International Journal of Clinical Pharmacy

, Volume 41, Issue 6, pp 1462–1470 | Cite as

Management of uncomplicated gastric ulcer in community pharmacy: a pseudo-patient study

  • Segun J. ShowandeEmail author
  • Adenike R. Adelakun
Research Article


Background Increasing role of community pharmacists sometimes demands the diagnoses of minor ailments using appropriate questioning skills and recommendation of over-the-counter medications to patients seeking self-care. Objective To evaluate community pharmacists’ questioning and diagnostic skills of minor ailment complaints, and the appropriateness of medication(s) recommendations made. Setting One hundred and thirty-one community pharmacies in Ibadan, Nigeria. Method A cross-sectional survey employing pseudo-patient study method. The pseudo-patient visited 131 community pharmacies from June 2017 to January 2018 and complained of stomach ache. The conversation between the pharmacists and pseudo-patient were audio-taped and transcribed verbatim. Two criteria were used to evaluate the questioning skill of the community pharmacists. One of the criteria was developed by a six-membered panel and had 13 questions while the other contained five questions:—Who is it for? What are the symptoms? How long have the symptoms been present? Action taken? and Medication used.? Questioning skill of the community pharmacists was classified based on the median scores of these two criteria as: poor, moderate and optimal. The diagnoses made by the community pharmacists from the pseudo-patients complaints were compared with the expected diagnosis of uncomplicated gastric ulcer caused by the use of ibuprofen. Recommendations for the pseudo-patients minor ailment were also compared with the Nigeria standard treatment guideline. Main outcome measure Pharmacists’ questioning skill, types of diagnosis made and appropriateness of medications recommended. Results The median scores for the questioning skill criterion containing 5 and 13 questions were 2 and 4, respectively; showing poor questioning skill. Differential diagnoses of gastric ulcer, dyspepsia, gastroesophageal reflux, and hyperacidity were made by 92 (67.4%) pharmacists but 3 (2.3%) correctly diagnosed the pseudo-patients’ minor ailment as uncomplicated gastric ulcer caused by short-term use of ibuprofen. Antacids were recommended in line with the standard treatment guideline by 46 (35.7%) pharmacists while proton pump inhibitors were recommended by 6 (4.7%) pharmacists. None advised the withdrawal of the provocative factor according to the treatment guideline. Conclusion The questioning skill of the community pharmacists in this setting was poor. Few community pharmacists diagnosed the pseudo-patients’ minor ailment correctly. Also, recommendations were mostly inappropriate compared with the standard treatment guideline.


Gastric ulcer Minor illness Mystery shopper Nigeria Pharmacist Pseudo-patient Self-care 



We thank all the owners of community pharmacies and pharmacists who participated in this study.


No funding was received from any organization or institution for this study.

Conflicts of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Paudyal V, Watson MC, Sach T, Porteous T, Bond CM, Wright DJ, et al. Are pharmacy-based minor ailment schemes a substitute for other service providers? A systematic review. Br J Gen Pract. 2013;63(612):e472–e481481.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Bereznicki BJ, Peterson GM, Jackson SL, Walters H, Fitzmaurice K, Gee P. Pharmacist-initiated general practitioner referral of patients with suboptimal asthma management. Pharm World Sci. 2008;30:869–75.PubMedCrossRefGoogle Scholar
  3. 3.
    George PP, Molina JA, Cheah J, Chan SC, Lim BP. The evolving role of the community pharmacist in chronic disease management-a literature review. Ann Acad Med Singap. 2010;39:861–7.PubMedGoogle Scholar
  4. 4.
    Mossialos E, Courtin E, Naci H, Benrimoj S, Bouvy M, Farris K, et al. From “retailers” to health care providers: transforming the role of community pharmacists in chronic disease management. Health Policy. 2015;119:628–39.PubMedCrossRefGoogle Scholar
  5. 5.
    Avery AJ, Pringle M. Extended prescribing by UK nurses and pharmacists: With more evidence and strict safeguards, it could benefit patients. Br Med J. 2005;331:1154–5.CrossRefGoogle Scholar
  6. 6.
    Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the pharmacy: a guide to the management of common illness. John Wiley & Sons; 2013. ISBN: 978-1-118-59844-3.Google Scholar
  7. 7.
    Kerr A, Strawbridge J, Kelleher C, Mertens F, Pype P, Deveugele M, et al. How can pharmacists develop patient-pharmacist communication skills? A realist review protocol. Syst Rev. 2017;6(1):14.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;4:1–35.Google Scholar
  9. 9.
    Collins JC, Schneider CR, Naughtin CL, Wilson F, de Almeida Neto AC, Moles RJ. Mystery shopping and coaching as a form of audit and feedback to improve community pharmacy management of non-prescription medicine requests: an intervention study. Br Med J Open. 2017;7:e019462.Google Scholar
  10. 10.
    Amsler MR, Murray MD, Tierney WM, Brewer N, Harris LE, Marrero DG, et al. Pharmaceutical care in chain pharmacies: beliefs and attitudes of pharmacists and patients. J Am Pharm Assoc. 2001;41:850–5.Google Scholar
  11. 11.
    Benrimoj SI, Werner JB, Raffaele C, Roberts AS, Costa FA. Monitoring quality standards in the provision of non-prescription medicines from Australian Community Pharmacies: results of a national programme. Br Med J Qual Saf. 2007;16:354–8.Google Scholar
  12. 12.
    Werner JB, Benrimoj SI. Audio taping simulated patient encounters in community pharmacy to enhance the reliability of assessments. Am J Pharm Educ. 2008;72:136.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Lynd LD. Prescription to over-the-counter deregulation in Canada: Are we ready for it, or do we need to be? Can Med Assoc J. 2005;173:775–7.CrossRefGoogle Scholar
  14. 14.
    Lalonde L, Tsuyuki RT, Landry E, Taylor J. Results of a National Survey on OTC Medicines, Part 2: Do pharmacists support switching prescription agents to over-the-counter status? Can Pharm J. 2012;145:73–6.CrossRefGoogle Scholar
  15. 15.
    Bell J, Dziekan G, Pollack C, Mahachai V. Self-care in the twenty-first century: a vital role for the pharmacist. Adv Ther. 2016;33:1691–703.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Banks I. Self care of minor ailments: a survey of consumer and healthcare professional beliefs and behavior. SelfCare J. 2010;1:1–13.Google Scholar
  17. 17.
    Horvat N, Koder M, Kos M. Using the simulated patient methodology to assess paracetamol-related counseling for headache. PLoS ONE. 2012;7:e52510.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Igun UA. Reported and actual prescription of oral rehydration therapy for childhood diarrhoeas by retail pharmacists in Nigeria. Soc Sci Med. 1994;39:797–806.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Berger K, Eickhoff C, Schulz M. Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany. J Clin Pharm Ther. 2005;30:45–57.CrossRefGoogle Scholar
  20. 20.
    Kippist C, Wong K, Bartlett D, Saini B. How do pharmacists respond to complaints of acute insomnia? A simulated patient study. Int J Clin Pharm. 2011;33:237–45.PubMedCrossRefGoogle Scholar
  21. 21.
    Anderson C, Alexander A. Response to dysmenorrhoea: An assessment of pharmacists’ knowledge and its application in practice. Int J Pharm Pract. 1993;2:180–3.CrossRefGoogle Scholar
  22. 22.
    Leiva A, Shaw M, Paine K, Manneh K, McAdam K, Mayaud P. Management of sexually transmitted diseases in urban pharmacies in The Gambia. Int J STD AIDS. 2001;12:444–52.PubMedCrossRefGoogle Scholar
  23. 23.
    Kwena ZA, Sharma A, Muga C, Wamae N, Bukusi EA. Management of simulated patients with sexually transmitted infections by staff of retail pharmacies in Kibera slums of Nairobi. East Afr Med J. 2008;85:419–24.PubMedCrossRefGoogle Scholar
  24. 24.
    Rutter PM, Horsley E, Brown DT. Evaluation of community pharmacists’ recommendations to standardized patient scenarios. Ann Pharmacother. 2004;38:1080–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Lamsam GD, Kropff MA. Community pharmacists’ assessments and recommendations for treatment in four case scenarios. Ann Pharmacother. 1998;32:409–16.PubMedCrossRefGoogle Scholar
  26. 26.
    Driesen A, Vandenplas Y. How do pharmacists manage acute diarrhoea in an 8-month-old baby? A simulated client study. Int J Pharm Pract. 2009;17:215–20.PubMedCrossRefGoogle Scholar
  27. 27.
    Morrow N, Hargie O, Donnelly H, Woodman C. “Why do you ask?” A study of questioning behaviour in community pharmacist-client consultations. Int J Pharm Pract. 1993;2:90–4.CrossRefGoogle Scholar
  28. 28.
    Wilson M, Robinson EJ, Ellis A. Studying communication between community pharmacists and their customers. Couns Psychol Q. 1989;2:367–80.CrossRefGoogle Scholar
  29. 29.
    Bissell P, Ward PR, Noyce PR. Appropriateness measurement: application to advice-giving in community pharmacies. Soc Sci Med. 2000;51:343–59.PubMedCrossRefGoogle Scholar
  30. 30.
    Krska J, Kennedy EJ. An audit of responding to symptoms in community pharmacy. Int J Pharm Pract. 1996;4:129–35.CrossRefGoogle Scholar
  31. 31.
    Morris CJ, Cantrill JA, Weiss MC. “One simple question should be enough”: Consumers’ perceptions of pharmacy protocols. Int J Pharm Pract. 1997;5:64–71.CrossRefGoogle Scholar
  32. 32.
    Consumers’ Association. Pharmacists: how reliable are they. Way Health. 1991;191–4.Google Scholar
  33. 33.
    Smith FJ, Salkind MR, Jolly BC. Community pharmacy: a method of assessing quality of care. Soc Sci Med. 1990;31:603–7.PubMedCrossRefGoogle Scholar
  34. 34.
    General Assembly of the World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent. 2014;81:14.Google Scholar
  35. 35.
    Sample Size Calculator—Confidence Level, Confidence Interval, Sample Size, Population Size, Relevant Population—Creative Research Systems Available from Accessed 13 May 2019.
  36. 36.
    Sandoval AC, Fernandes DR, da Silva EA, Terra Junior AT. The indiscriminate use of non-steroid anti-inflammatory (NSAID). Sci J Fac Edu Environ. 2017;8:165–76.Google Scholar
  37. 37.
    Anon. NPA Launches training with a W-WHAM. Pharm J. 1989;243(40).Google Scholar
  38. 38.
    Sharpe SE, Norris GW, Ibbit ML, Staton TJ, Riley JS. Protocols: getting started. Pharm J. 1994;253:804–5.Google Scholar
  39. 39.
    Garner M, Watson MC. Using linguistic analysis to explore medicine counter assistants’ communication during consultations for nonprescription medicines. Patient Educ Couns. 2007;65:51–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Nordin N, Sarriff A, Hassali Ma. STARZ-DRP: a tool for pharmacy triage services. Asian J Pharm Clin Res. 2017;10:151–7.CrossRefGoogle Scholar
  41. 41.
    Braddick L. Royal Pharmaceutical Society of Great Britain. Public health legislation in Scotland: a consultation. 12 January 2007. Accessed 13 May 2019.
  42. 42.
    Krska J, Greenwood R, Howitt EP. Audit of advice provided in response to symptoms. Pharm J. 1994;252:93–6.Google Scholar
  43. 43.
    Akhtar S, Rutter P. Pharmacists thought processes in making a differential diagnosis using a gastro-intestinal case vignette. Res Soc Adm Pharm. 2015;11:472–9.CrossRefGoogle Scholar
  44. 44.
    Rutter P, Jignaben P. Decision making by community pharmacists when making an over-the-counter diagnosis in response to a dermatological presentation. SelfCare J. 2013;4:125–33.Google Scholar
  45. 45.
    Miller R, Goodman C. Performance of retail pharmacies in low-and-middle-income Asian settings: a systematic review. Health Policy Plan. 2016;31:940–53.PubMedCentralCrossRefPubMedGoogle Scholar
  46. 46.
    Watson MC, Bond CM, Grimshaw J, Johnston M. Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting. Br Med J Qual Saf. 2006;15:53–7.Google Scholar
  47. 47.
    Schneider CR, Everett AW, Geelhoed E, Padgett C, Ripley S, Murray K, et al. Intern pharmacists as change agents to improve the practice of nonprescription medication supply: provision of salbutamol to patients with asthma. Ann Pharmacother. 2010;44:1319–26.PubMedCrossRefGoogle Scholar
  48. 48.
    Federal Ministry of Health. Standard Treatment Guideline 2008. The Federal Ministry of Health in Collaboration with World Health Organisation; Available from Accessed 13 May 2019.
  49. 49.
    Kashour TS, Joury A, Alotaibi AM, Althagafi M, Almufleh AS, Hersi A, et al. Quality of assessment and counseling offered by community pharmacists and medication sale without prescription to patients presenting with acute cardiac symptoms: a simulated client study. Eur J Clin Pharmacol. 2016;72:321–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Friedman B-C, Schwabe-Warf D, Goldman R. Reducing inappropriate antibiotic use among children with influenza infection. Can Fam Physician. 2011;57:42–4.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Al-Azzam S, Al-Husein B, Alzoubi F, Masadeh M, Ali M. Self-medication with antibiotics in Jordanian population. Int J Occup Med Environ Health. 2007;20:373–80.PubMedCrossRefGoogle Scholar
  52. 52.
    Akinyandenu O, Akinyandenu A. Irrational use and non-prescription sale of antibiotics in Nigeria, a need for change. J Sci Innov Res. 2014;3:251–7.Google Scholar
  53. 53.
    Ibrahim MI, Palaian S, Al-Sulaiti F, El-Shami S. Evaluating community pharmacy practice in Qatar using simulated patient method: acute gastroenteritis management. Pharm Pract (Granada). 2016;14(4):800.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Clinical Pharmacy and Pharmacy Administration, Faculty of PharmacyUniversity of IbadanIbadanNigeria

Personalised recommendations