaceutical Society.http://www.mps.org.my/html/universiti_yang_diiktiraf.htm (5 Apr. 2001).

2. Continuing education logbook for 1999. Pharm J1999;262:15.

3. Society starts consultation on a new frameworkfor professional regulation. Pharm J 2000;

264: 4000.4. Shaw JP, Drumm D. Prescription for registration:

The New Zealand pharmacy pre-registrationtraining programme. Pharm J.1999;263:98-101.

5. Caldwell J. NZ Society introduces practicecertificate based on competence. Pharm J2000;265:320.

6. Latiff A. Traditional use, potential for


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exploitation and conservation of medicinal plantsin Malaysia. In: Proceedings of the Seminar onTraditional Herbs and Medicinal Plants inSarawak; 2000 Oct. 10; Kuching : SarawakDevelopment Institute, 2000.

7. Chai PPK. Global perspectives on the herbs andmedicinal plants industry. In: Proceedings of theSeminar on Traditional Herbs and Medicinal

Plants in Sarawak; 2000 Oct 10; Kuching:Sarawak Development Institute, 2000.

8. Ghazally I, Murtedza M, Laily BD. ChemicalProspecting in the Malaysian forest 1st ed.Malaysia: Pelanduk Publications;1995.

9. Malaysian Industry-Government Group for HighTechnology. October 2000.http://www.might.org.my (5 Apr. 2001).

From page 14

Continuing Pharmacy Education question:Study this case and give your response (100-200 words) based on the bioethical principles outlined in theCPE article on page 9. You may earn 2 CPE points if you submit a credible response to the MPS-CPESecretariat at the Malaysian Pharmaceutical Society, P.O. Box 158, Jalan Sultan, 46710 Petaling Jaya,Selangor.

As a pharmacist at a regional transplant centre, you are in the team that allocates organs for transplantation.Your committee is at a deadlock as to which option to choose. The first is to allocate according to need (thesickest person gets the organ). The second option is to allocate according to an ordered pair. In the orderedpair formula, people who have abused their bodies (a heavy smoker) will be considered only after otherswho have not abused their bodies have received their transplants. The third proposal suggests that thosewho have agreed to be organ donors (usually by a pledger card that they carry) should be put at the top ofthe list. Your vote is key for the majority. Who will you vote for? Why?

Malaysian Journal of Pharmacy 2001;1:9-14 CPE Article

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Continuing Pharmacy Education

BioethicsAbu Bakar Abdul Majeed

Continuing Pharmacy Education Chairman, Malaysian Pharmaceutical Society, c/o InstitutKefahaman Islam Malaysia, No 2, Langgak Tunku off Jalan Duta, 50480 Kuala Lumpur

ABSTRACT

Bioethics was originally proposed in the early 1970s to denote the incorporation ofbiological knowledge and human values. It is becoming more relevant in thebiological age. This paper looks at some of the biological issues that require anethical input. These include the Human Genome Project, human cloning andassisted reproductive technologies, contraception and abortion, organ donation andtransplantation, euthanasia, brain death, human embryonic cells and AIDS.Examples of issues that have been raised in this area: Who owns our genes? Can wedesign our babies? Should humans be cloned? Can pregnancy be terminated? Ismercy killing all right? Is brain death equivalent to death? Can embryonic cells beused in experiments? While some have been settled, others still persist till today.The numerous ethical questions pertaining to biology beg serious efforts on the partof ethical theorists to dig deep into their established principles. Similarly thoseworking within applied ethics cannot operate effectively without referring totheoretical ethics. Hence thus far, many of the bioethical issues have been tackled. Itis proposed that as a member of the health team, pharmacists too need to be wellversed in issues pertaining to bioethics.

Keywords: ethics, biotechnology, cloning, euthanasia, brain death

INTRODUCTION

A new revolution in the making

The 20th century was an auspicious century indeed.It showcased numerous achievements in scienceand technology. This is especially true of researchin the field of biology and its related discipline,biotechnology. It is not an exaggeration to statethat so soon after the information revolution of thelast few decades, the dawn of the 21st centurymarks the start of yet another revolution, thebiological revolution.

Although advances in the various fields of biology

have thus far resulted in major achievements, theyalso pose an inventory of real and potentialhazards, as well as create new ethical conundrums.According to Lemkow (1993), an American studyon Public Perceptions of Biotechnology revealsthat the public accepts science and technology ingeneral (1). However, attitudes to biologicalresearch indicate certain ambivalence. Sixty-sixpercent felt that genetic engineering wouldimprove life compared with 92 percent for solarenergy and 51 percent for nuclear energy.

CPE Article: Bioethics

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However, 42 percent of the respondents said that itwas morally wrong to change the geneticmakeup of human cells.

In a similar European study, the main ethicalissues in science and technology centre on humangenetics (1). Apprehension and anxiety wereexpressed about the manipulation of humangenetic material even when diagnostic benefitscould be demonstrated. While therapeutic anddiagnostic applications found much support, therewas concern about the use of genetic information,such as the social pressure to have an abortion inthe face of negative prenatal diagnosticinformation, although this does not necessarilyrequire genetic engineering techniques. Concernwas also expressed about the requirement ofgenetic information at work in relation to the rightto privacy.

A TIME/CNN telephone poll of 1,1015 adultAmericans conducted in early 2001 on the issue ofhuman cloning, found that 90 percent ofrespondents thought that human cloning is a badidea (2). The reasons for opposing cloning are:religious belief (34 percent), interference of humandistinctiveness and individuality (22 percent), fearof it being used to breed a superior race (22percent) and that the technology is dangerous (14percent). Further, 93 percent of respondents wouldnot want to have themselves cloned if they had thechance to do it.

The aim of this article is to look at severalcontemporary biological issues that beg an ethicalinput and to consider bioethical principles thus farapplied to cope with some of these issues.

Human Genome Project

The Human Genome Project is aimed at figuringout what protein each gene produces and for whatpurpose. This human encyclopaedia may be usedto identify diseased genes and design methods tosubstitute them with healthy ones. Hopefully, thistype of disease prevention envisaged byproponents of gene therapy will be able to dealwith many debilitating disorders such asAlzheimers Disease, Parkinsons Disease andHuntingtons Disease, problems that have beenattributed to genetic malfunctions.

Other spin-offs from the Human Genome Projectinclude the ability to predetermine the babysattributes, grow new tissues and organs fortransplantations, slow aging body parts and

prepare more effective vaccines. However all theseprocedures are not about to happen soon. In fact,not only do several technical posers appear to bedaunting, the moral implications of the project areequally mind-boggling. First and foremost is ofcourse the question of ownership. Who owns ourgenes?

Thus, scientists have begun to patent whicheversections of the genome that they can lay theirhands on (3). Patenting proponents insist on theneed to have such protection to ensure returns ontheir investment. Naturally ethicists have differentopinions. Were the early anatomists grantedentitlements to the various bodily organs theydiscovered? Galen could have staked claims tosome of our veins and arteries. Ibn Sina too shouldhave been granted rights to certain parts of thebrain.

The other question is whether the benefits ofgenetic science research like the Human GenomeProject could be distributed to the worldspopulation in a just manner. While someresearchers prefer the human genome data to befreely available, others want a premium be put forusing it. Therefore those who have had no part inthe venture at all will have to wait and see if theycan afford to pay for the information on humangenes, should they need it for research anddevelopment.

Similarly, on the application side of this type ofresearch, since gene therapy involves a high cost,only the minority already well supplied withmedical goods and services will be able to affordit. This will only widen the existing differentials inhealth status between different social classes, andfurther broaden the North-South divide in terms ofaccessibility to modern medical treatment.

Genetic engineering and eugenics

Genetic engineering may help doctors developways to correct or compensate for some geneticdefects, perhaps even during conception. This willsurely give rise to ethical questions. Although atthis stage we are talking about preventing orprotecting our children from genetic diseases,artificial improvement of other traits of thedeveloping embryo would surely be sought not toolong in the future. This opens a whole newpossibility of designing babies. Many agree thatgenetic engineering must not be adopted as ameans for changing the human geneticconstitution, in what is called the improvement of


12

the human breed, or in genetically tampering withthe human personality or interfering in humancompetence or individual responsibility.

Cloning, assisted reproductive technologies andsurrogacy

In 1997, there was a focus on the success of ananimal cloning procedure using matured, ratherthan the usual embryonic cells (4). As thisexperiment involved a large mammal, thepossibility of cloning a human becomes realindeed. The greatest motivation of cloningexperiments described above is in finding ways ofproviding infertile couples with the opportunity tosecure an offspring. But is human cloningdesirable? Should parents be allowed to clone achild they lost? Should they clone to have twins atdifferent times? Should cloning be allowed toproduce vital organs for use to help others?

The birth of the first test tube baby in 1978 markedyet another milestone in the history of reproductivetechnologies. In vitro fertilization became wellaccepted as a relatively-risk-free technique and by1990, there were more than 25,000 test-tube babiesin the world. Related to artificial reproductivetechnologies are the issues of sperm banks andsurrogate motherhood. There are men who are notable to produce viable sperms for fertilization tohappen. The wife in this case, probably would needto request sperms from donors. In order to facilitatethis procedure, sperm banks have been established asa resource centre to provide sperms on demand.Then there are women who are physiologicallyunable to conceive and nourish foetuses. Conceptionof embryos prepared in laboratories will have to bedone in a third partys womb, thus the term surrogatemotherhood. Surrogacy is considered a legalprocedure in some developed countries. Artificialreproductive technologies, though implementedpreviously, still attract public attention as moralquestions with regard to these procedures keepcropping up.

Contraception and abortion

These are two biological issues that simply refuseto go away. Contraception is vital for familyplanning. Various types of contraception areavailable, either natural or artificial, and ethicalissues that are still being debated today pertain tothe suitability and permissibility of these methods.Abortion in particular generates moral questions ofenormous magnitude. At what stage of the embryodoes life begin? Does it start with the very first

beat of the developing heart? And when thishappens, how does one justify terminating thepregnancy?

Organ donation and transplantation

Numerous ethical questions have been raisedregarding tissue and organ transplantationprocedures. They include whether human beingshave the right to give away a part of their bodysuch as the kidney or a portion of their liver,whether it is all right to harvest body parts of acadaver, and how available parts are assigned tothose who are in need of them. Although theseissues may appear to be rather straightforward insome of todays societies, there are still those whoare unsure of how to deal with them.

Then there is always the question ofxenotransplantation, or transplantation using partsfrom animals. There may well be a lot ofreservations among certain communities aroundthe world regarding the suitability andpermissibility of this method. In any case, there arecontemporary ethical issues regarding offspringdonor where for reasons of genetic compatibility,a couple decides to conceive a second child in thehope that he or she would become a donor for thefirst child who is in need of certain bodily parts,for example, the bone marrow. And with thecoming of therapeutic cloning and new procedureslike organogenesis (where specific organs ratherthan a whole human may be grown fromembryonic stem cells), tougher ethical issues arebound to crop up.

Euthanasia

Euthanasia or mercy killing may be active orpassive. Active euthanasia means patients aredeliberately killed, for example by injecting anoverdose of sedatives. Active euthanasia isnormally voluntary, where a patient with a rationalframe of mind requests and is granted death.Passive euthanasia happens when a patient isdeliberately allowed to die from whatever illnesshe is suffering from, by refusing to performsurgery, initiate heart resuscitation procedure, oradminister medication. Passive euthanasia may bevoluntary, when the patient consents to it, or non-voluntary, when he does not express the desire todie.

Euthanasia has always been a prime issue in thedebate on the right to die. It, however, is legallypermitted in at least one western nation, that is,


13

Holland. In 1973, the Royal Dutch MedicalAssociation approved guidelines for physician-assisted suicide (PAS), a form of euthanasia. Theseguidelines are: euthanasia must be done by aphysician; a second physician must concur withthe decision; death must be requested by thepatient while competent; the request must be freeof doubt, well-documented and repeated; therequest must not have been coerced; the patientscondition must be intolerable; and that, there mustbe no way to improve the patients lot.

The American Medical Association takes a verydifferent approach on PAS. Although activeeuthanasia is forbidden, passive euthanasia appearsto be allowed. The practice of allowing patients todie by not treating them, endorsed by thinkers asearly as Socrates, is an inescapable part of modernmedicine. Today more than 80% of people die inhospitals, and advances in medical technologyhave made it possible to keep almost anyone aliveindefinitely, even after they have no thought orfeeling or hope of recovery. The maintenance oflife by artificial means in such cases is deemedpointless, as the hospitals would quickly be filledwith living corpses, leaving more deservingpatients no beds. Thus, many would agree that it isethically acceptable to cease treatment and let suchpatients die (5).

Brain death

The traditional criteria for determining death, untilrecently, was the permanent cessation of heart andlung function. When a person stopped breathingand the heart stopped beating for more than a fewminutes, that person was declared dead. The lossof oxygen to the brain would almost instantlyproduce irreversible brain damage and loss of allcognitive function (6).

However, the introduction of new medicaltechnology, and most importantly of respirators,has enabled modern medicine to continueartificially maintaining patients heart and lungfunction. This can often save lives that previouslywould have been lost. Sometimes, it may evenpermit the patient to recover a normal level offunction.

In other cases, however, heart and lung functioncan be restored or continued by these artificialmeans after brain function has been partially orcompletely destroyed, for example, fromprolonged loss of oxygen or severe trauma of thebrain. Such possibilities have forced a rethinking

of the traditional criteria for the determination ofdeath. There is now an additional criterion fordeath, that is, the complete and irreversible loss ofall brain function, or so-called brain death. Theconcept of brain death was first proposed in 1959by a team of French doctors. The criteria adoptedfor brain death were coma, cessation of breathing,the absence of brainstem and tendon reflexes, andthe absence of electroencephalographic (EEG)waves. If these conditions persisted in the patientfor more than 24 hours, then he or she would bepronounced dead, and the ventilator switched off,even though the heart might still be beating.

Further discussions led to the announcement at the22nd World Medical Assembly in Sydney in 1968,which in a nutshell stated that death had occurredif there were no means of saving the patient,regardless of whether some of his organs were stillfunctioning. In the same year, the Harvard criteriato determine death was introduced. In addition tothe original French criteria, the Harvard criteriastipulates that there must also be an absence ofpupil and spinal reflexes, no movement of thepatient for an hour, and that breathing should ceasethree minutes after switching off the ventilator (7).

Human embryonic cells

Most recently in several countries, scientists andpolicy-makers are revisiting the issue on the use ofhuman stem cells and embryos for research. Stemcells have the capability of developing into anytype of tissue, as well as growing into humanbeings. Thus, in the United States, current lawsforbid the use of public funds to obtain stem cellsfrom human embryos (8). In Germany, a humanembryo is protected under the law from thefertilization to the implantation stage. Anyresearch on or with human embryos is prohibitedunless the embryo can be ascertained of animmediate and direct benefit to it (9). But effortsare underway to reverse this situation (10). Forexample, the American National Institute of Health(NIH) recently issued guidelines on funding ofmedical research that makes use of humanembryos (11). Similarly the British governmenthas allowed cloning of stem cells for scientificstudy of transplants. This study would help bolsterthe prospect of therapeutic cloning that coulddevelop new treatments for diseases such asAlzheimers Disease and Parkinsons Disease.

Acquired Immunodeficiency Syndrome (AIDS)

The human immunodeficiency virus (HIV) that


14

causes AIDS continues to be a major threat to thehealth of millions of people worldwide. Sadlythough, there is little sign that the disease isabating. Today it has been established that apartfrom the sharing of infected needles and bloodtransfusion, indiscriminate sexual practices are themain modes of HIV transmission. In view of thegravity of the situation, whatever means that canhelp to wipe out the scourge are stronglyrecommended, regardless of whether they are ofpreventive, curative or palliative in nature.

Prevention must be the primary strategy adopted tominimize the risk of HIV transmission. However,in relation to the compulsory HIV antigen orantibody screening that has been proposed formembers of the high-risk groups, many ethicalissues have to be surmounted. Is it morally correctto simply focus on the high-risk HIV-carriers, suchas drug addicts, prostitutes, transsexuals andconvicts? In order to avoid transfusion ofcontaminated blood, should donors, rather than theblood per se, be tested for HIV antibody orantigen? Should compulsory screening be imposedon brides and bridegrooms to ensure that they arefree from HIV, thus preventing them from passingon the virus to their potential spouses or later evento their offspring? These are no doubt difficult andchallenging questions. They must be dealt withextreme care and heartfelt concern for the partiesinvolved. When it comes to ethics, there is alwaysthe dilemma of choosing between the interests ofthe community and those of the individual.

Ethics

Lets turn now to the issue of ethics and howhumans have developed a system to tackle it.Bertrand Russel elegantly describes ethics as inorigin the art of recommending to others thesacrifices required for cooperation with oneself.Ethics, or the study of morality, makes up one ofthe four main divisions of philosophy. Here it isfurther subdivided into categories of meta-ethics ortheoretical ethics, that is the study of meanings ofethical terms and the forms of ethical argument;descriptive ethics, that deals with the study ofmoral and ethical beliefs and customs of differentcultures; normative ethics, which is the study ofethical principles that have been accepted as normsor right behaviour; and applied ethics, that relatesto the application of moral standards used indecision-making to concrete rather than abstractconditions (12).

The various ethical questions pertaining to

biological sciences in the contemporary world areclear indications that the time has come whenethical theorists can no longer ignore the problemsof application. Similarly, those working withinapplied ethics can no longer operate effectivelywithout taking theoretical considerations intoaccount. This is especially true where principlesand codes appear to make conflicting claims on thecondition or situation under examination. Whensuch conflicting claims occur it is referred to as anethical dilemma. When this occurs, we will have toresort to ethical reasoning that is, the process ofanalysis in determining what is right or wrong, andwhat is the correct or more responsible choice in agiven situation. It is also an examination of ourmoral judgements, and an attempt to determine thegrounds on which these judgements are based.

The literature is filled with the variousclassifications of ethical theories. For example,they can be classified as, one, principle-basedtheories (normative ethics), and two, virtue-basedtheories (12). Principle-based theories are of eitherthe deontological or consequentialist(utilitarianism) types. The former relates to thetheory of obligation or duties, or rules and rights,while the latter links the rightness of an act to thegoodness of the state of affairs it brings about.Judgements made may be general or specific. Theyare all normative, they affirm or apply norms orstandards to making decisions. They must beuniversal, applicable to all relevant cases, impartialand objective. The procedure to implementprinciple-based ethical theory are, (i) identifyethical principles, and (ii) evaluate ethical choicesin terms of how well they fit with those principles.

Virtue-based theories include communitarinismthat applies the Aristotelian approach wherepractical wisdom is employed in the reasoningprocess, the focus is on the uniqueness of eachethical situation, and is based on sharedcommunity values. It also includes relationalismthat emphasizes the values of love, family andfriendship inherent to the situation at hand. Theprocedure to do this is by identifying the ethicallyvirtuous person, and evaluating ethical choices interms of how well they exemplify the deliberationsof the ethically virtuous person. This theory is verymuch situation-based.

Bioethics

Bioethics can be defined as the study of therightness and wrongness of acts performed withinthe life sciences, through the application of both


15

ethical theory and casuistry (case-study method) tothe complexity of development in the biologicalsciences. The bioethics practiced today mostlyderives its rulings from the normative andsituational ethical principles. The word bioethicswas first coined by the oncologist Professor VanRensselaer Potter II in 1970 in an article entitledBioethics: The Science of Survival (13). Afterdoing much work in the field of cancer researchwhere he managed to establish links betweencertain types of cancer and environmentalpollutants, Potter argued that a science of survivalmust be more than science alone. It shouldincorporate two ingredients, namely, biologicalknowledge and human values. Later, Potter (1975)refined the definition of bioethics as a product ofcross-fertilization between the two branches,medical bioethics and ecologicalbioethics(14). However, medical practitioners didnot generally accept these concepts. Theypreferred to redefine bioethics to mean clinicalethics.

And thus, from then on bioethics conjured a muchnarrower meaning than its original scope andbreadth. And it is in this context that many of therecent and contemporary discussions on issuesrelated to health, life and death are being looked at.This was particularly true during the era ofheightened debates on reproductive sciences likecontraception and abortion in the 1950s and 1960s.At the time, the founder-director of the Kennedy

Center of Ethics at Georgetown University,Professor Andr Hellegers seized the opportunityto turn bioethics into an academic discipline thatreflected the needs of the time. This was rathereasily acceptable as bioethics can readily beidentified with the established field of medicalethics. In essence medical ethics began with theadvent of medicine itself, that is, the HippocratesOath. And then there was the anti-vivesectionistmovement (15) that was already influential in the19th century that helped to keep researchers whouse animals as subjects for experiments, on theirtoes.

CONCLUSION

Today, bioethics is a full-fledged subject matterwith a number of international professionalsocieties, and courses offered in universitiesthroughout the world. It will become even moreimportant in the future. As a member of theprofessional healthcare team, pharmacists too needto be aware of the controversial issues pertainingto medical practice and how to deal with them.One way in which this can be done is to refer tolong-established ethical guidelines. With this,pharmacists can play an important role inalleviating patients and their relatives anxiety, aswell as clear their conscience on morally-challenging issues.

See page 8 for the CPE question

*****REFERENCES

1. Lemkow L. Public attitudes to genetic engineering:Some European perspectives. Luxembourg: Officeof Official Publications of the EuropeanCommunities; 1993.

2. TIME/CNN Poll. TIME 2001 Feb. 26. p. 45.3. Thiele. Moral problems in the patenting of human

genes. Europische Akadamie Newsletter 2000; 21:1-3.

4. Campbell KHS, McWhir J, Ritchie WA, Wilmut I.Sheep cloned by nuclear transfer from a culturedcell line. Nature 1997; 385:810-813.

5. Beauchamp TL. Suicide. In: Regan T, editor.Matters of Life and Death. USA:McGraw-Hill Inc.

6. Brock DW. Life and Death - philosophical essaysin biomedical ethics. Cambridge: CambridgeUniversity Press; 1993.

7. Jusoh MR. Mati otak - Perspektif doktor Islam(Brain-death - A Muslim Doctors perspective). In:Ibrahim I, editor. Islam dan Pemindahan Organ(Islam and organ transplantation). Kuala Lumpur:

Institute of Islamic Understanding Malaysia(IKIM); 1998.

8. Shapiro HT. Ethical dilemmas and stem cellresearch. Science 1999;285:2065.

9. Kaiser J. Stem cells as potential nerve therapy.Science 1999; 285:649-650.

10. Abbot A. German researchers seek legal backingfor stem cell work. Nature 2000;404: 424.

11. Zitner A. Embryo stem cell work could get publicfunding, Los Angeles Times; 2000 Aug. 13.

12. Beach R. The responsible conduct of research.Weinheim:VCH; 1996.

13. Potter VR. Bioethics: the science of survival.Perspectives in Biology and Medicine 1970;14:127-153.

14. Potter VR. Global Bioethics: Building on theLeopold Legacy. East Lansing:Michigan StateUniversity Press; 1988.

15. Koenig R. European researchers grapple withanimal rights. Science 1999;284:1604-1606.

Malaysian Journal of Pharmacy 2001;1:15-21 Research Article

16

Career Choice of Malaysian PharmacyStudents: A Preliminary AnalysisAb Fatah Ab Rahman1, Mohamed Izham Mohamed Ibrahim1*, Zuraidah MohdYusoff1, Mohd Baidi Bahari1 & Rusli Ismail2

1School of Pharmaceutical Sciences, 11800 Universiti Sains Malaysia, Penang, Malaysia.2Department of Pharmacology, School of Medical Sciences, Universiti Sains Malaysia, 16150Kelantan, Malaysia.

*Author for correspondence

ABSTRACT

A cross-sectional study was conducted among pharmacy students to determinefactors influencing their choice of work place and to evaluate whether a one-yearhospital pre-registration training programme had any effect on these choices.Questionnaires were distributed to graduating students at the School ofPharmaceutical Sciences, Universiti Sains Malaysia. The questionnaires were againsent to the same group of students by post at the end of their pre-registrationtraining year. The response rate during the follow-up stage was 46%. Resultsindicated that students in the survey were more interested in independent and chaincommunity pharmacies compared to other practice settings. Students choices offirst place of practice appeared to be influenced by both intrinsic and extrinsic jobfactors. Our findings did not show major changes in students preferences forpractice sites before and after the hospital pre-registration period. This informationis expected to be useful for pharmacy employers.

Key words: pharmacy, career choice, job factor, workplace, Malaysia

INTRODUCTION

Changes within the pharmacy profession over thepast 15 20 years have been inspiring. Pharmacyis expected to continue to be an exciting andinnovative field in the coming new systems ofhealth care. It will provide new roles andopportunities for pharmacists to serve the healthcare needs of the society. Therefore, futurepharmacists need to make wise decisions regardingeducational and professional preparedness,keeping in mind the mobility and flexibility ofcareer positions.

Until 1995, there was only one pharmacy school in

Malaysia. Pharmacy students at Universiti SainsMalaysia (USM) undergo a 4-year academicprogramme towards a Bachelor of Pharmacydegree. The curriculum for the first three yearsconsists of basic pharmaceutical science subjectsunder the general categories of pharmaceuticalchemistry, pharmaceutical technology, physiologyand pharmacology. Students are exposed toclinical pharmacy curriculum during their fourthacademic year (1). They spend an average of 20hours per week at a university hospital for theirclinical attachments. They rotate through variousclinical pharmacy services, medical and surgical-

Research article: Career choice of Malaysian pharmacy students

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Sgfdptpits(uased attachments, including attachments atarious community pharmacy outlets. Afterraduating, they undergo a one-year trainingrogramme at a recognized pharmacy institutionefore they are registered with the Malaysianharmacy Board. This training is also known asre-registration training, similar to that practised inhe United Kingdom.

s a preliminary study, we decided to evaluateharmacy students choices of practice sites uponraduation and the factors influencing thesehoices. Since this coincided with the compulsoryne-year pre-registration training programme, weere also interested to see whether this trainingad any influence on the students choices. Weelieve that this information will be useful tootential employers when recruiting newly

in the national language (i.e., Malay). Todetermine its clarity, the questionnaire was pre-tested on hospital pharmacists and Master ofClinical Pharmacy students at the university. Forsome questions, students were allowed to checkmore than one answer. Towards the end of the one-year pre-registration training, anotherquestionnaire was mailed to the same batch ofstudents to their respective home addresses.

Data were analysed using the Statistical Packagefor Social Sciences (SPSS) Version 7.5 (SPSS Inc.,Ill). Descriptive data are presented as percentages.Discrete data were analysed by chi-square orFishers Exact tests. Significance level chosen forstatistical testing was 0.05.

RESULTS17

egistered pharmacists.

ETHODS

urvey questionnaires were distributed to 71raduating pharmacy students at USM after theirinal examinations. The questionnaires asked foremographic data, preference of practice sites,revious experience or work, and whether any ofheir immediate family members were healthrofessionals. Students were also asked to rate themportance of identified factors (2), which theyhought would affect their preference of practiceites. These were rated on the Likert scale of 1 to 51 = extremely important, 5 = extremelynimportant). These questionnaires were designed

All 71 final year students (100%) took part in thefirst evaluation (before pre-registration). Thirty-three responded after pre-registration traininggiving a response rate of 46%. All studentsunderwent a one-year period of pre-registrationtraining at government hospitals.

Demographic data

The mean age of students at the time of graduationwas 24.3 years old and nearly two-thirds werefemales. Malay students constituted approximatelyhalf of the graduating class. The number ofrespondents before and after pre-registrationtraining based on gender and race were notstatistically significant (Table 1).

Table 1. Demographic data of students who responded to both surveys.

Before pre-registration(n=71)

After pre-registration(n=33)

Chi-Square Test/FishersExact Test

Gender Male Female

24 (34%)46 (65%)

12 (36%)19 (58%)

P=0.661 (NS)

Race Malay Chinese Indian Other

37 (52%)23 (32%)7 (10%)2 (3%)

15 (45%)12 (36%)2 (6%)2 (6%)

P=0.839 (NS)

Note: The total percentages are not equal to 100 due to missing values NS=not significant

Research article: Career choice of Malaysian pharmacy studentsMajority of students did not have a family member(defined as parents or siblings) as a healthprofessional. Five however, had a pharmacist,three had doctors, one had a dentist, four hadnurses, one had a pharmacy technician and one hada medical assistant among their family members.

Relationship between gender and race withdesired place of work

The most common preferred place of work indecreasing order was, independent communitypharmacy, chain community pharmacy,government hospital, private hospital, andpharmaceutical industry (Table 2).

When grouped according to three major places ofwork (i.e. hospital pharmacy, communitypharmacy, industry), over 60% of female studentsplanned on going into community pharmacy, andjust under 30% planned on pursuing hospital work.Among male students, about 50% preferredcommunity pharmacy, and about 30% planned toenter hospital pharmacy practice. The differencesbetween gender preferences were not statisticallysignificant (p>0.05).

Community pharmacy was the first choice among87% Chinese students and 58.3% of the Malaystudents (Table 3). On the other hand, about 36%of the Malay students chose hospital pharmacy ascompared to about 4 % of the Chinese students.Indian students were relatively equally divided intheir choice of desired places of work. Thedifferences between races in terms of their desiredplaces of work were not statistically significant(p>0.05).

Relationships between previous workingexperiences with the desired place of work

Table 4 shows that 60.6% students had experienceworking at pharmacies or drug stores; 43.7% athospital pharmacies and 5.6% at pharmaceuticalindustries. When results for independent and chaincommunity pharmacies were combined to give anoverall picture of the choice for communitypharmacy practice, a total of 43 students (61%)preferred to work at this site. Of these, 29 (67%)had worked at a pharmacy or drug storepreviously, 20 (46%) at a hospital pharmacy, and 2(5%) in the pharmaceutical industry.18

Table 2. Relationship between gender and desired place of work (first survey).

MaleN (%)

FemaleN (%)

TotalN (%)

Fishers Exact Test

Government hospital 1 (4.3) 11 (23.9) 12 (17.4) 0.06 (NS)

Private hospital 6 (26.1) 2 (4.3) 8 (11.6)

Independent communitypharmacy

7 (30.4) 17 (37.0) 24 (34.8)

Chain communitypharmacy

5 (21.7) 14 (30.4) 19 (27.5)

Pharmaceutical industry 2 (8.7) 2 (4.3) 4 (5.8)

Postgraduate studies 1 (4.3) 0 1 (1.4)

Others 1 (4.3) 0 1 (1.4)

Total 23 (100) 46 (100) 69 (100)

Note: The total number of students are not equal to 71 due to missing values.The percentages are based on the number of students responded on the itemsNS=not significant


Table 3. Relationship between race and desired place of work (first survey).

MalayN (%)

ChineseN (%)

IndianN (%)

OtherN (%)

TotalN (%)

FishersExact Test

Government hospital 9 (25.0) 1 (4.3) 1 (14.3) 1 (33.3) 12 (17.4) 0.06 (NS)

Private hospital 4 (11.1) 0 (0) 2 (28.6) 2 (66.6) 8 (11.6)

Independent communitypharmacy

11 (30.5) 12 (52.2) 1 (14.3) 0 24 (34.8)

Chain communitypharmacy

10 (27.8) 8 (34.8) 1 (14.3) 0 19 (27.5)

Pharmaceutical industry 2 (5.6) 1 (4.3) 1 (14.3) 0 4 (5.8)

Postgraduate studies 0 0 1 (14.3) 0 1 (1.4)

Other 0 1 (4.3) 0 0 1 (1.4)

Total 36 (100) 23 (100) 7 (100) 3 (100) 69 (100)

Note: The total number of students are not equal to 71 due to missing valuesThe percentages are based on the number of students responded on the items NS=not significant

Table 4. Relationship between previous working experiences with the desired place of work (firstsurvey).Desired place of workaPreviousworking

experienceb

Governmenthospital

N (%)

Privatehospital

N (%)

IndependentcommunitypharmacyN (%)

ChaincommunitypharmacyN (%)

Pharmaceu-ticalindustryN (%)

PostgraduatestudiesN (%)

Other

N(%)

Total

N(%)Pharmacy/drug store Yes No

7 (16.3)6 (21.4)

6 (14.0)3 (10.7)

16 (37.2)8 (28.6)

13 (30.2)6 (21.4)

1 (2.3)3 (10.7)

013 (3.6)

01 (3.6)

43 (100)28 (100)

Hospitalpharmacy Yes No

4 (12.9)9 (22.5)

5 (16.1)4 (10.0)

8 (25.8)16 (40.0)

12 (38.7)7 (17.5)

2 (6.5)2 (5.0)

01 (0.03)

01 (0.03)

31 (100)40 (100)

Pharmaceu-ticalindustry Yes No

1 (25.0)12 (17.9)

1 (25.0)8 (11.9)

1 (25.0)23 (34.3)

1 (25.0)18 (26.9)

04 (6.0)

01 (1.5)

01 (1.5)

4 (100)67 (100)

a only one practice choice was allowed

b each student may choose more than one answer19


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similarly, when results for government and privateospitals were combined as hospital pharmacyractice, a total of 22 students (31%) preferred toork at this site. Of these, 13 (59%) hadreviously worked at pharmacies or drug-stores, 941%) at hospital pharmacies and 2 (9%) atndustry-based pharmacies.

hus, the majority of those who preferredommunity pharmacy had previous experience atharmacies or drug-stores. On the other hand,mong those who preferred hospital pharmacy asheir future place of work, only 41% had previousxperience with hospital work.

f the four students who preferred industry-basedharmacies, one had worked at a pharmacy or arug-store and two at hospital pharmacies. Noneorked at industry-based pharmacies before.

preferences for practice sites before and after thepre-registration training. However, overall resultshowed a drop in percentages for most practicesites.

Factors affecting practice choices

The top ten factors that students believed affectedtheir choices of future practice sites before preregistration training were desire for a satisfyingand self-fulfilling position, job securityopportunity for advancement, salary, sense oaccomplishment, opportunity to use ones abilitieand education, opportunity to serve thecommunity, geographic location, nature of workand employers policies (Table 6). Except foemployers policies, these remained in the top tencategories of factors even after the pre-registrationtraining period. None of the changes in rating20

esired place of work/practice before and afterre-registration training

able 5 demonstrates the students desired placesf work before and after pre-registration training.he majority showed interest in communityharmacy (i.e., independent and chain) both beforend after the training (61% and 57%, respectively).he percentages of students who chose hospitaletting (combined both government and privateettings) before and after pre-registration periodere 31% and 24%, respectively. Only a smallercentage chose pharmaceutical industry. Overall,he results did not show major changes in students

which occurred after the pre-registration periodwere statistically significant.

DISCUSSION

There was not much difference between theproportion of female and male students in ourstudent population as compared to recentenrollments in the US schools of pharmacy (3).The majority of our students did not have anyfamily member working as a health professional.

Parents might exert significant influence onstudents decision to choose pharmacy as a career

Table 5. Respondents desired place of work before and after pre-registration training

Desired place of work Before pre-registration(n=71)

After pre-registration(n=33)

Independent community Pharmacy 24 (34%) 7 (21%)

Chain community Pharmacy 19 (27%) 12 (36%)

Government hospital 13 (18%) 4 (12%)

Private hospital 9 (13%) 4 (12%)

Pharmaceutical industry 4 (6%) 1 (3%)

Postgraduate studies 1 (1%) 1 (3%)

Others 1 (1%) 3 (9%)

Note: The total percentages are not equal to 100 due to missing values


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Table 6. Top ten rating of respondents perception of factors affecting choice of future workplace

FactorsBefore pre-registrationmean (SD)

After pre-registrationmean (SD)

Studentst-test

1 Desire for a satisfying and self-fulfilling position

1.6 (0.6) 1.7 (0.9) NSa

2 Job security 1.6 (0.8) 1.9 (1.0) NSa

3 Opportunity for advancement 1.6 (0.7) 1.6 (0.9) NSa

4 Salary 1.7 (0.7) 1.8 (0.7) NSa

5 Sense of accomplishment 1.8 (0.8) 1.7 (0.7) NSa

6 Opportunity to use ones abilitiesand education

1.8 (0.8) 1.5 (0.8) NSa

7 Opportunity to serve community 1.8 (0.7) 1.8 (0.7) NSa

8 Geographic location 1.8 (0.8) 1.8 (0.8) NSa

9 Nature of work 1.9 (0.8) 1.8 (0.8) NSa

10 Employers policies 1.9 (0.8) 2.1 (0.9) NSa

a All comparisons were not significantly different at alpha level of 0.054), but our results showed that this factor was notmong the ten most important factors (Table 6) influencing their choice of field work as a

harmacist.

t is interesting to see that government and privateospital practices were less favoured by studentsompared to independent or chain communityharmacies. These choices were similar to thoseeported by others (2,4). The findings mayartially explain the consistently low filling rateor the positions of pharmacist in governmentospitals. In 1995, the Malaysian Ministry ofealth (MOH) annual report showed that of the70 positions for staff pharmacists available atovernment hospitals, only 341 were filled (5).his trend has been consistent for the last fewears where the filling rate was only around 60%6,7).

tudies on gender difference in preference forractice sites have shown conflicting results (4,8).ur results showed that only about one-third of thetal number of female students would like to goto hospital pharmacy practice. However,tended and actual practice settings tend to

iffer. In fact, among pharmacy practitioners,

investigators have shown a growing trend ofsimilarity in gender distributions of practicesettings (9, 10). It is interesting to see from ourfindings that community pharmacy practiceseemed to be more favourable among Chinesestudents whereas hospital pharmacy practiceseemed to be more favourable among Malaystudents. This tendency for a difference in racialpreference of practice sites needs to be furtherexplored.

Approximately half of our students had previousexperiences either at hospital pharmacies,community pharmacies or drug stores. Previousexperience at a hospital pharmacy did not havemuch effect on students preference to practise athospitals (29%). On the other hand, previousexperience at a pharmacy or drug-store might haveinfluenced many students (67%) on theirpreference to practise at a community pharmacy.In general, regardless of whether students hadprevious working experience or not, thecommunity pharmacy setting was the most desiredplace of work.

Factors known as intrinsic factors are associatedwith good feelings about a job, and that bad21


22

feelings are associated with extrinsic factors.Intrinsic factors include the nature of work, desirefor a satisfying and self-fulfilling position,opportunity for advancement, sense ofaccomplishment, opportunity to use ones abilitiesand education, and opportunity to serve thecommunity. Extrinsic factors include job security,salary, geographic location, availability ofposition, working conditions, influence of family,friends or professors, and employers policies. Asreported by others (1,11), the results from oursurvey showed that a combination of these jobfactors were involved in students selection ofpractice sites. Although six out of ten wereintrinsic factors, this may change once in theprofession. Other factors may also affectpharmacists choice of current practice sites (12)and most of them can be considered as extrinsicfactors (e.g. income potential, and influence ofspouse).

Our findings showed that hospital pre-registrationexperience did not have a major effect on thechoice of practice sites. In one study, it was foundthat although the percentage of students whoparticipated in a hospital internship programmewas high, there was a lower percentage of studentswho selected a career in hospital pharmacies whencompared to community pharmacies (11). Theauthors suggested that the activities students did

during their internship might not be viewed aspersonally rewarding by many of them. This mighthave influenced their lack of preference forhospital pharmacy practice. Hospital pre-registration in our setting may not be similar tohospital internship programme practised in the USbut suggestions to improve students experience inhospital setting (11) may be applicable to ours.This includes providing a more structuredprogramme which provides emphasis in theoperations, administration and patient - orientedpharmaceutical services to enable students toexperience hospital pharmacy practice in greaterdepth.

CONCLUSION

This survey provides some insights into thereasons why pharmacy graduates choose their firstsite of practice. An understanding of the factorsthat influence graduates practice-site choices isimportant if employers wish to design effectivestrategies to employ future pharmacists. Ourfindings did not show major changes in studentspreferences for practice sites before and after thehospital pre-registration period. Speculation thatstudents would be more inclined toward hospitalpractice because of additional clinical education intheir final year is not supported by our data.

*****REFERENCES

1. Hassan Y. Challenge to clinical pharmacy practicein Malaysia. Ann Pharmacother 1993;27:1134-8.

2. Besier JL, Jang R. Factors affecting practice-areachoices by pharmacy students in the Midwest. AmJ Hosp Pharm 1992;49:598-602.

3. Meyer SM. The pharmacy student population:applications received 1995-96, degrees conferred1995-96, fall 1996 enrollments. Am J Pharm Educ1997;61:63s - 74s.

4. Rascati KL. Career choice, plans, and commitmentof pharmacy students. Am J Pharm Educ1989;53:228 - 234.

5. Malaysian Ministry of Health. Pharmaceuticalservices resources. In: Annual Report. KualaLumpur: Ministry of Health; 1995. p 155.

6. Malaysian Ministry of Health. Hospital pharmacy.In: Annual Report. Kuala Lumpur: Ministry ofHealth; 1993. p 7.

7. Malaysian Ministry of Health. Health manpower.

In: Annual Report. Kuala Lumpur: Ministry ofHealth; 1994. p 10.

8. Ferguson JA, Roller L. Career aspirationscompared by gender and generation status:preliminary analysis of pharmacy students. Am JPharm Educ 1986;50:39-43.

9. Lurvey P. Pharmacist career patterns: alongitudinal study of practice settings. Am JPharm Educ 1992;56:114 - 123.

10. Lee M, Fjortoft N. Gender differences in attitudesand practice patterns of pharmacists. Am J PharmEduc 1993; 57:313 - 319.

11. Carter EA, Segal R. Factors influencingpharmacists selection of their first practicesetting. Am J Hosp Pharm 1989;46:2294-2300.

12. Scott DM, Neary TJ, Thilliander T, et al. Factorsaffecting pharmacists selection of rural or urbanpractice sites in Nebraska. Am J Hosp Pharm1992;49:1941-1945.

Malaysian Journal of Pharmacy 2001;1:22-28 Research article

23

Public Awareness of Community Pharmacyand PharmacistsHadida Hashim1*, Ahmad Mahmud2, Lim Wai Hing1, Lum Peck Yoong3,Natasha Mohd. Yusof1 & Tang Yoke Bun1

1Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur,Malaysia.2Pharmaceutical Services Division, Selangor State Health Department, 15th Floor, Wisma MPSA,Persiaran Perbandaran, 40000 Shah Alam, Malaysia.3Farmasi Wu, No.4, Jalan SS2/63, 47300 Petaling Jaya, Selangor, Malaysia.

*Author for correspondence

ABSTRACT

An exploratory study to ascertain the publics awareness of community pharmacyand pharmacists in a selected subset of the Malaysian population was undertaken,utilising an interviewer-administered structured questionnaire approach. A totalscore was computed for each respondent, ranging from a possible minimum of 0 anda maximum of 24. The scores achieved were arbitrarily categorised into poor (19) levels of general knowledgeregarding community pharmacy and pharmacists. The scores achieved ranged from3 to 21, with an average fair score of 13.7. The results showed that 93.6% of therespondents (n = 561) interviewed had heard of the term pharmacist before.Interestingly, 17.5% of the respondents were of the opinion that pharmacistsworked on farms. A significant 77.4% perceived that a pharmacist served in adoctors clinic. It was noted that 84.1% of those surveyed would go to doctors foradvice on medicine, while only 49.4% would seek a pharmacist. A majority (76.7%)of the respondents interviewed chose to go to a doctors clinic for a screening test.The study amplifies the need for a more aggressive projection of the pharmacistsimage in the community in order to be recognized and accepted by the public as anintegral partner in the health care profession.

Keywords: pharmacy, pharmacists, survey, perception, awareness

INTRODUCTION

In this day and age, pharmacists play anessential role in educating patients regardingdrug therapy as patients become increasinglyresponsible for their own health care.Community pharmacists are the health care

professionals most accessible to the public (1).The community setting is a platform for thepharmacist to project himself beyond thetraditional image of being simply a drugsupplier in that he is able to provide

Research article: Public awareness of community pharmacy

24

pharmacotherapeutic counselling to patients,apart from general health care information tothe public. This is in line with Hepler andStrands concept of pharmaceutical care (2).

However, this professional expertise will onlybe fully utilised if the public is aware of andunderstands the role played by the pharmacistin the community. Hence, this exploratorystudy was conducted to ascertain the publicsawareness regarding the community pharmacyprofession and pharmacists.

AIM

The aim of this study is to examine the publicsawareness about community pharmacy andpharmacists, in a selected subset of theMalaysian population.

METHOD

Study design

This public opinion survey was conductedusing a structured interview technique, inwhich the respondents were asked questions bytrained researchers (25 undergraduate studentsand 1 pharmacist). It took place over a 4-dayperiod in August 1997, during the University ofMalaya Convocation Festival. Visitors to thePharmacy booth who appeared to be over 18years of age were approached aboutparticipation in the survey. The samplingmethod used was that of convenience sampling.Only those who agreed (97.9%) participated inthe study, with each interview takingapproximately 8 to 10 minutes to complete.

Questionnaire

A structured questionnaire was used. Apartfrom the portion relating to the demographicprofile of the respondents, there werealtogether 10 questions focussed on thefollowing aspects:a) the respondents general awareness of

pharmacists and their places of workb) the purchasing pattern of respondents in

relation to pharmacies, sinseh(traditional Chinese medicinepractitioner) shops and other places

c) the awareness of services offered bycommunity pharmacies such as treatment

of minor ailments, screening tests andadvice on medications.

Each question had pre-formulated responses.The questionnaire designed by the researchteam was piloted with a sample of 25 staffmembers of the Faculty of Medicine,University of Malaya.

Data analysis

The data was entered into a worksheet andanalysed using Microsoft Excel. A scoringsystem was practised as follows:

a) For any question requiring either a Yes orNo or Unsure response, only the positiveresponse was given a score of 1, whilst any of theother two responses was awarded a score of 0each. As an example, for the question Have youheard of the term Pharmacist? a Yes responsewas scored as 1.

b) For any question requiring the choice of one ormore than one answer, only the answers deemedappropriate was given a score of 1 each and adeduction of 1 was made for each inappropriateanswer, with the lowest possible final score of 0for any question. As an example, for the questionTo whom would you go for advice onmedicines? where more than one answer may begiven, a respondent who chose Pharmacist,Doctor and/or Nurse was given a score of 1for each of the answers with a deduction of 1 ifSinseh was also selected along with any of theappropriate answers. If Sinseh was the onlyanswer selected, the respondent received a finalscore of 0 for that question.

A total score was computed for each respondent,ranging from a possible minimum of 0 and amaximum of 24. The scores achieved werearbitrarily categorised into poor (19) levels ofgeneral knowledge regarding communitypharmacy and pharmacists.

RESULTS AND DISCUSSION

General

There were 561 respondents, who were mainlyMalaysians (97.5%). The ethnic representationwas 59% Malays, 29% Chinese and 9%Indians. The majority (61.5%) of therespondents were between 18 25 years oldwith 18.2% and 17.1% aged between 26 35

Research article: Public awareness of community pharmacy

years and 36 50 years respectively. In termsof gender distribution, 41% of the respondentswere malrespondentprofessiona(20.3%), postgradua(1.1%) and(75%) of re

The responout of a posthe respondand goodwas 13.7 ancategory). distribution.the respondthree-quartehad attainedwere only foscores: twohousewife executive. achieved athe differegroups weon the stud

Public imag

The respon

awareness of the term Pharmacist as well as thenature of work and workplace of a pharmacist.

of the term respectively,acist did andowever, thequired thelace of theotion. Whilermacist with

and factories,macists withs! [Figure 2].d of the termreness of aity was notiation withuggested apensers and

ociated withe perceivedrmacy andion (91.1%)e. The composition of thes include undergraduates (55.1%),ls (16.6%), non-professionalsschool-going students (3.7%),

te students (2.3%), housewives pensioners (0.9%). The majorityspondents lived in urban areas.

dents scores ranged between 3 to 21sible maximum of 24. The majority ofents obtained scores in the fair (48%) (39.6%) categories. The mean scored the mode was 14 (both in the fairFigure 1 reflects an almost normal The generally fair scores achieved byents were not unexpected with almostrs (74%) of them either undertaking or a tertiary level of education. Thereur respondents who obtained excellent were undergraduates, one was a

while the other was a sales

Most respondents (93.6%) had heardpharmacist while 89.7% and 88.2%thought they knew what the pharmwhere the pharmacist worked. Hfollowing question, which rerespondents to choose the workppharmacist, disproved the above nmost respondents associated the phathe retail sector, hospitals, academia a shocking 77.4% associated phardoctors clinics and 17.5% with farmObviously, the respondents had hearpharmacist; however, their awapharmacists role in the communcompletely accurate. The assocworking in a doctors clinic sconfusion between the roles of dispharmacists. Farms were also asspharmacists, possibly due to thsimilarity between the words phafarm. Most of the study populat25

Surprisingly, no professionaln excellent score. The scores fornt occupations, genders and ethnicre not significantly different basedents t-test (p>0.05).

e of pharmacists

dents were assessed on their level of

associated pharmacists with the community orretail pharmacies and less with hospitals,factories and pharmaceutical trading houses.This confirms that community pharmacistshave a higher visibility and hence would be ina better position to disseminate information andinfluence public opinion on pharmacy.

In this survey, quite a large proportion of the

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Figure 1. Distribution of the respondents scores based on theappropri

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