Gelayee and Mekonnen BMC Medical Education (2018) 18:95

https://doi.org/10.1186/s12909-018-1216-0

RESEARCH ARTICLE Open Access

Pharmacy students’ provision of health

promotion counseling services during a
community pharmacy clerkship: a cross
sectional study, Northwest Ethiopia
Dessalegn Asmelashe Gelayee1* and Gashaw Binega Mekonnen2

Abstract
Background: Globally, undergraduate pharmacy education comprises practice programs aimed to address different
competencies. This study was intended to investigate pharmacy students’ provision of health promotion (HP)
counseling services during a community pharmacy clerkship in Northwest Ethiopia.
Methods: A prospective cross-sectional study was conducted on fifty one fifth-year pharmacy students immediately
after completion of a 2-week community pharmacy clerkship. Data were collected through a self-administered
questionnaire. Relationship between variables was examined using Pearson’s Chi-square test of independence,
Mann–Whitney U test, and Spearman’s rank correlation coefficient.
Results: The mean number of HP counseling service types delivered during the clerkship was 6.3 ± 2.8 out of
12. It is positively correlated with the number of HP counseling service types delivered in students’ previous
training (rho =0.437, p = 0.001). Nearly half (n = 25, 49%) of the students were actively-involved (i.e delivered
≥ 7 types of HP counseling service types) in the service and those who were well involved in previous training are
more likely to do the same during the clerkship (X2 = 4.581, p = 0.032). The main barriers perceived to hinder health
promotion service were clients’ lack of time and interest as well as absence of a guideline for health promotion service.
Conclusion: Community pharmacy clerkship is a good opportunity for pharmacy students to develop health promotion
counseling skill. Clerkship performance can best be improved through successful exposures to similar activities in previous
courses and students shall be encouraged to carry out self-assessments of their health promotion counseling practice
against standards set for the clerkship.
Keywords: Clerkship, Counseling, Ethiopia, Health promotion, Pharmacy, Students

Background stated in the Joint FIP/WHO guideline on good phar-

Pharmacists’ role in patient care continues to grow along macy practice [2]. The importance of the role of phar-
with the profession. Thus undergraduate pharmacy edu- macists in patient counseling is recognized [3] and
cation has been changed in many ways. Practice pro- because of increased accessibility, they are in a key pos-
grams account for a significant part of these changes [1]. ition to provide HP services [4]. Several studies have
Pharmacists are required more than ever to contribute shown the benefits of pharmacists’ involvement in a
in the area of health promotion (HP), and it is one of wide range of important public-health issues including
the six components that contribute to the health im- smoking cessation, diabetes, hypertension and contra-
provement of individuals accessing pharmacy services as ception [5]. However most pharmacy schools in Africa
do not ingrain public health concepts including health
* Correspondence: [email protected]
promotion in their curricula. Thus review of the the cur-
1
Department of Pharmacology, College of Medicine and Health Sciences, ricula and teaching methodology seems vital [6]. In
University of Gondar, P.O.Box 196, Gondar, Ethiopia Ethiopia, the minimum entry level for pharmacy practice
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Gelayee and Mekonnen BMC Medical Education (2018) 18:95 Page 2 of 7

is diploma (for pharmacy technicians) and they are University of Gondar. It is a public university located in
qualified to run drug stores. Whereas, community phar- Gondar, Northwest Ethiopia and offers Bachelor of phar-
macies need to be run by a pharmacist with at least a macy education in both regular and continuing educa-
Bachelor degree in Pharmacy. This is a 5-year program tion program. All clerkship students of 2016/17 were
with final year allocated for a clerkship programme. The assigned to community pharmacies (6 students per facil-
nationally harmonized curriculum incorporates a Com- ity on average) which are run by a B.pharm graduate
munity Pharmacy clerkship course of 5 ECTS points and all of which were at the same level. Drug stores
during the fifth year [7]. The nationally harmonized cur- which are run by pharmacy technicians were not used to
riculum stated that one of the objectives to be met in train the students in the clerkship.
the clerkship is provision of public health and wellness
services tailored to the needs of patients. Study population
On the other hand, non-commuicable diseases (NCDs) All 51 undergraduate fifth year pharmacy students en-
have become a major public health concern in the na- rolled in the regular program of University of Gondar in
tion accounting for 30% of deaths in 2014 alone. Eighty 2016/17 were involved in the study. This population was
percent of this is accounted for by cardiovascular dis- purposely selected because they were final year students
eases, cancers, diabetes and chronic respiratory diseases who have completed all the pre-requisite courses to
[8]. The shared common risk factors are tobacco, insuffi- practice in a Community Pharmacy Clerkship, and were
cient physical activity, unhealthy diet and excessive alco- thought to have assimilated the knowledge and skill of
hol use which are preventable [8]. Pharmacists can join counseling. They were the best student population for
the campaign against such risks through health promo- an evaluation of the counseling practice of pharmacy
tion services. Workye et al. [9] and Ayalew et al. [10] undergraduate students.
have shown that the majority of clients in Gondar town,
Northwest Ethiopia expect health promotion services Data collection procedure
from pharmacies such as life style modifications required The students were contacted immediately after com-
for the underlying medical condition. The importance of pletion of the 2 weeks clerkship and data were collected
teaching student pharmacists how to implement and de- through a self-administered questionnaire prepared
liver wellness and prevention services has been recog- based on previous studies [13, 14] with some modifica-
nized [11]. Early exposure to health promotion and tions (see Additional file 1).
disease prevention concepts may help strengthen stu- It consisted of 3 main parts: Previous involvement in
dents’ desire and expectations to fulfill these expanded HP counseling services; Involvement in HP counseling
pharmacy roles [12]. services during the clerkship; Barriers that limit the
The future of the pharmacy profession is in the hands of practice.
todays students. Thus student pharmacists must be taught The questionnaire was validated for its content by
how to provide the health promotion service. This is espe- three senior pharmacologists and pretested on 10 clerk-
cially so for community pharmacists who are very access- ship students enrolled in the continuing education of
ible to the community and hence are an in an ideal setting the same university. Necessary modifications were made
to provide the sevice. Community Pharmacy Clerkships in before distributing the questionnaires to the students.
particular, need to boldly address the issue of developing The reliability of the different sub-components of the
student health promotion counseling skill in the settings questionnaire was measured and the Cronbach’s alpha
of community pharmacies. Then evaluation and assess- value was 0.892 (involvement in health promotion coun-
ment of the clerkship outcomes would have much greater seling services during previous training, 12 items), 0.798
implications for health educators and authorities. (health promotion counseling services delivered during
This study therefore aimed to investigate health pro- community pharmacy clerkship, 12 items), and 0.766
motion counseling practice, its quality and the barriers (barriers for health promotion counseling service
to provision of the service, as reported by pharmacy stu- provision during the clerkship, 6 items).
dents during a 2 week community pharmacy clerkship.
The study also aimed to determine is there was any Data analysis
‘bottleneck’ to developing students as health promotors, The data were entered into computer for analysis by the
in pharmacist education. statistical package for social sciences (SPSS) version 20.0
for windows (SPSS Inc., Chicago, Illinois). Descriptive
Methods statistics, Mann–Whitney U test, Pearson’s Chi square
Study design and setting test of independence and Spearman’s rank correlation
This prospective cross-sectional study was conducted coefficient were employed in the data analyses. Results
during December 2016 among pharmacy students of are assumed to be significant at p < 0.05.
Gelayee and Mekonnen BMC Medical Education (2018) 18:95 Page 3 of 7

Ethical considerations However, cancer and immunization related services were

All respondents were asked for their verbal consent as reported to be the least. Nearly half (n = 25, 49%) of the
approved by Ethical Review Committee of the School of students were actively involved in the service (i.e deliv-
Pharmacy, University of Gondar. Only the aggregate data ered ≥ 7 types of health promotion counseling services)
was used for research purpose. during the clerkship.

Results Health promotion counseling practices during previous

This prospective cross sectional study was conducted study years
among undergraduate fifth year pharmacy students in a A similar pattern of health promotion service was re-
public Ethiopian University. It describes health promo- ported by the students in previous years of study. The
tion counseling practice and the barriers that students mean number of service types given was 6.6 ± 2.7, min =
faced in providing that service during a Community 0, max = 12. The mean of females (6.8 ± 2.8) and mean
Pharmacy Clerkship. of males (6.5 ± 2.7) were not significantly different (p = 0.
679) in the Mann-Whitney U test, as shown in Fig. 2.
Socio-demographic characterstics and additional There was a significant positive correlation between
responses the number of HP service types practiced in previous
As shown in Table 1, the majority of them were male (n years and those delivered in the Community Pharmacy
= 32, 62.7%) and the mean age was 22.63 ± 1.02 years Clerkship (rho =0.437, p = 0.001). The proportion of stu-
with minimum of 20 and maximum of 25 years. The dents actively involved in health promotion service dur-
overall pharmacy training curriculum of the university ing the clerkship was 49% (n = 25) while that for
was perceived to be adequate to prepare graduates to previous training was 56.9% (n = 29). No significant dif-
render health promotion counseling service (n = 39, 76. ference was found between females and males in being
5%). There is no significant difference between male and actively involved during either the clerkship (p = 0.447)
female students with regard to this opinion. Only 29 (56. or previous training (p = 0.484). However, those who
9%) students received a course syllabus for the Commu- were actively involved in HP services previously were
nity Pharmacy Clerkship ahead of the practice. more likely to be actively involved during community
pharmacy practice (X2 = 4.581, p = 0.032).
Health promotion counseling practices during the
clerkship Perceived quality of HP counseling practice during the
Of the 12 different types of health promotion counseling clerkship and satisfaction of the students
services assessed, the mean number of service types de- Only 22 (43.1%) students perceived that the quality of
livered during the 2 weeks Community Pharmacy Clerk- the health promotion service delivered in the commu-
ship was 6.3 ± 2.8, min = 0 and max = 12. The mean for nity pharmacy clerkship, was of good quality. The same
females (6.0 ± 2.2) and mean for males (6.5 ± 3.1) were proportion of students (43.1%) reported that preceptor
not significantly different (p = 0.517) in the Mann- quality in coaching for health promotion during the
Whitney U test. As shown in Fig. 1, the most commonly clerkship was good, while 5 (9.8%) rated preceptor qual-
delivered services were counseling related to drug ity as very good (See Table 2). About 31 (60.8%) students
misuse, diabetes mellitus and cardiovascular diseases. were satisfied/very satisfied with the service they pro-
vided. The satisfaction of students with the service pro-
Table 1 Socio-demographic characterstics and additional vided was positively correlated with the quality of the
responses (N = 51) service (rho = 0.398, p = 0.004).
Variables N (%)
Gender Perceived barriers to provide health promotion
Female 19 (37.3%) counseling during the clerkship
Male 32 (62.7%)
Only 28 (54.9%) students reported that they observed
health promotion services being delivered in the com-
Age mean = 22.6 ± 1.0
munity pharmacy in which they were assigned to
Training curriculum is adequate for offering health promotion service practice. As shown in Table 3, the main barriers
Yes 39 (76.5%) (agree/strongly agree) hindering health promotion ser-
No 12 (23.5%) vice were lack of time (n = 32), lack of clients’ interest
Received course syllabus for the clerkship (n = 32) and absence of a guideline for health promo-
Yes 29 (56.9%)
tion service (n = 27). Based on the Mann-Whitney U
test, no group difference was observed based on gen-
No 22 (43.1%)
der of the respondents.
Gelayee and Mekonnen BMC Medical Education (2018) 18:95 Page 4 of 7

Fig. 1 Health promotion counseling practices during community pharmacy clerkship (n = 51). DM: Diabetes Mellitus; CVD: Cardiovascular Disorder;
NPA: Nutrition and physical activity; Mgt: management

Discussion as counseling on alcohol consumption and on healthy eat-

The findings of the present study indicated that Com- ing [15] as well as counseling on traditional medicines
munity Pharmacy Clerkship is an important means for [16] and oral health [17]. Community pharmacists in
developing the skills of undergraduate pharmacy stu- Africa seem to have a positive attitude towards public
dents on health promotion counseling practices. Yet, health roles such as health promotion counseling [14, 18].
there is a perception that it lacks diversity and quality. The contemporary curriculum for Bachelor of Phar-
The main barriers for the practice were lack of time and macy in the University of Gonadr was perceived to be
interest among clients and absence of a guideline for sufficient enough by the majority of students to prepare
health promotion counseling practice. The finding high- them to deliver health promotion services. However this
lights for health educators and authorities the import- is in contrast with the report that concepts of public
ance of revising the curriculum and its delivery. health are hardly entertained in the curricula of most
pharmacy schools in Africa [6]. It is encouraging that
Health promotion counseling practice nearly half of the HP topics included in the survey were
A limited number of studies have identified different delivered during the clerkship with no statistical differ-
health promotion counseling topics for community phar- ence between males and females (p = 0.517). The fact
macists in Africa: Asthma; Diabetes; Cardiovascular that the most used topics were drug misuse, diabetes
Disease; Drug misuse; Nutrition and Physical Activity; mellitus as well as cardiovascular diseases, could be due
Smoking Cessation; Oral health; Immunization; Trad- to the higher proportion of clients visiting the pharma-
itional Medicine; Weight Management; Family Planning; cies requesting medications useful in cardiovascular dis-
and Cancer [14]. Other studies have reported public orders and diabetes mellitus. Both of these diseases are
health roles of community pharmacists in Ethiopia such among the major NCDs linked to high mortality in

Fig. 2 Health promotion counseling practices in previous study years (n = 51). DM: Diabetes Mellitus; CVD: Cardiovascular Disorder; NPA: Nutrition
and physical activity; Mgt: management
Gelayee and Mekonnen BMC Medical Education (2018) 18:95 Page 5 of 7

Table 2 Perception of quality of health promotion counseling practice and satisfaction with the service provided (N = 51)
Variable Response
Poor Fair Good Very good
Quality of health promotion service provided 7 (13.7%) 22(43.1%) 22(43.1%) 0
Preceptors’ effort to introduce students in health promotion services 7 (13.7%) 17(33.3%) 22(43.1%) 5 (9.8%)
Very unsatisfied Unsatisfied Satisfied Very satisfied
Satisfaction with the health promotion service students provided 3 (5.9%) 17(33.3%) 30(58.8%) 1 (2%)
4 point likert scale (1 = poor/very unsatisfied, 4 = very good/very satisfied)

Ethiopia [8]. The finding highlights that the diversity of The satisfaction of students with the service they pro-
health promotion topics covered in the clerkship is lim- vided was positively correlated with the quality of the
ited. It is in contrast to a previous study where lots of service (p = 0.004). Professional attitudes of students
health promotion topics were covered [14]. Specially, may be influenced by such poor practice experiences
cancer related health promotion service was the least and much emphasis shall be given to promote quality
performed and students need to be well trained to im- practice. Observations of practicing pharmacsists who
prove this service since cancer accounts for a significant were less involved in HP counseling service might have
share of mortality related to NCD [8]. its own negative influence on students’ practice. In the
Overall, the majority of students were not actively in- present study, nearly half of the students did not observe
volved in HP service during the clerkship. In the era of HP services in the practice site. Thus, it seems import-
more patient focused pharmacy profession [19], students ant to improve the practice of pharmacists if they are to
need to be trained very well to enhance their involve- successfully support the clerkship and participate as po-
ment in HP service. Previous experience and current tential preceptors.
practice of HP counseling were positively correlated (p = Several factors have been identified as barriers to prac-
0.001) highlighting the importance of diversifying and tice health promotion in community pharmacy settings
strengthening practice of students in the study years such as lack of time, lack of training, and absence of
prior to the clerkship. Quality education should be built standard practice guideline [5, 13–15, 23]. The barriers
from the bottom during pre-service training. However, identified in the present study are consistent with these
this contrasts the findings of Offu et al. [18] where com- studies. In this regard we suggest further studies to as-
munity pharmacists’ public health practice in Nigeria sess preceptors’ competency and commitment in moni-
was independent of previous experience. toring such clerkships. The reasons why clients are not
interested with health promotion services requires fur-
Perceived quality and barriers of health promotion ther assesment. It would sometimes be important only
counseling practice during the clerkship to sensitize clients on health promotion topics and ask
As the majority of students rated the quality of HP ser- them to come back some other time.
vice they delivered and the preceptors’ quality in training This is a baseline study and a pioneer in the nation.
health promotion poorly, much emphasis shall be given Although it may not apply to all pharmacy students in
to build capacity of preceptors and properly monitor Ethiopia, it gives an insight into health promotion coun-
students’ performance in clerkships to meet the desired seling practice of pharmacy students in a developing
objectives. If pharmacy education is to be improved, pre- country. The present study is not without limitations.
ceptors are also responsible for improving their coaching The fact that the community pharmacy clerkship was
skills [20–22]. only of 2 weeks duration might affected the number of

Table 3 Barriers that limit students’ involvement in health promotion cousseling practice (N = 51)
Barrier Response
SD D A SA
Lack of time by clients 5 (9.8%) 14 (27.5%) 27 (52.9%) 5 (9.8%)
Lack of interest by clients 5 (9.8%) 14 (27.5%) 25 (49%) 7 (13.7%)
Absence of standard guideline for the services 10 (19.6%) 14 (27.5%) 18 (35.3%) 9 (17.6%)
Lack of training/knowledge 9 (17.7%) 17 (33.3%) 20 (39.2%) 5 (9.8%)
Lack of confidence 10 (19.6%) 20 (39.2%) 19 (37.3%) 2 (3.9%)
I have no interest 22 (43.1%) 18 (35.3%) 8 (15.7%) 3 (5.9%)
SD strongly disagree, D disagree, A agree, SA strongly agree
Gelayee and Mekonnen BMC Medical Education (2018) 18:95 Page 6 of 7

health promotion topics covered by the students and Author details

1
thus undermined the finding in the present study. Department of Pharmacology, College of Medicine and Health Sciences,
University of Gondar, P.O.Box 196, Gondar, Ethiopia. 2Department of Clinical
Since it is a retrospective study and only assesses Pharmacy, College of Medicine and Health Sciences, University of Gondar,
sudents’ perception, qualitative and observational P.O.Box 196, Gondar, Ethiopia.
studies need to support its findings. There could be
Received: 8 June 2017 Accepted: 27 April 2018
some response bias as the questionnaire was self-
administered and the small sample size may also limit
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