Assessment of Community Pharmacists' Performance in Managing Pediatric Fever and Pain: A Simulated Patient Study in Tehran

Pain and fever are among the most prevalent symptoms of illness in children and cause substantial distress and anxiety for parents (1). When fever presents without an identifiable focus, the clinical challenge increases, and community pharmacists are often the first point of healthcare contact in such cases (2). Pain is recognized as a complex, multidimensional subjective experience that is difficult to diagnose and manage, particularly in pediatric populations (3). Statistics indicate that 30% to 40% of children complain of pain at least once a week (1). If left unmanaged, acute pain can lead to negative long-term sensory experiences, increased sensitivity to stimuli, and heightened anxiety about future painful encounters (4).

Within the healthcare system, pharmacists are among the most accessible members of the medical team, and pharmacies often serve as the first and most frequent point of contact for pain and fever control (5). In Iran, this role is particularly vital because community pharmacies serve as the primary gatekeepers of the healthcare system (6). Owing to a cultural tendency to seek over-the-counter solutions before visiting a pediatrician, the pharmacist’s role in clinical screening is a matter of public safety. If a pharmacist fails to identify red flags in a 2-year-old child, such as symptoms of acute otitis media or meningitis, delayed treatment and catastrophic health outcomes may occur (7). This study is essential for the Iranian system because it identifies a specific educational gap through which theoretical knowledge fails to translate into effective clinical triage. Although common medications such as acetaminophen and ibuprofen are effective tools for symptom reduction, they must be used correctly to avoid complications (8). Effective pain relief is an essential component of high-quality healthcare and requires pharmacists to be well versed in pain mechanisms, assessment, and management (9).

However, global studies have identified gaps in this area. Research in Ethiopia showed that pharmacists may lack sufficient knowledge and appropriate attitudes toward pediatric pain management (5). Similarly, studies in Nigeria (10) and Saudi Arabia (11) have highlighted the need for intensive professional education for healthcare providers to bridge knowledge gaps.

These concerns are echoed by research in other parts of Iran, suggesting a nationwide systemic issue. For instance, a previous simulated patient study in Mashhad, Isfahan, and Qom found that although pharmacists were technically knowledgeable, only a small fraction provided adequate patient counseling (12). Similarly, research in Tehran, Isfahan, Mashhad, and Shiraz on pediatric diarrhea and respiratory infections showed that pharmacists often prioritize medication dispensing over thorough history taking (13). These studies suggest that community pharmacies in Iran are currently underused clinical resources (14), thereby increasing the burden on already overcrowded hospital emergency departments.

In Iran, assessing pharmacists’ knowledge and attitudes toward pediatric pain management is a relatively new and necessary field of study. Inadequate management can delay a child’s recovery or lead to the development of chronic conditions (3). Major barriers to optimal care include insufficient knowledge, lack of assessment skills, and misconceptions among healthcare staff (15).

This study was designed to evaluate the professional performance of pharmacists in Tehran in managing pediatric fever and pain using a simulated patient approach, thereby providing a realistic assessment of counseling provided in local pharmacies.

To evaluate the clinical performance of community pharmacists in a real-world setting, this descriptive-analytical study was conducted across the 22 municipal districts of Tehran. A stratified random sampling approach was used, and 333 pharmacies were selected from the official database of the Iranian Food and Drug Administration to ensure that the findings reflected the city’s diverse geographical and socioeconomic landscape. Rather than using self-reported surveys, which are often prone to bias, the study used a simulated patient (SP) methodology. A single, highly trained researcher visited each pharmacy while portraying a parent seeking help for a 2-year-old child weighing 12 kg with moderate fever and ear pain.

To ensure authentic interactions and minimize the Hawthorne effect, whereby practitioners may improve their performance when aware of being evaluated, the SP followed a standardized script and disclosed specific details, such as the child’s weight or symptom duration, only when directly requested by the pharmacist. Immediately after leaving the pharmacy, the researcher completed a standardized assessment form to minimize recall bias. To ensure consistency across all 333 pharmacy visits, the same standardized script was used. The clinical parameters and fixed responses provided by the SP to the pharmacists’ inquiries are presented in Table 1.

Each interaction was documented using an assessment form that had been prevalidated by a panel of pediatric pharmacology experts. Four main areas of practice were evaluated: The thoroughness of the pharmacist’s history-taking, the appropriateness of the medication recommended, the accuracy of the dose calculated for the child’s weight, and the quality of safety advice and education provided to the parent.

To standardize the evaluation, a weighted 100-point scoring algorithm was implemented. The weighting reflected clinical priorities as follows: history-taking, 30 points, covering age/weight, fever duration, and symptom localization; medication appropriateness, 30 points, with first-line agents receiving full marks and irrational choices such as diclofenac or aspirin receiving zero; dosing accuracy, 20 points, based on the 12-kg weight; and counseling/referral, 20 points, for which medical referral for ear pain was mandatory for a satisfactory score. Final scores were calculated as percentages and categorized into 5 levels: excellent (> 90%), good (75% - 89%), moderate (50% - 74%), weak (25% - 49%), and very weak (< 25%).

All data were processed using SPSS version 26.0. Chi-square and Fisher exact tests were used for bivariate comparisons. To quantify the strength of associations, crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the binary outcome of high performance (good/excellent) versus suboptimal performance (moderate/weak/very weak). Because individual-level raw data were not retained, multivariable logistic regression could not be performed; therefore, all reported ORs are unadjusted.

In this study, non-pharmacological advice was defined as supportive care instructions intended to manage fever and improve patient comfort without medication. To receive credit for this category, pharmacists were required to recommend at least 2 of the following evidence-based strategies: 1) fluid replacement/hydration, instructing the parent to increase the child’s intake of water or oral rehydration solutions to prevent dehydration; 2) environmental cooling, advising the use of light, breathable clothing to facilitate heat loss; or 3) physical cooling, explaining the proper technique for tepid sponging using lukewarm water while explicitly cautioning against the use of ice-cold water or alcohol rubs.

The study protocol received formal approval from the Research Ethics Committees of Islamic Azad Tehran Medical Sciences University, Pharmacy and Pharmaceutical Branches Faculty (ethical code: IR.IAU.PS.REC.1403.539). Strict measures were implemented to ensure that all data remained anonymous and that the privacy of participating pharmacies was protected.

This study evaluated pharmacists’ knowledge and practices in Tehran regarding the management of fever and pain in children. A total of 333 pharmacies were selected from the 22 districts of Tehran using Cochran’s formula. Of these, 301 (90.4%) were urban pharmacies and 32 (9.6%) were hospital pharmacies. During the simulated patient visit, a pharmacist was present in 296 pharmacies (88.9%), whereas in 37 cases (11.1%), the pharmacist was absent. One of the 296 interactions had incomplete data and was excluded from the final scoring, leaving 295 evaluable pharmacists. Demographic analysis of the active pharmacists showed that 153 (51.7%) were female and 143 (48.3%) were male. Regarding age distribution, the workforce was predominantly young: 180 pharmacists (60.8%) were younger than 30 years, whereas 116 (39.2%) were older than 30 years (Table 2).

In terms of history-taking and clinical assessment, performance varied substantially across indicators. Pharmacists frequently asked about the child’s demographics: 243 (82.1%) inquired about age, and 223 (75.3%) inquired about weight. However, inquiries regarding the specific nature of the condition were less frequent. For fever management, 210 pharmacists (70.9%) asked about the duration of fever, but only 114 (38.5%) asked about its intensity. Pain assessment was notably poor; only 92 pharmacists (31.1%) asked about pain duration, and only 61 (20.6%) inquired about pain intensity. Furthermore, only 49 pharmacists (16.6%) assessed signs of restlessness in the child (Table 3).

Regarding management and counseling practices, the vast majority of pharmacists (288, 97.3%) recommended appropriate first-line analgesics, such as ibuprofen or acetaminophen, and 223 (75.3%) correctly calculated the dosage based on the child’s weight. Education on proper medication administration was provided by 218 pharmacists (73.6%). However, proactive safety counseling was limited; only 83 pharmacists (28.0%) explicitly warned against the use of inappropriate medications, and only 29 (9.8%) offered non-pharmacological management strategies. Notably, 40 pharmacists (13.5%) inappropriately recommended diclofenac suppositories for the child, whereas 42 (14.2%) advised referral to a physician (Table 4).

Overall pharmacist performance was categorized based on the cumulative score for assessment and management choices. The results showed that the largest proportion of pharmacists, 151 individuals (51.2%), demonstrated moderate performance. Only 24 (8.1%) achieved an excellent rating, and 33 (11.2%) were rated as good, whereas a substantial proportion fell into the lower categories, with 47 (15.9%) rated as weak and 40 (13.6%) as very weak (Table 5).

Inferential statistical analysis revealed significant relationships between performance and specific variables. A significant association was found between pharmacy type and pharmacist performance (P = 0.031), with urban pharmacies generally performing better than hospital pharmacies (Table 6).

To further quantify these associations, crude ORs were calculated. In unadjusted analyses (Table 7), the association between pharmacy type and high performance was not statistically significant (crude OR = 1.56; 95% CI, 0.52 - 4.66; P = 0.421). Female gender showed a borderline, non-significant positive association (crude OR = 1.98; 95% CI, 0.96 - 4.09; P = 0.061), whereas age was not associated with performance (P = 0.961). Because these analyses are unadjusted and bivariate, they should be viewed as exploratory and do not identify independent predictors of performance.

Community pharmacists are often the first point of contact for managing pediatric conditions, shifting their role from mere dispensers to key providers of public health services (5). This study aimed to evaluate pharmacists' knowledge and practice in Tehran regarding the management of fever and pain in children. The results indicated that most pharmacists (51.2%) demonstrated a moderate level of performance, with a substantial proportion in the weak or very weak categories and only 19.3% achieving good or excellent ratings. These findings of suboptimal performance align with several international studies, suggesting that pediatric pain management remains a neglected area globally. For instance, a study by Ogunyinka et al. (2021) in Nigeria found that a significant proportion of pharmacists answered fewer than 50% of pediatric pain management questions correctly, indicating an alarming knowledge gap (10). Similarly, studies conducted in Ethiopia by Yabeyu et al. (5) and in Canada by Patel et al. (2016) (16) also highlighted insufficient knowledge regarding pediatric pain among community pharmacists.

To provide a balanced perspective, it is essential to distinguish between knowledge-based studies and behavioral evaluations. Previous survey-based research often reports that pharmacists have high knowledge and positive attitudes toward counseling. However, this study, which used an SP methodology, revealed a knowledge-to-action gap. Although participants demonstrated the technical ability to calculate doses (75.3%), their behavioral performance in spontaneous history-taking and counseling was substantially lower. This suggests that, although a theoretical foundation exists, it does not always translate into clinical practice in a high-pressure retail environment.

A critical aspect of the pharmacist's role is ensuring medication safety. In the present study, the net appropriate management rate, defined as the rate of recommending a first-line analgesic without also recommending diclofenac, was 83.8%, and only 28.0% of pharmacists provided specific safety warnings against inappropriate medication use. This is consistent with the findings of Alorfi et al. (2022) in Saudi Arabia, where 39.1% of pharmacists failed to communicate appropriate risk factors associated with nonsteroidal anti-inflammatory drugs (11). However, a positive finding in this study was that only 13.5% of pharmacists inappropriately recommended diclofenac suppositories for the child. This suggests better adherence to safety guidelines for specific contraindications than for general safety counseling, which is particularly important given that general knowledge of nonsteroidal anti-inflammatory drug safety is often low.

One of the most encouraging findings of this study was the high proficiency in dosing. Approximately 75.3% of pharmacists in Tehran correctly calculated the dose based on the child's weight. This finding contrasts with several other studies. For example, Keewan et al. (2021) in Jordan found that most community pharmacists lacked sufficient knowledge regarding appropriate pediatric antibiotic dosing (17). Similarly, Brown et al. (2019) reported that community pharmacists frequently failed to identify proper doses (18). The superior performance of pharmacists in Tehran in this domain may be attributed to the strong emphasis on dosage calculation in the local pharmacy curriculum. Conversely, the study revealed a substantial gap in non-pharmacological care, with only 9.8% of pharmacists providing non-drug advice. This rate is much lower than that reported in a study by Jairoun et al. (2022) in the United Arab Emirates, in which most pharmacists demonstrated adequate knowledge of non-pharmacological pain management (19). Structured psychoeducational interventions for caregivers have been shown to improve non-pharmacological pain management practices in children, highlighting a potential strategy that could be adapted for community pharmacist-led counseling (20).

Regarding demographic factors, this study found no significant association between pharmacist gender and performance (P = 0.060). This contrasts with a study by Zahreddine et al. (2018) in Lebanon, which found that female pharmacists had better knowledge regarding pediatric antibiotic use (21). No significant correlation was found between pharmacist age and performance (P = 0.961). This finding diverges from the literature in Saudi Arabia (11), which suggests that recent graduates have better knowledge, as well as studies in Canada (16) and the United Arab Emirates (19), which reported that pharmacists with more experience perform better. However, a statistically significant difference was observed by setting, with urban pharmacies outperforming hospital pharmacies (P = 0.031). The superior performance of urban community pharmacies over hospital-based pharmacies was unexpected. This may be explained by the fact that, in Tehran, urban community pharmacists are often the first point of contact for minor pediatric ailments such as fever, leading to more frequent outpatient counseling. Conversely, hospital pharmacists may be more focused on inpatient medication systems and administrative tasks. However, given the smaller sample of hospital pharmacies, these results should be viewed as a preliminary trend that requires further study with a more balanced cohort. The corresponding crude OR of 1.56 (95% CI, 0.52 - 4.66) further illustrates this uncertainty, as the wide confidence interval reflects the small number of hospital pharmacies and precludes a definitive conclusion.

A major deficiency identified in this study was the lack of comprehensive history-taking. Although demographic questions regarding age and weight were common, clinical questions were rare; for instance, only 20.6% of pharmacists asked about pain intensity. This mirrors the findings of Alomar et al. (2011), in which the vast majority of pharmacists dispensed medications without adequate screening (22). However, the integration of clinical pharmacists into pediatric care has been shown to significantly reduce prescribing errors and improve treatment outcomes, as demonstrated by a comprehensive meta-analysis of 19 studies showing a 73% decrease in prescription mistakes (23) and recent randomized controlled trials confirming that pharmacist-led interventions significantly lower the proportion of drug-related problems in pediatric outpatients (24).