Despite pharmacists' extensive knowledge in the optimization of patients' medical treatments, community pharmacies are still fighting to earn patients' trust with respect to medicinal counselling at the counter.
Despite pharmacists' extensive knowledge in the optimization of patients' medical treatments, community pharmacies are still fighting to earn patients' trust with respect to medicinal counselling at the counter.
The aim was to investigate how patients perceive pharmacy counselling at the present time, in order to develop the patient–pharmacy relationship for the benefit of both patients and pharmacies.
Short semi-structured interviews were carried out with pharmacy customers by pharmacy internship students.
One hundred and eight customers in 35 independent pharmacies across Denmark were interviewed during the spring of 2011.
Customers were interviewed about their expectations of pharmacies in general and their experiences with medical counselling in particular.
Customers perceive community pharmacies very differently in terms of both expectations of and positive experiences with counselling. They appear to be in favour of pharmacy counselling with respect to over-the-counter medicine and first-time prescription medicine in contrast to refills. Customers find it difficult to express the health-care role of pharmacies even when experiencing and appreciating it.
Lack of appreciation of pharmacy counselling for refill prescription medicine and the difficulty in defining the role of pharmacies might stem from the difficulties that customers have in understanding medicine and thus the role of counselling services with respect to medicine. The pharmacy staff does not seem to realize these barriers.
For pharmacies to encourage customer interest in pharmacy counselling, the staff should start taking the identified barriers into account when planning communication strategies.
Community pharmacies have, during the last decades, been struggling to become an integral part of health-care systems worldwide by developing their counselling services both in terms of medicine dialogues at the counter and by providing more substantial services such as medication reviews and inhaler technique assessments.[1, 2] One of the challenges identified in this process is that customers rather than the pharmacy staff appear to be less interested in these services, thus hampering a more active counselling role for community pharmacies in society.[3, 4]
As the extent of unresolved and preventable drug-related problems still mount a massive pressure on health-care budgets, and pharmacists/pharmacies have been shown to alleviate some of the identified drug problems of patients,[6-8] attempts to increase our understanding of the lack of customer interest in pharmacy counselling seem to be worthwhile.
Several aspects of the differences of perceptions between customers and staff regarding pharmacies' roles in society have been explored. First, customers themselves have shown to differ in their expectations of and wishes for pharmacy visits. Renberg et al. identified seven different ideal customer scenarios for pharmacy encounters. They identified two overall dimensions of expectations for encounters: those in which customers focus on the physical drug product as the central object of the encounter and those in which the customers emphasize staff support as being desirable. Hibbert et al. (2002) showed that when compared to those customers seeking professional advice, those who focused on buying an over-the-counter (OTC) product believed they have sufficient knowledge about how to manage their disease with medicine. The authors stressed the potential conflict between the interests of pharmacists and reflexive and powerful customers regarding the counselling role of pharmacists. This has similarly been highlighted by other researchers in the field.[3, 4]
Secondly, it has been shown that customers who do appreciate staff support differ regarding the type of counselling they desire. Worley et al. showed how pharmacists, to a much higher degree than customers, think that both staff and customers ought to share information and cooperate to achieve the treatment goals of the customers' medication. Customers agreed with pharmacists that the staff should inform them about side effects and interactions between prescription and OTC medicines. Assa-Eley et al. similarly found that customers agreed with pharmacists that pharmacists should inform them about drug interactions and make sure that the information given to the customers was correctly understood, whereas they disagreed on whether pharmacists should assist them in clarifying and achieving treatment goals. Furthermore, the customers did not realize how important pharmacists rated counselling activities to be. A lack of agreement on the more clinical aspects of counselling were explained in both studies by the customers' lack of experience with this type of counselling as many pharmacies are not providing it. Thus, customers might start appreciating a more active and clinical role of pharmacies when they are exposed to it.
Other studies have, however, indicated that exposure to counselling is a complex phenomenon that should be investigated further to deliver it in an appropriate manner. The results by Hassell et al. described how customers have difficulties remembering the information given by staff, which might be the result of customers perceiving the information as politeness rather than as an attempt by the staff to help them improve the clinical outcome of their medication therapy. Holford et al. found that customers emphasize elements of service in community pharmacies such as politeness simply because they are unable to comprehend the complex nature of medicine. Furthermore, Hibbert et al. suggested that the customers' lack of interest in counselling is because they do not find it relevant, even when it is offered by pharmacists.
There is only little knowledge on how to involve customers in various types of pharmacy counselling in order to interest them in a more active role with pharmacies in helping them manage their medications. The aim of this study was to further explore the kind of counselling that customers are interested in receiving from the pharmacy staff in Denmark and to start elucidating the rationale behind the identified interests.
The pharmacy sector in Denmark is privately owned and regulated by the Ministry of Health and Prevention. In 2010, there were 240 pharmacies. Chain ownership is not allowed although one pharmacy owner can own up to four individual pharmacies. In 2010 an average-sized Danish pharmacy had an annual gross turnover of approximately 7.5 million Euros and employed 15 people full time consisting of in average 2.4 pharmacists (5 years of education) and eight pharmacy assistants (3½ years of education). Since 2007, the Danish Pharmaceutical Association has urged Danish pharmacies to seek a more active role when serving customers at the counter, encouraging them to ask all customers at least two clinical questions and to provide some information accordingly. Thus, the study can be viewed as an indicator of how these specific types of counselling services are perceived by customers.
A pilot study regarding ‘How do patients’ views and expectations of pharmacists match those of the profession?' was conducted in 2010 at the Faculty of Pharmaceutical Sciences, University of Copenhagen. Customers' expectations were considered as an important factor in understanding the relationship between patients and professional health-care workers and, hence, how interactions between the parties develop. The study involved three components: (i) a questionnaire for students in pharmacy internships on their perceptions of pharmacies, the pharmacists' main tasks and the customers' expectations of pharmacies, (ii) short interviews with the pharmacist tutors of the students on their perception of their main tasks as pharmacists and their perception of customers' perceptions of pharmacies and (iii) short interviews with customers on their expectation of pharmacies and pharmacy staff. The study used pharmacy internship students as data collectors for interviews with both tutors and customers. This particular approach has proved to be a valuable research design ensuring relevant results for practice as well as a high volume of data.[17, 18] The students participated in the study on a voluntary basis.
In 2011, the study was repeated using the same design. Some corrections in the interview guide for customers were made to ensure the collection of high-quality data that allowed for both a quantitative comparative analysis of the three groups regarding the perceptions of the roles of pharmacies and a qualitative analysis concerning customers' interests in counselling. The interview guide for customers was amended according to the opinion of the pharmacist tutors (although it was conducted by students) to make it as relevant as possible for practice. This paper deals only with the analysis of customers' interests in pharmacy counselling.
The final customer interview guide consisted of the following topics:
As is the norm in Danish pharmacies to employ both pharmacists and pharmacy assistants at the counter, the term ‘staff’ refers, both in the interview guide and in the following sections, to both groups of professionals. The questions were open-ended in order to obtain the customers' own perceptions of pharmacy services rather than having them respond to categories pre-developed by the researchers. Thus, the students were instructed to probe only if necessary. Students were asked to either record and transcribe the customers' answers or to take notes by hand during the interview. The estimated time per interview was 10 min.
All of the participating students were asked to interview two customers during their pharmacy internship by adhering strictly to the interview guide, thereby trying to compensate for using several interviewers at the same time. Further, the students were, in the introduction section of the interview guide, encouraged to avoid recruiting only customers whom they felt had very positive attitudes towards pharmacies, when interacting with them at the counter. To facilitate this, the students were advised to devise a system of random selection (for example, inviting every 10th customer to participate in the study). Thus, it was up to the students to decide whether to interview customers before or after being served by the staff to make it as easy as possible for them to recruit. The customers who agreed to be interviewed were questioned about their purpose for coming to the pharmacy and on how frequently they visited it, but as the study was considered to be in an exploratory stage, no further personal data were gathered. As mentioned already, instructions for probing were given to students to ensure consistency in the data.
A two-step analysis was applied. The first step was to identify which type of counselling the customers were interested in receiving from the pharmacy; the second was to try to explain these results.
An induction analysis was applied to condense the collected data material in order to identify the types of counselling that the customers found interesting. Relevant statements were selected from the transcriptions, and according to the traditional work method of induction analysis, analysed – one by one, resulting in the emergence of relevant themes. Relevant statements of interest in counselling were interpreted as expressions of positive experiences and/or expectations of counselling. Resulting in a list of overall themes, subcategories were then identified and condensed to make the patterns more clear. Hence, we found the induction analysis to be an appropriate method in that it captured the nuances in relevant statements as well as made visible the links between these nuances in the data material – a necessity as we used a grounded, not theoretical, approach.
A common-sense interpretation (as described by Kvale) was applied as the second step of the analysis to connect the developed understanding of customers' interests in counselling with details providing explanations for these interests. Thus, the material was condensed regarding the ideas and perceptions pertaining to the customers' opinions about pharmacy counselling. Subsequently, these opinions were linked to the identified interests in counselling by logical interpretation and arguments.
The analyses were validated by a group of researchers (the three authors of this paper) who discussed the developed themes and the connections between them, reaching a consensus on the emerging patterns and results.
As the results of this exploratory study showed considerable variation between customers, we chose to depict the results in terms of the actual number of answers pertaining to the emerging themes for the reader to better judge the tendencies. For the same reasons, we chose to present a wide scope of results instead of describing only the most frequently mentioned aspects of counselling.
In keeping with the guidelines of the Danish National Committee on Biomedical Research Ethics, ethical approval was not sought because the study was not biomedical in nature. Nor did we seek approval from the Danish Data Protection Agency as data contained no personal traceable information of the participants.
Fifty-eight pharmacy internship students conducted 108 customer interviews in the period from February to May 2011. Customers from 35 different pharmacies throughout Denmark were interviewed.
A considerable number of the interviewees (46 out of 108) stated that they expected to be asked questions by the staff when purchasing medicine. However, 11 customers said that they did not expect to be asked questions, but they experienced it nonetheless. Four interviewees said that they expected questions when purchasing OTC medicine, and two interviewees said that they expected questions when buying several products at the same time.
They usually ask about symptoms and the effect of the medicine. They mostly ask about OTC medicines. They do not ask about prescription medicine in which case they refer to the general practitioner (GP) (respondent 73)
A considerable percentage of the interviewees (84 out of 108) reported that they received valuable help from the pharmacy on at least one previous occasion. Thirty-two customers described the help in general yet frequently vague terms.
It becomes clear to me how I should take my medicine (respondent 65)
The most predominant categories in terms of general perception of pharmacy help were feelings of reassurance (14 out of 84) and help with substitution and reimbursement (8 out of 84).
I do not feel insecure about anything when I leave the pharmacy (respondent 58)
When reporting on valuable help, 52 (out of 84) customers referred to one concrete example involving specific drugs being handled in one particular situation.
There was a time when I did not feel that the pain in my back was adequately dealt with. I remember I talked with one of the staff who told me there was something stronger… (respondent 79)
The prominent types of specific help involved shifts from one drug to another (12 out of 84), ensuring the appropriate time of medicine intake (12 out of 84) and ensuring the correct use of the medicine (7 out of 84). Additionally, the alleviation of side effects (5 out of 84), identifying the most relevant product for the presented symptom (4 out of 84) and the discovery of interactions (3 out of 84) were described by several interviewees.
I got some medicine for the heart which I thought was unpleasant to take. The pharmacy found something else which I can tolerate better (respondent 15)
The only medicine I get is for low metabolism, then they remind me I should take it before I eat breakfast (respondent 87)
Thirty-six customers expressed that they did not find the pharmacy to be the right place to discuss how medicine functions in their daily lives. The most predominant explanation was that customers simply preferred discussing their medicine use with the GP (22 out of 36).
I speak with the GP, it is more his task (respondent 48)
A few reasons for this preference were given, including that the GP possesses knowledge about the medicine used (2 out of 36), that it is often too busy in the pharmacy to have dialogues about medicine (2 out of 36) and that medicine counselling does not usually take place at pharmacies (1 out of 36). Four interviewees stated that the pharmacy is just a shop to purchase medicines ordered by the GPs and that the pharmacy staff should not interfere with the customers' use of medicine.
It's a shop. The GP knows about the medicine…they should not interfere with what is written on the prescription (respondent 85)
Out of 108 interviewees, 56 expressed that the counselling by staff addressed their needs and 21 said that the staff did not address their needs. The main reason stated for not meeting one's needs was that the customer believed that they had no unmet needs (9 out of 21). Five interviewees mentioned that their needs could be addressed by the pharmacy if necessary.
I could possibly have gotten some advice if I needed it. However, I haven't had any needs (respondent 77)
Nine customers explained that they had a need only when purchasing new medicine, and four customers said that the GP had already covered their needs.
I take my medicine regularly; therefore I do not need any counselling (respondent 32)
Finally, five interviewees explained how they had needs only regarding OTC medicine. The different needs of customers for counselling in OTC medicine, first-time prescription medicine or refills were consistent throughout the data material and occurred even though the interview guide did not specifically address this issue.
Seventy out of the 108 customers said that they preferred pharmacies over other retailers when purchasing OTC medicine. The predominant reasons were convenience (23 out of 70), the expertise of staff (15 out of 70), feeling more secure (10 out of 70) and habit (12 out of 70). Examples of convenience included living nearby or the ease of being able to purchase both prescription and OTC medicine at the same time.
I have the impression that medicine belongs here and I feel that if I have any questions then they are competent to answer (respondent 36)
I only use the pharmacy because it is closer for me (respondent 23)
A notable result was that many customers distinguished between prescription and OTC medicine when describing their needs and interests in pharmacy counselling, and they expressed different needs when purchasing prescription medicine for the first time compared to refill medications. The results indicate that many customers feel that they have some need for pharmacy counselling on OTC medicine and first-time prescriptions and have therefore greater interest in pharmacy counselling in these situations compared to refill prescription medicine.
The questions can sometimes be irritating. I know you have to ask but it's irritating… I only want information about OTC medicine (respondent 88)
However, several of the customers gave examples of valuable help from staff regarding long-term prescription medicine. The majority of these examples related to a particular drug being purchased at a particular instance. These results may suggest that staff intervention regarding long-time prescription medicine is more acceptable when it concerns only the actual product being sold – for example, with regard to sparing customers from unpleasant side effects of a drug or identifying drug interactions. The results may also indicate that despite the staff helping customers with these types of products on a regular basis, the experience of customers has not manifested itself into a more overall perception of pharmacies as they failed to express this idea as a general and well-articulated concept.
A further clue to understanding the rationale for customers' interest in counselling was in the reason for the customers' preferences for choosing pharmacies to purchase OTC medicine. The arguments were almost equally divided between convenience and a need for a feeling of trust in the competencies of the staff. Our results showed that pharmacies are perceived by some customers to play a bigger role with respect to the handling of OTC medicine compared to prescription medicine. However, one-third of customers who preferred to pick up OTC medicine at the pharmacy did it for practical reasons. Thus, even the relatively high need for pharmacy counselling for OTC medicine may be relatively weak compared to other practical considerations of purchasing medicine.
The qualitative analysis of customers' interest in pharmacy counselling, based on 108 short customer interviews, showed a considerable complexity of answers. A majority of the customers expressed that they found pharmacy counselling helpful, although approximately one-third of these customers expressed it in terms of their general perception of pharmacies as opposed to describing a particular incident in the past when they received help. Customers in this study appeared to differentiate between their needs for counselling (according to what type of medicine they were purchasing), showing more interest in receiving help with OTC medicine and first-time prescriptions. However, even these needs competed with the practical issues of a customer's everyday life, thereby compromising the establishment of a more active role for pharmacies in society. Despite an expressed need for less counselling for refill prescriptions, several specific incidents were described when such help took place, suggesting that this type of help is more accepted if the counselling pertained to the specific drug being purchased.
There were considerable variations in the participants' answers, indicating that caution should be taken when generalizing customers' expectations of and their interest in pharmacy counselling. Customers are individuals and have different interests in counselling for different reasons, thereby supporting the results of Renberg et al. who showed that the customers' normative expectations of pharmacies differed. As the study is qualitative, we consider this variation in answers a strength.
As we had little knowledge about pharmacy customers' expectations in Danish pharmacies, we decided to employ an exploratory approach in order to increase our understanding on the subject. On the one hand, the strength of our approach can be found in the rich and nuanced understanding of customer expectations. On the other hand, the loose structure of the interview and the use of many different interviewers, produced, at times, data that made it difficult to compare both customers and pharmacies. For example, the systematic collection of demographic characteristics was lacking and therefore it is unclear whether the 35 pharmacies in this study are representative of the approximately 240 community pharmacies in Denmark. However, the transcripts and the hand notes of the interviews support our belief that there is a consistency of data despite the high number of interviewers.
In summary, although, because of its lack of statistical strength, an exploratory approach cannot be used to draw definite conclusions, this approach gave us an insight into the nuances and complexity of customer expectations – an understanding which will serve as a basis for future research that, among other things, will be looking at the differences between satisfaction surveys and studies of expectations. It is firmly believed that our results would not have changed the meaning generated had we used a more stringent design, but it is recognized that other issues could have been brought up by the use of other methods and approaches.
Despite the relatively low need for counselling on refill prescriptions, participants described several specific incidents when such counselling took place. This suggests that this type of help is acceptable for many customers when certain circumstances are present such as when the counselling offers advice only regarding the drug being purchased. These results are supported by the findings of Worley et al. and Assa-Eley et al., who both showed how customers are interested in the staff informing them about, for example, the side effects and interactions of the specific drugs being purchased as opposed to assisting them in achieving the goals of their overall medical treatment. The result might not be as surprising when taking into account Renberg et al.'s finding that many customers perceive the actual product as the core of the pharmacy encounter. However, from the large extent of customers in our study reporting specific drug incidents where valuable help had been obtained indicate also that those customers who appreciate the counselling services of the staff (according to the categorization of Renberg) share this tendency. This pattern may partly be explained by tradition and previous experience. Hassel et al. discovered that staff counselling behaviour focused exactly on product recommendations and product use with little general health advice.
Other explanations, however, also have to be considered. Customers have been found to have difficulties in assessing the outcomes of counselling services in community pharmacies because of the difficulties in interpreting the complex nature of medical services. One reason why customers tend to focus on the particular drug being sold might then be that customers (in contrast to the staff) find it easier to understand their disease through the context of the specific drug used to treat it. The staff, in contrast, could be argued to understand the symptoms of diseases and their treatments with respect to the complex intrinsic physiological and pharmacological reactions involved. Besides, the customers might not see the potential risk of having drug-related problems that need continuous monitoring why their interest in counselling on refill prescriptions remain relatively low.
Counselling is further challenged by our results, showing that several customers found dealing with the overall treatment to be the job of the GP and not the pharmacy, at least with regard to prescription medicine. These results have also been shown by other researchers.[23-25] As Hassell et al. discovered, even when help is received in pharmacies, it is often not remembered. Pre-conceived expectations appear to be deep-rooted, although cultural differences may occur across different countries. Pharmacies across the world differ according to the education of their staff at the counter as well as, for example, the average size and lay-out of the pharmacy, which might influence the relationship customers develops with staff.[26, 27] Deeper cultural differences in terms of accepted paternalism of relationships between health-care professionals and patients might also be important in this respect.[28, 29]
The results revealed that although two-thirds of the interviewees expressed having received valuable help from the pharmacy, only one-third transformed the experience into a general (although vague) perception of pharmacies in the area. Thus, many customers' perceptions of the counselling role of pharmacy appeared to apply to only isolated incidents without further generalization taking place. Renberg et al. have similarly found that many of the customers who had received an extended counselling service in Swedish community pharmacies were unable to explain the purpose of the service. The connection between low expectations and a high level of satisfaction with pharmacy services, including counselling, have been shown previously,[30, 31] which could account for why the customers in our study appeared to be happy about counselling but were unable to explain why.
The frequency of incidents deserves further attention. Our data do not allow us to draw conclusions about the frequency of incidents of perceived help. However, one explanation for why participants often reported one particular situation could of course be that they only experienced it once. If customers only rarely received valued help, it could explain why they were unable to formulate a firm and general concept of pharmacy counselling. However, they realized that such help is possible, explaining why they answered positively when asked whether they experienced fruitful outcomes from dialogues at the counter. Another explanation for why only relatively few customers were able to express general perceptions of the pharmacies' ability to counsel might be due to unfamiliarity on the part of the customers in expressing such an understanding of medicine. This might be based on the previously discussed difficulty for customers to comprehend the nature of medicine (at least in the way that the staff see it) and, hence, the purpose of pharmacy counselling.
Our findings indicate that only relatively few of the many questions that the staff posed (as approximately half of the interviewees expected or experienced staff questioning frequently) turned into valuable help observed from the customer's point of view. If the statistical estimates of the large amount of the unresolved drug-related problems are valid, it means that, at the moment, the communication techniques of the staff seem inappropriate to deal with the problems.
However, as our study showed that the feeling of safety was relatively general and often beyond the scope of specific drugs, we suggest that the actual experience with counselling does not manifest itself often as a perception of how the staff helps to improve drug utilization but rather as a feeling of safety. This hypothesis is supported by the results of Renberg et al.  and Montgomery et al. who found that the outcome of an extended consultation service with Swedish pharmacists did not lead to significant improvements in the customers' clinical status but to an increased feeling of safety and self-empowerment.
The results of the qualitative study of customers' interests in pharmacy counselling and the rationale behind these interests showed considerable variation due both to differences among customers and to the differential of the needs of the customers for counselling. In future, pharmacies should consider whether to adhere to relatively ‘safe’ areas of counselling, advising mainly on OTC and first-time prescription medicine, or to try to expand their services. Pharmacies ought to take into consideration how to address customers' relationships to their GPs and their understanding of medicine, which often differs from that of the staff. Perhaps, pharmacies should also start explaining their reasons for interfering with refill prescriptions, thereby helping customers form a more general understanding of the clinical aspects of pharmacy counselling. The area of customers' understanding of medicine deserves more attention as several of the developed hypotheses in this study point to new notions that have yet to be validated.
The study received no external funding and the authors declare no conflict of interests.