Good Pharmacy Practice (GPP) is based on pharmaceutical care given by pharmacists. The practice guidelines recommend that national standards are set for: the promotion of health, the supply of medicines, medical devices, patient self-medication care, and improving prescribing and medicine use by pharmacists’ activities. National pharmaceutical organizations should also take action to ensure that pharmaceutical education,in both pre- and post-initial qualification, is designed to equip pharmacists for the “professional roles” they have to undertake in hospital and community practice [1].

From these pharmacy professional roles are “Maintain and improve professional performance” and “Contribute to improve effectiveness of the health-care system and public health” [2].

In Iraq, there are two types of pharmacies: hospital pharmacy and community pharmacy and the patients can get two legal categories of medicines: prescription medicines and over the counter medicines. No medicines can be sold from any other outlet including supermarkets and drugstores. Adverse drug reactions are very likely when self-medication is practiced through buying medicines from community pharmacies without consulting a doctor. The problem can be much augmented if pharmacists/pharmacist assistant fail to comply with the standards of GPP.

Duhok Governorate is one of the three governorates in Kurdistan region of Iraq. During the years following the invasion of Islamic State of Iraq and Syria (ISIS) in summer 2014, Duhok population increased from 1,205,110 in 2013 to 1,511,585 in 2017 [3]. The number of hospital admissions increased up to 31, 5% in the four years following the invasion [4]. As a result of that, the medical staff became unable to cope with such a significant increase in the number of patients mainly because of the staff shortage [5]. In addition to that, the educational system suffered regression and descent in both the academic curriculums that are taught and teaching techniques of both undergraduate and postgraduate medical professionals [6], which worsened the situation further.

One of the goals of Duhok Directorate General of Health (DOH) in those difficult circumstances surrounding Kurdistan region was to ensure GPP through exploring ways of improving services to minimize the adverse drug reactions which can be an important cause for hospital admission [7].

This study aimed to assess the professional performance of the staff of community pharmacies in the management of self-medication needs.

This study adopted a cross-sectional design using a simulated client methodology. The study investigated the pharmaceutical practice in coping with self-care and selfmedication needs of those clients reporting to community pharmacies of Duhok city during the period from August 2016 to February 2017. All the 53 community pharmacies in Duhok city were included.

The professional performance of the responsible pharmacist and/or the assistant in each community pharmacy was assessed through the act of six successive case scenarios accomplished by two simulated clients: male and female. Each of the implemented case scenariostook 2–3 days to complete and was done at a rate of one scenario per month. The pharmacies were divided into two groups: group 1 comprised 27 and group 2 comprised 26 pharmacies. The simulated clients changed their look and interchanged the pharmacy group in successive scenarios with the aim of minimizing bias, according to the schedule given in Table 1

The adopted case scenarios focused on common selfcare problems in Kurdistan region. The six case scenarios were the following:

1. A client asks for a medication that helps improving the symptoms of runny nose and itchy eyes [8], [9].

2. A parent asks for a medication that helps a child with diarrhea [10].

3. A client wants to buy “Diclofenac” tablets [11].

4. A worried woman asks if missing a planned contraceptive pill results in pregnancy [12], [13].

5. A client carrying an empty pack of Tramadol (50 mg tablet) asks for a similar pack [14], [15].

6. A client asks adding “Beclomethason inhaler” to the already used “Salbutamol inhaler” [16].

During the act of each scenario, three practice domains were assessed by a series of relevant questions. The assessed practice domains included communications skills, problem analysis, and advice. The question series adopted for assessing each domain were arranged in a check list format that was filled by the simulated client soon after the end of each case scenario. The investigator thereafter scored the whole check lists.

The check list format included the following questions:

1. Communication skills [17]:

• Was the client greeted in a friendly manner?
• Was there eye contact?
• Did the pharmacist and/or the assistant listen well?
• Was the language of the pharmacistand/or the assistant understandable?
• Did the pharmacist and/or the assistant seem self-confident?
• Did the client feel helped?
• Did the pharmacist and/or the assistant summarize the advice?

2. Problem analysis (WWHAMpathway) [18]:

• For whom the advice is intended?
• What are the symptoms?
• How long has the customer already had complaints?
• Which Action has the customer already undertaken?
• What other Medications does the customer use?

3. Advice:

• Was there any information given about the condition?
• Was there an appropriate drug/answer given?
• Was there any instruction given?

Scoring procedure

A scoring procedure was adopted to assess the quality of pharmacy practice as reflected by professional performance of the pharmacy staff (pharmacist/assistant) The questionnaire covered the three studied domains; each domain included a number of questions, each question requires a specific act/response on the part of the pharmacy staff. For each question, a correct act/response per any included question was given a score of one compared to zero for the incorrect one.

Statistical analysis: Data were analyzed using Stata version 14. Frequency tables were used to describe the data. Chi square test was used to test the association between research domains and frequency of mean scores by different case scenarios. A p-value

The study findings revealed clear defects in the performance of community pharmacy staff in all the studied domains. Such findings clearly point to the gap in pharmacy practice, a situation which is lagging far behind the presumed ideal of GPP. The overall mean score of the three practice domains was 18.6, that is around one-third (35.1%) of the presumed score of ideal performance. Communication skills reflected the best score 34.8 (65.6%) followed by advice 15.2 (28.7%) and problem analysis 5.9 (11%). Statistically the differences were highly significant, p-value <0.001, Table 2, Figure 1.

In a study previously conducted at Netherlands, Dutch pharmacies achieved 75.5% in communication skills, 49.9% in problem analysis, and 38.4% in advice, with an overall mean score of 54.6% [19]. Compared to the figures in the current study, the differences are quite evident particularly in the components of problem analysis and the advice. These differences may be attributed to the fact that the staff of Dutch pharmacies were evaluated after being trained on applying an advanced system to assess the quality indicators for pharmaceutical care [20].

Regarding communications skills, the mean domain score was 34.8 (65.7%). The staff showed different performance in the items of this domain, with high scores in friendly greeting, language, self-confidence, and eye contact, 49.8 (94%), 49.8 (94%), 47(88.7%), and 45.8 (86.4%), respectively. The performance in the remaining items did not achieve 50% of the ideal level and was as follows: proper listening (42%), satisfaction of the client (43.8%), and summary advice (10%). Statistically the differences were highly significant, p-value <0.001, Table 3.

Despite that the overall mean score of this domain exceeded 50%, the communications cannot be regarded as successful because client dissatisfaction exceeded 50%. The failure in active listening can lead to miscommunication and/or lack of clarity of the condition. This communication defect has been shown in other studies conducted in Middle East countries, such as the one done in Qatar (37%) which attributed the defect to two reasons: lack of personnel in the pharmacy and lack of time [21].

As to problem analysis the staff performance was very bad across all its items and that even its best level (in the item; asking for whom?) did not achieve one-third of the ideal. The mean domain score of 5.9 (11%) was the lowest between the three domains. Statistically, performance differences in different items were highly significant, p-value <0.001, Table 4.

The failure of using the WWHAM pathway for probing information about the client amounted to 89%. In a study conducted in Baghdad, the capital of Iraq, the failure in this respect was less than 40% [22]. This poor conduct in analysis of the client problem indicates that the pharmacy staff may have no or very poor idea about the performance of WWHAM pathway which is one of the required activities in the element of self-care within the context of GPP adopted by the WHO guidelines [1].

In regard to advice domain, the mean score was also low 15.2 (28.7%). Out of the three items included, the score exceeded the midpoint of the mean only in the item of giving appropriate drug/answer?; 28.7 (54.2%). The differences were also highly statistically significant, p-value <0.001, Table 5.

Such low scores in this domain indicate either an incorrect advice or no advice was given by the pharmacy staff, a point which relates to defective educational level and/or imperfect professional conduct of the advisor. As reported in a comparative study between Jordan, United Arab Emirates, and Iraq, it was shown that 41.9% of Iraqi patients chose the pharmacist as their primary source of advice on medication use vs. 36.7% chose the specialist physician [23]. This low score in providing advice can have negative effects on the patient’s health, in addition to its negative impact on increasing costs and draining resources. Such a low professional performance contrasts the expected important role of the pharmacist which has been proved to reduce the costs in a variety of different healthcare settings [24]. This last effect on costs and resources is certainly of great concern for Duhok particularly under the difficult circumstances experienced by the country.

The assessed professional performance of the staff did not exceed one-third of the presumed ideal reflecting defective practice of community pharmacy. Such a low performance highlights the urgent need for professional training of the staff in pharmacy practice, reviewing the national standards for practicing pharmacists, and arrangement of accreditation courses, by the pharmacy syndicate and Department of Health (DoH). Further studies are needed to explore the precise ways of improving professional performance and community pharmacy practice.