An investigation of the factors affecting community ... - Springer Link

Article

An investigation of the factors affecting community pharmacists’ selection of over the counter preparations • Emily Kennedy and Marta Moody

Pharm World Sci 2000;22(2): 47-52. © 2000 Kluwer Academic Publishers. Printed in the Netherlands. Emily Kennedy and Marta Moody (correspondence): The School of Pharmacy, The Robert Gordon University, Schoolhill, Aberdeen AB10 1FR, Aberdeen Keywords Community pharmacist Influences OTC drug therapy Decision making Selection Abstract A postal survey of pharmacists in a random sample of community pharmacies in Great Britain was carried out to ascertain the factors which influenced their decisions when recommending a product for Over The Counter (OTC) sale. Six categories of condition which regularly present in community pharmacies were selected and the pharmacists were asked to state which first line product they would recommend for each condition, in an uncomplicated situation with no other relevant problems. Of the 1138 questionnaires sent, 635 were suitable for analysis giving a response rate of 56.7%. The recommendations were found to be appropriate in 99.7% of cases. Factors which had the greatest influence on product selection were active ingredients, evidence of product efficacy, ease of use by patient and patient characteristics such as age and concurrent medication. Economic factors such as profit, pressures of excess stock and product promotion by sales representatives were shown to have a significantly greater influence on proprietor pharmacists than the other categories of pharmacist. The results of this study suggest that in the majority of cases pharmacists’ decisions on OTC drug therapy are based on clinical and patient factors and whilst commercial factors may be involved they do not compromise the quality of the recommendations. Accepted December 1999

Introduction

Method

47

Volume 22 Nr. 2 2000

A pilot study was carried out with a sample of 23 pharmacists working in 15 community pharmacies in the Grampian region, using semi-structured interviews. The sample was selected in order to include as many variables as possible in terms of type and location of pharmacy and in position and length of experience of pharmacists. From the pilot study data the selection criteria for the conditions to be studied were identified and a questionnaire designed to be used as a postal survey. The selection criteria for the conditions to be studied were: regular presentation to community pharmacists and eight or more products available for selection. The conditions chosen were chesty cough, dry cough, sore throat, haemorrhoids, hangover and travel sickness. The pharmacist was asked to state what first line product they would recommend for each of these conditions in an uncomplicated situation with no other relevant problems. Pharmacists were then asked to indicate, using a five-point Likert scale [11], their level of agreement with eighteen factors identified from the pilot study and a further nine factors which had been identified additionally in a previous study [8]. They were also asked if there were any other factors which might affect their choices. Further questions were included to ascertain information sources and the use of complementary medicines. Information was also requested regarding the type and location of the pharmacy, the position, gender and year of registration of the respondent and their participation in continuing education. Using the Annual Register of Pharmaceutical Chemists, 1995 [12] the type of each pharmacy was identified i.e. multiple or independent. Using population density, these were further divided into location groups, city, suburban, town and rural. Random numbers were identified by computer program and sampling for each stratum was carried out, resulting in a stratified random sample of 1138 registered pharmacies.

Pharmacy World & Science

Pharmacists in Great Britain now have a wider range of products to select from when recommending Over The Counter (OTC) medicines due to the increased re-regulation of many Prescription Only Medicines (POM) to Pharmacy Medicines (P). Other factors such as consumer expectations, General Practitioners’ increasing workload and high prescription costs have also led to an increased demand for OTC products and advice from the community pharmacy [1]. To carry out this function community pharmacists must possess a knowledge base of disease processes, drug information and the ability to select a suitable remedy or recommend appropriate treatment. The principles of clinical governance and evidencebased decision making are now well established as underlying best practice. [2] Pharmacists must take responsibility for and be able to justify if necessary, their choices for recommendations of OTC products from the wide range available. There are practical guides available for the community pharmacist [3 4 5 6 7] which give information on drug treatments but most do not differentiate between products. Other guides which deal exclusively with branded OTC products, such as the Proprietary Association

of Great Britain OTC Directory and the Chemist and Druggist Guide to OTC Medicines merely give information on the uses of the products and their components and do not prioritise products in relation to efficacy. The choices made by an individual pharmacist could be influenced by a wide range of factors involving advertising, experience, financial and social, and clinical issues. [8] As the community pharmacy operates as a commercial enterprise it is of interest to discover whether economic matters override professional decisions in any situation as has been suggested [9]. Previous studies [8 10] have identified factors involved in pharmacists’ preferences for non-prescription cough suppressants and analgesics but influences over a range of OTC medicines for a variety of conditions have not been investigated. The aim of this project was to identify these influences.

The questionnaire was posted during the summer of 1996 to the selected pharmacies along with an explanatory covering letter and reply paid envelope. Each questionnaire was numbered to allow a follow up questionnaire to be sent to non- responders. As the questionnaire was sent to pharmacies selected on the basis of location and type the variables of gender and years of experience of the respondents could not be controlled. To check whether the sample of pharmacists was representative in these two variables, manpower statistics were obtained from the Royal Pharmaceutical Society of Great Britain (RPSGB). To allow comparison of the pharmacists` selection with the current recommended management of the six selected conditions, five readily available reference sources [3 4 5 6 7] were scrutinised and the recommendations noted. The data analysis was carried out using the World Health Organisation Word Processing Database and Statistics Program for Public Health Epi-info v 6 software package. [13] Chi - squared tests were used and differences were considered to be statistically significant if probability P was less than or equal to 0.05.

Table 2 Position held in pharmacy. (n= 633, 2 non responders) Position held

Frequency n (%)

Manager Proprietor Locum tenens pharmacist Consultant Second pharmacist Part time employee pharmacist Others

305 (48.0) 241 (38.0) 35 (5.5) 27 (4.3) 9 (1.4) 8 (1.3) 8 (1.3)

Participation in continuing education The majority of respondents, 581 (91.5%) said that they participated in continuing education, 42 (6.6%) said they did not and 12 (1.9%) did not respond. One hundred and fifty five (26.7%) respondents spent more than 30 hours per year, 280 (48.2%) spent between 10 and 30 hours and 144 (24.8%) spent less than 10 hours per year. Analysis of the results using a chi squared test showed that the extent to which pharmacists participated in continuing education had no significant Results Of the 1138 questionnaires sent, 19 questionnaires influence on their responses (p< 0.05). were returned unopened due to a change of address and 640 replies were received, of which 5 were not OTC selections for six conditions which regularly completed (3 required payment, 1 said it was not present in community pharmacies company policy and 1 ‘did not fill in questionnaires’). The therapeutic components and the OTC preparaThis gave 635 questionnaires suitable for analysis, a tions which were most frequently selected are indicated in Table 3. final response rate of 56.7%. Demographic details. The respondents comprised 395 (62.2%) males and 240 (37.8%) females. The RPSGB statistics for 1996 indicated that 53.9% of community pharmacists were male and 46.1% were female. The location of the pharmacies was suburban 238 (37.5%), town 212 (33.4%), rural 98 (15.4%) and city 82(12.9%), 5 did not respond. The type of pharmacy was single independent pharmacy 220 (34.6%), national multiple 256 (40.3%) and small multiple (2 - 9 branches) 157 (24.7%), 2 did not respond. The year of registration and gender of the respondents is indicated in Table 1 with the pharmacist’s position in the pharmacy shown in Table 2. The RPSGB`s statistics gave information on age of pharmacists therefore a direct comparison with year of registration and consequently, years of experience cannot be made. The sample of respondents in this study appears to be more heavily weighted to the younger age range than the national figures.

Sources of information which influence OTC selections Journal articles 514 (80.9%) and reference books 408 (64.3%) were indicated as the sources of information that were most likely to influence OTC product selection. Television/radio and wholesalers/distributors were least likely to influence OTC product selection, with 398 (62.7%) responders indicating ‘no’ for TV/radio and 412 (64.9%) indicating ‘no’ for information from wholesalers/distributors. Neither the gender of the pharmacists, the year of registration nor the position the pharmacist held in the pharmacy was found to have a significant influence on these results. Complementary medicines stocked Three respondents indicated that they were qualified homoeopathic practitioners and overall three hundred and seventy nine (59.7%) pharmacists indicated they stocked complementary medicines. Only one pharmacist selected a complementary medicine as his first line recommendation. This was for the treatment



Table 1 Year of registration and gender of respondents (n=624, 11 non responders)

48

Year of registration

Males n (%)

Females n (%)

Total n (%)

1986 - 1995 1976 - 1985 1966 - 1975 1956 - 1965 1946 - 1955

92 (23.7) 129 (33.2) 87 (22.3) 68 (17.5) 13 (3.3)

113 (48.1) 71 (30.2) 36 (15.3) 15 (6.4) 0 (0.0)

205 (32.9) 200 (32.1) 123 (19.7) 83 (13.3) 13 (2.1)

Table 3 The therapeutic components and the OTC preparations most frequently selected by pharmacists for six conditions which regularly present in community pharmacy n=635 Condition

Therapeutic components of preparations most frequently selected (n,%)

Total number of preparations cited

Preparation most frequently selected (n,%)

Preparation second most frequently selected (n,%)

Chesty cough

guaiphenesin (369, 59.0)

18

Benylin (guaiphenesin) (176, 27.7)

Meltus (guaiphenesin) (99, 15.6)

Dry cough

pholcodine (383, 61.3)

17

pholcodine (372, 58.6)

Benylin (dextromethorphan) (73, 11.5)

Haemorrhoids

soothing agents only (507, 81.1)

8

Anusol (soothing agents) (483, 76.1)

Anodesyn Soothing agent + local anaesthetic) (56, 8.8)

Hangover

analgesic plus antacid 11 (360, 57.6)

Resolve (Paracetamol + antacid) (315, 49.6)

paracetamol (131, 20.6)

Sore throat

benzocaine plus bactericide (334, 53.4)

15

Merocaine Benzocaine + bactericide) (178, 28.0)

Strepsils (Bactericide) (90, 14.2)

Travel sickness

cinnarizine (467, 74.7)

9

Stugeron (Cinnarizine) (462, 72.8)

Kwells (Hyoscine) (59, 9.3)

of haemorrhoids. Two (0.3%) stated that they would recommend ‘ wrist bands’ for travel sickness. Two hundred and sixty one respondents (68.9%) said the availability of these products did not influence their product selection. Of these, 99 (37.9%) indicated that they were stocked to offer increased choice to meet customer demand. The remainder gave no reasons for stocking them. Of the 118 respondents who indicated that stocking complementary medicines did influence their prescribing, 64 (54.2%) said that it allowed them a wider choice of product, particularly in situations where allopathic medicines were contraindicated or were inappropriate. The other 54 respondents gave no reasons.

49



Factors which influence product selection Table 4 shows the factors which influence product selection, in rank order, ranging from those with the greatest positive influence on pharmacists’ selection of OTC products to those with the least influence. Using a chi squared test, gender and year of registration had no significant influence on pharmacists’ responses, however there was a wide variation in the influences of certain factors according to the status of the pharmacist. Differences in the influences of factors between the groups as determined by chi-squared tests were either found to be not statistically significant (p