Barriers and Facilitators for Evidence-Based Self-Care Counselling in Community Pharmacy, a qualitative study

doi:10.21203/rs.3.rs-1975396/v1

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Research Article

Barriers and Facilitators for Evidence-Based Self-Care Counselling in Community Pharmacy, a qualitative study

https://doi.org/10.21203/rs.3.rs-1975396/v1

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Journal Publication

published 08 Apr, 2023

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Background

Community pharmacy is easily accessible for self-care advice, supported by self-care guidelines. Such guidelines were introduced in several countries, including the Netherlands, in the 1990s. Previous studies have shown room for improvement of self-care advice in daily pharmacy practice.

Aim

To map community pharmacists’ and pharmacy assistants’ views on their role in self-care advice and barriers and facilitators for providing evidence-based advice in the community pharmacy.

Method

Semi-structured interviews were conducted face-to-face or online with pharmacists and assistants using a topic guide based on the Theoretical Domains Framework (TDF). Interviews were audio-recorded and transcribed verbatim. Transcripts were deductively analysed to identify barriers and facilitators.

Results

In total, 13 pharmacists and 12 assistants were interviewed to reach data saturation. Overall, important barriers were lacking ready knowledge, lacking cooperation with GPs, time-pressuring due to crowded waiting areas, prioritising the handling of prescribed medications, beliefs that WWHAM questions would always lead to correct advice and consumers’ trust in commercial drug information. Important facilitators were availability of guidelines, conversational, process and analytical skills, training and assessment and access to patient records.

Conclusion

Pharmacists should strive for an optimal environment in the pharmacy for self-care advice, such as minimising environmental stressors and providing sufficient time for advice. In addition, they should arrange knowledge and skills training, assessing themselves and their team to improve the quality of self-care advice. Pharmacists should also improve cooperation with GPs and raise awareness of the importance of appropriate use of self-care products with consumers.

Pharmacists should arrange structured knowledge and skills training and assessment on minor ailments for themselves and their team.
Pharmacists should discuss self-care advice in the pharmacy and the reciprocal referral of consumers/patients with general practitioners.
Pharmacists should raise awareness of the importance of appropriate use of self-care products with consumers.

According to the World Health Organisation, self-care is the ability of individuals, families and communities to promote health, prevent disease, maintain health and cope with illness and disability, with or without the support of a healthcare provider [1]. In self-care for minor ailments, community pharmacists (CPs) can play an important role in supporting individuals with health-informed decision-making, as they are among the most accessible and well-trusted healthcare professionals [2].

In the 1990s, governments worldwide promoted the enhancement of self-care with over-the-counter (OTC) medicines as a way of shifting some healthcare costs onto consumers [3]. Nowadays, self-care increasingly is regarded as an option to decrease the burden on healthcare providers since, depending on the definition of minor complaints, 5–20% of GP consultations are related to minor ailments [4–6].

CPs can provide consumers and patients with evidence-based self-care advice to support their self-care decision-making. In the 1990s, the Dutch professional pharmacists’ organisation introduced self-care guidelines, including a protocol containing the WWHAM mnemonic with lifestyle and medication advice for minor ailments. In total, 23 guidelines were developed [7].

Pharmacy assistants (PAs) who have completed a three-year vocational programme assist the pharmacist by advising consumers on OTC use for minor ailments [8], and CPs and PAs are trained in self-care counselling based on the guidelines during their education. Nevertheless, publications have shown room for improving self-care advice in Dutch pharmacies [9, 10].

CPs’ and PAs’ perspectives and experiences should be assessed to understand the impact of self-care counselling. Thus, an explorative, qualitative approach was chosen to answer questions about the ‘what’, ‘how’ and ‘why’ of self-care counselling [11]. Moreover, theory-based frameworks have been increasingly used to explore healthcare professionals’ perspectives on behaviour changes related to practice as they can capture a broad understanding of how a service is integrated into practice [12].

This study aimed to map CPs’ and PAs’ views on the role of the community pharmacy in evidence-based self-care advice and barriers and facilitators for providing evidence-based self-care advice.

Ethics Approval

This study was approved by the Institutional Review Board of the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University (UPF1901, 9 September 2020).

Study design and procedure

This qualitative study used the Theoretical Domains Framework (TDF) during data collection and analysis [13, 14]. Semi-structured interviews were conducted with CPs and PAs in community pharmacies.

Topic guide development

Two topic guides were developed for the semi-structured interviews, one for CPs and one for PAs, based on general TDF development studies [14], previous TDF studies in pharmacy [15], and the personal experience of the main author with self-care guideline implementation [16, 17]. TDF includes domains that provide a view of the cognitive, affective, social and environmental influences on behaviour [14, 15]. This study used the second version of TDF with 14 domains [14].

The topic guides consisted of open-ended questions for each of the 14 theoretical domains with several prompts for in-depth follow-up questions (Online resources 1 and 2). The topic guides started with an introduction to the study and concluded with demographic questions. Questions related to the relationship with GPs, reimbursement and reclassification were discussed exclusively with CPs. After interviewing three CPs and three PAs, the topic guides were refined.

Setting

Dutch law on the medical treatment agreement (WGBO) regards CPs as healthcare providers with an autonomous duty to correctly serve and inform their patients according to current guidelines. CPs can delegate self-care advice to PAs, who normally are consumers’ first contact at the counter. In 2021, 30% of 2,000 Dutch pharmacies were owned by a pharmacy chain [18]. Four of ten pharmacies employed an additional pharmacist next to the pharmacist-owner or managing pharmacist [19]. On average, the equivalent of 8.4 full-time PAs was employed per pharmacy [20].

Study participants

Initially, purposive sampling was applied to identify CPs with a high interest in self-care based on publications in the pharmacists’ professional journal. When willing to participate by telephone, each CP was asked to invite one of their Pas for a separate interview. This initial contact was followed by snowball sampling, aiming for diversity in location, type of pharmacy and pharmacists’ working experiences. Of the 17 CPs approached, 13 (77%) agreed to cooperate, and appointments were scheduled to interview the CP and the PA. The CPs chose between face-to-face or online interviews. This choice was supported by a study suggesting that completing online interviews is a viable alternative to face-to-face interviews [21]. Initially, ten interviews were planned per profession, followed by additional interviews until data saturation was reached (no new information or insights were gained) [22]. Data saturation was discussed within the research team after 24 interviews.

Data collection

First, interviews were conducted in July and August 2020. However, interviewing was interrupted by COVID-19 and resumed from November 2021 to January 2022. The face-to-face interviews occurred at community pharmacies. The online interviews were conducted with a secured online meeting tool, Jitsi. All interviews were performed by RL (interview experience) and were audio-recorded with informed consent from the participants. Interviews were transcribed verbatim, coded and entered into NVivo 20 (QSR International, Release 1.5.1).

Data analysis

A coding book was developed, including TDF domains and corresponding items. The transcripts were analysed deductively with NVivo 20, using the TDF domains as coding categories. Within each domain, content analysis was used to identify facilitators and barriers. The deductive phase started with reading the transcripts. The responses were initially attributed to one or more TDF domains, constituting the deductive analysis codes [14]. Two researchers (EK and RL) coded three interviews independently using the predefined TDF domain coding book and discussed the results and discrepancies in the first consensus meeting. Disagreements in coding were discussed, an agreement was reached and the coding book was adapted. After this discussion, RL and EK coded the fourth interview independently, and disagreements were again discussed in the second consensus meeting. The coding book was adapted accordingly and discussed with the entire research team. The remaining transcripts were coded by one researcher (RL). The main domains and illustrating quotes appear in the subsequent section.

In total, 13 CPs and 12 PAs from 12 pharmacies were interviewed, and data saturation was reached. Table 1 shows the demographic characteristics of CPs and PAs, along with characteristics of the community pharmacies. The mean interview time for CPs was 41 minutes (33–57 minutes), while for PAs, the mean was 27 minutes (20–36 minutes). Online resource 3 shows a summary of the domain content for TDF sub-themes.

Table 1

Characteristics of pharmacies, community pharmacists and pharmacy assistants
Number of pharmacies Type of pharmacy chain other Location town < 50,000 inhabitants town 50,000–100,000 inhabitants city > 500,000 inhabitants Number of prescriptions per day 100–200 >200 Number of OTC* products sold per day <10 10–50 >50 Druggist within a distance of 250 meters of the pharmacy Supermarket selling OTC* products within 250 m of pharmacy	13 2 11 5 4 4 2 11 1 8 4 10 9
Number of participating community pharmacists Female Position owner/ pharmacist managing pharmacist locum pharmacist Years of experience in pharmacy <5 years 5–10 years >10 years	13 10 3 6 4 4 4 5
Number of participating pharmacy assistants Female Years of experience in pharmacy <5 years 5–10 years >10 years	12 12 4 3 5
*OTC = Over-The-Counter

Insert Table 1 here

All CPs acknowledged delegating consumer self-care advice to PAs under their supervision. According to all participants, the CP’s professional role is to provide self-care advice if needed and to be available for consultations from the PA in complex situations, such as symptoms already present for one to two weeks, young children, indistinct symptoms, underlying conditions, interacting medication use and frequent purchases of painkillers or heartburn medication.

All respondents intended to provide consumers with appropriate advice with or without OTC medication, so they know what to do. Both CPs and PAs intended to provide high-quality advice by using protocols, providing lifestyle advice, checking medication safety and advising evidence-based products:

PA03: ‘It is my role to advise the patient, help as much as possible and refer the patient to the GP if needed. And, that doesn’t mean that they always leave with a product, but that they anyway know what to do’.

When asked about increasing their professional role in self-care as a healthcare provider by widening access to medicines through reclassification (‘switching’) from prescription to non-prescription, most CPs reported a lack of confidence about diagnosing reclassified medication (Knowledge, Skills), and they expected objections from GPs (Environmental context). CPs preferred a legal regulation already in use for birth control pills or making agreements with GPs for long-lasting repeat prescriptions.Most CPs considered training about conditions and differential diagnoses necessary (Knowledge, Skills):

CP11: ‘We already dispense birth control pills without repeat prescriptions. The GP prescribes the initial prescription, and the patient can get a repeat prescription directly from the pharmacy. It’s up to the pharmacy to monitor the use. I don’t see any objections to make similar arrangements for medicines such as triptans and intranasal corticosteroids’.

Barriers and facilitators

Table 2 shows barriers and facilitators that CPs and PAs experienced in providing self-care advice.

Table 2

Barriers and facilitators for providing self-care advice
TDF domain	Barrier	Facilitator
Knowledge	• Lack of ready knowledge of minor ailments • Believing that WWHAM questions always lead to correct advice according to the guideline • Lack of guideline update communication	• Availability of self-care guidelines • Accessibility to computerised protocols for minor ailments and pharmacy-only products • Assigning CPs¹ or PAs² responsible for updates and product introductions • Regular guideline advice updates • Team app for communicating updates and new product introductions or weekly/monthly newsletter • Availability of training on self-care guidelines during CP¹ and PA² education • Regular on-the-job training from CPs¹ (i.e. in work meetings) • Availability of web-based training programmes • Annual training on seasonal complaints
Skills	• Lack of skills training • Lack of skills to retrieve sufficient information from consumers/patients • Information about different cultural backgrounds and attitudes towards pharmacists lacking in PA² and CP¹ education	• Optimal conditions for self-care advising, such as personal development plans and team training • Presence of conversation (verbal and nonverbal), process and analytical skills • Roleplaying within the team or with trainees • Assessing patient self-care skills by web-based testing and simulated patient visits
Professional role and identity	• CPs¹ underestimating the importance and difficulty of provision of self-care advice	• Actively offering advice on self-care and lifestyle • CPs¹ creating optimal pharmacy conditions for self-care advice by PAs² and securing task delegation
Beliefs about capabilities	• Lack of active CP¹ support for knowledge and skills training	• PAs’ intrinsic motivation • PAs feeling capable due to available information and support from colleagues and CPs¹ • Awareness of follow-up questions in addition to WWHAM for correct problem analysis and self-care advice • Attention to empathic staff attitude at the counter • Realising the limits of one’s knowledge
Optimism	• Lack of recognition of the added value of self-care advice in pharmacy from policymakers and healthcare insurers	• Consumers/patients return to the pharmacy for self-care advice based on earlier advice • Increase of recognition of self-care advice and the added value of pharmacy by CPs¹ communicating about minor ailments and self-care online or in journals
Beliefs about consequences	• Compromised medication safety by lack of self-care products registration in electronic patient records • Less trust from patients and consumers in information based on guidelines than in commercial drug information (e.g. from the internet, advertisements, commercials) • Less critical alternatives available (asking fewer questions) for consumers to purchase self-care products	• Adding self-care products to electronic patient records enabling clinical risk management (e.g. interactions, contraindications) • Appropriate self-care advice may prevent minor ailments from developing into diseases • Lifestyle advice may help to prevent or decrease minor ailment symptoms after stopping self-care medication • Appreciating the initiative of the consumer/patient to research products (e.g. on the internet), thereby improving the attitude of consumers/patients towards advice for an evidence based alternative
Reinforcement	• Self-care product registration in electronic patient records requiring non-reimbursable time • Additional workload for self-care advice not covered by margin from generic self-care products • Lack of public communication campaign about the added value of self-care advice in pharmacy	• CPs¹ and GPsᶾ working together to measure the added value of self-care advice in the pharmacy by showing decrease of GPᶾ consultations and healthcare costs
Intentions	• Time pressuring by prioritising dispensing of prescription medicines or crowded waiting area, leading to assistants paying less attention to problem analysis questioning and registering of self-care medicines in the pharmacy information system	• Adjusting problem analysis questioning to the consumers depending upon openness to self-care advice • Adding self-care products to electronic patient records; at least NSAIDs for patients with cardiovascular disease, elderly patients and home-care patients • Providing lifestyle advice according to self-care guidelines • Registration of pharmacy-only questionnaires in the pharmacy information system
Goals		• Providing easy and timely access to self-care advice in pharmacy • Striving for high-quality pharmaceutical care • Clinical risk management for patients using chronic medications or having potential contraindications to secure medication safety
Memory, attention and decision processes	• Asking WWHAM questions without incorporating spontaneous information from consumer/patient • Lack of support for correct appraisal of answers to questions	• Structured advice according to protocols in self-care guidelines • Practising self-care cases in the pharmacy with trainees or team practice during work meetings to iterate knowledge and skills • Stickers on pharmacy-only self-care products and products that interact with chronic medicines
Environmental context and resources	• Priority for dispensing of prescribed medicines prohibiting asking out problem analysis questions • Priority for dispensing of prescribed medicines prohibiting self-care product registration in electronic patient records • Consumers/patients not open to receiving advice • Language problems • Patient attitude towards self-care advice, depending on cultural background • Consumers/patients with low health literacy level • Lack of privacy at the counter • Image with GPsᶾ and consumers/patients that products in pharmacy are more expensive than at the druggist • Effort and time needed to build good relationship with GPsᶾ • Lack of pharmacotherapeutic meetings with GPsᶾ about minor complaints as a main subject • Lack of healthcare provider profile of CPs¹ in consumers/patients	• Availability of sufficiently private consultation areas (consulting room or privacy counter) • Sufficient distance and separation between counters to provide more privacy • Background music in the waiting area • Measuring loudness of PAs’ voices at the counter and listening to consultations in the waiting area • Communicating indirectly about privacy-sensitive issues when privacy is limited • Pharmacy team familiar with various languages in areas with patients from different cultural backgrounds • Google Translate app or translator by telephone for communicating when language is not spoken in the pharmacy • Visual and verbal communication with low-literacy patients • Availability of an electronic pharmacy information system to check interactions and contraindications on patient level • Organising logistic processes in the pharmacy and implementing innovative logistic developments to provide time for self-care advice • Agreement with GPsᶾ in pharmacotherapeutic meetings on self-care protocols in the pharmacy and reciprocal referral policy • Agreement with GPsᶾ on registering self-care medicines in patient medication records: specific products and patients • Product prices discussed with GPsᶾ in pharmacotherapeutic meetings, comparing generic and brand products • Offering consumers/patients a choice of more and less expensive products with information about effects and prices
Social influences		• Team members supporting one another in providing self-care advice • CP¹ available for advice on complex situations • Spontaneous positive feedback from patients • Positive feedback from GPsᶾ after referral
Emotion	• Disappointment when consumers are not open to lifestyle advice	• Satisfied customers following up on advice and providing positive feelings
Behavioural regulation	• PAs² not accepting responsibility when receiving feedback	• Discussing project results (e.g. pharmacy-only product registration) or knowledge/skill test results, including assessment of improvement opportunities • CPs¹ providing feedback to PAs immediately after incorrect self-care advice • CPs¹ encouraging PAs² to share new information with colleagues • CP² encouraging trainees and starting PAs to listen to self-care advice provided by experienced PAs
*CP = community pharmacist; PA = pharmacy assistant; GP = general practitioner

Insert Table 2 here

Some CPs mentioned creating optimal conditions for self-care advice (e.g. knowledge and skills development and facilities in the pharmacy), securing task delegation, providing feedback to assistants and discussing the importance of appropriate self-care advice with team members (Professional role, Behavioural regulation):

CP03: ‘Ensuring that your team has enough expertise and skills, so you have to impose requirements on the training programme, partly team training, partly personal training. Facilities and product assortment should be state of the art’.

CP01: ‘A pharmacist should monitor and correct assistants’ advice where needed. When assistants start working in the pharmacy, their knowledge and skills levels are comparable, but after 6 months, the influence of the pharmacist shows; but if pharmacists let it slip, then, yes, of course, quality decreases’.

According to most CPs, during pharmacotherapeutic meetings with GPs, self-care medication was merely discussed when OTC medicines were relevant for treating chronic conditions (e.g.vitamin D or NSAIDs; Environmental context). Consumers and GPs perceive pharmacies as more expensive than other OTC outlets (Environmental context). GPs with whom the CPs discussed self-care in the pharmacy realised that generic OTC products for which pharmacies mostly advise are less expensive than brand products. One pharmacist agreed with GPs on a local formulary based on national self-care guidelines and agreed on measuring the decrease in GP consultations. However, most pharmacists doubted whether GPs were aware of pharmacy self-care advice (Environmental context):

CP06: ‘I never discussed self-care with the GPs, and they may very well not know what we do. But, I hope they have any idea of our pharmacy providing self-care advice’.

Both CPs and PAs emphasised the importance of the availability of and adherence to national self-care guidelines for correct evidence-based self-care advice (Knowledge). A barrier was that most assistants were unaware of guideline medication updates because of a lack of attention in the pharmacy. Some CPs assigned a team member to track guideline updates and new product introductions or preferred central updates in an electronic decision-support system. Most participants thought their ready knowledge was reasonable, but some CPs mentioned as a barrier that PAs’ and CPs’ ready knowledge was insufficient to provide the correct advice for all self-care requests (Knowledge):

CP01: ‘We should pay more attention to ready guideline knowledge at the counter’.

In contrast, most PAs did not mind the lack of thorough guideline knowledge because, according to them, they knew where to find information when needed (Knowledge). PAs reported that they asked their colleagues or the CP for advice when their knowledge at the counter was insufficient (Social influences). At the counter, only a few PAs searched for information online, while others thought this approach was unprofessional.

All participants responded that they applied the WWHAM protocol for problem analysis. Nevertheless, CPs thought that the extent of the advice could depend on the PA at the counter. To achieve more straightforward advice, some pharmacies use an electronic decision-support system for asking WWHAM questions since the system also considers lifestyle advice and provides first- and second-choice medications according to the guideline. Most CPs and all PAs thought that the correct advice would be provided when WWHAM questions were asked for condition-based, symptom-based and product-based requests. However, CPs who participated in a simulated patient programme mentioned a barrier: WWHAM questions were not always sufficient for symptom-based requests (Knowledge):

CP10: ‘No, I don’t think that WWHAM is always sufficient. We learned that from a simulated patient visit on a symptom-based request in our pharmacy. We did not grasp the catch’.

Next to the knowledge of the guidelines, PAs and CPs mentioned the following important skills for appropriate advice: (1) verbal and nonverbal conversational skills, such as maintaining eye contact, retrieving sufficient information from consumers, asking open-ended questions and shared decision-making; (2) process skills, such as explaining when using a tool or consulting a colleague, deviating from the strict WWHAM order by integrating spontaneous consumer information and advising consumers to return when having questions; and (3) analytical skills, such as the ability to interpret answers and estimating when and how long to ask follow-up questions (Skills):

CP04:‘Knowledge, of course, relating to the content but also to products, and communication skills of course, that you are able to ask open-ended questions and follow up on them and the ability to convey it well’.

PA03: ‘You have to listen carefully and listen between the lines because they provide a lot of information spontaneously’.

PA03: ‘You always keep eye contact, and you explain to the consumer what you are doing’.

CP10: ‘We trained to customise our advice when implementing the Consultation guideline, trying to attune to what people need, and we found it quite hard’.

PAs thought that providing correct advice from colleagues was not defined by years of experience in the pharmacy but depended on intrinsic motivation to maintain and improve knowledge and skills while working (Beliefs about capabilities, Knowledge, Skills). CPs and PAs mentioned learning about minor ailments from the guidelines during their pre-graduate training, although all reported they learned most in pharmacy practice by listening to experienced PAs (Social influences). PAs also mentioned that during education, the emphasis was on communication skills instead of ready knowledge (Skills). CPs who implemented knowledge and skills development and assessment facilitated it mainly by organising web-based training and testing, patient-simulated visits, on-the-job training, discussing assessment results in work meetings, assigning accountable PAs and CPs and communicating guideline updates and product introductions. Some CPs and PAs reported roleplaying within the pharmacy team and interns (Skills):

PA10: ‘We also practice when we discuss a minor ailment during work meetings .We always see to it that we discuss that and update our advice accordingly’.

PAs noticed that consumers were unaware of the healthcare provider role of CPs and sometimes had less confidence in evidence-based information from the pharmacy than from advertisements, commercials and the internet (Beliefs about consequences). Some CPs genuinely believed that the pharmacy team could help patients distinguish between reliable and unreliable information. However, PAs thought it important to appreciate consumer efforts to search out information before discussing an evidence-based alternative. Access to electronic patient records and the ability to monitor interactions with chronic medications and contraindications was a facilitator for medication safety and an important added value to the pharmacy (Beliefs about consequences). Moreover, PAs reported checking the legally required appropriateness of pharmacy-only medications with a questionnaire (Memory, attention and decision processes):

PA05: ‘We have a sticker or label on OTC products. A yellow sticker tells us the product has to be checked for interaction with chronic medication, and we also have blue stickers for pharmacy-only products; we check these products with a questionnaire’.

PAs noticed that consumers who did not appreciate being asked questions switched to other OTC outlets where fewer questions would be asked. Most PAs mentioned they did their best, but it was the consumers’ responsibility if they did not appreciate the advice (Beliefs about consequences):

CP06: ‘They don’t have time nor feel like answering our questions; they think that pharmacy is always asking questions; they prefer to get it at the druggist or supermarket’.

Participants thought that good advice with or without self-medication in the pharmacy might prevent the development of chronic disease and thereby save costs for society (Beliefs about consequences). CPs thought that self-care advice and checking medication safety was a barrier, requiring time that is not reimbursed or covered by margin for generic self-care medication (Reinforcement). CPs also experienced a barrier in the lack of recognition for the added value of self-care in the pharmacy by GPs, consumers, patients and healthcare insurers (Optimism).

Environmental barriers, such as time pressure caused by a crowded waiting area and prioritising dispensing of prescribed medicines, are reasons for omitting WWHAM questions. According to a CP, innovative logistic interventions such as central filling might free up time for self-care advice and on-the-job training (Environmental context, Skills). A lack of privacy at the counter was a barrier for PAs to retrieve sufficient information (Environmental context). Participants observed different perceptions of consumers regarding privacy in the waiting area. In some pharmacies, consumers appreciated the offer of a consulting room, whereas, in other pharmacies, consumers felt embarrassed visiting it. Some pharmacies introduced background music in the waiting area, but this may affect PAs concentration when advising. Moreover, PAs experiencing the loudness of their voice by sound measurement and listening to consultations at the counter in the waiting area were mentioned as facilitators.

Respondents mentioned language problems and some consumers from different cultural backgrounds having more confidence in a GP from their country of origin as a barrier (Environmental context, Skills). Team members speaking various second languages, using Google Translate and interpreting by telephone were measures to overcome language problems.

Overall, important barriers to evidence-based self-care counselling were CPs’ and PAs’ lack of ready knowledge regarding minor ailments and suboptimal cooperation with GPs. Further barriers included beliefs that WWHAM questions would always lead to correct advice, time-pressuring by the priority assigned to prescribed medications or by crowded waiting areas and consumers having more confidence in commercial drug information than in evidence-based advice from the pharmacy. Important facilitators were availability of guidelines, conversation, process and analytical skills, training and assessment, and access to patient records.

Knowledge can be improved by training and assessment and should include diagnosing minor ailments and lifestyle advice. This finding aligns with an earlier study that recommended a structured training approach for the entire community pharmacy team to promote the delivery of robust, high-quality minor ailment services [23]. Our study found that CPs over-relied on the WWHAM mnemonic for problem analysis. Mnemonics might allow for standardising the information gained from the patient, but interpreting the acquired data might be problematic [24]. Problem analysis needs follow-up questions, correct problem identification and adequate problem-solving [25, 26]. Our findings align with earlier research findings that CPs show poor clinical reasoning due to an overreliance on protocol-driven questioning [27, 28].

According to participants, registering self-care products in electronic patient medication records enables clinical risk management (e.g. by generating alerts for patients with concomitant morbidity or reduced renal function). As identified in an earlier study, CPs tend to put medication safety first [29]. Their main motivation is the health and well-being of their patients, not financial incentives [30]. Earlier research has demonstrated that safety and effectiveness are important factors for consumers when purchasing OTC products [31]. Therefore, CPs should raise public awareness among consumers and patients about how pharmacies can facilitate the safe and effective use of OTC products [32]. Informing consumers about the background of safety related questions in the pharmacy and the reasons to record OTC products in the patient file could improve the perception of the added value of self-care advice in the pharmacy.

Widening access to medicines through reclassification (‘switching’) from prescription to non-prescription is an international trend [33–35]. In the Netherlands, OTC medicines consist of three classes: (1) pharmacy only, (2) pharmacy and druggist only, and (3) general sales provided by druggists, supermarkets and other OTC outlets. This study showed that most CPs were not in favour of reclassifying prescription medicines but preferred being able to rely on a primary GP diagnosis and subsequently repeat the GP prescription.

Participants observed different perceptions of consumers regarding privacy in the waiting area and visiting a consultation room. In self-care, a perceived lack of privacy might sometimes be a barrier for consumers to share information on minor ailment symptoms with CPs [36]. Sufficiently private areas at the counter for private pharmacy discussions, could be a solution to address varying views on privacy in the pharmacy [36]. Moreover, preventing sound reflection by sound absorbing materials may improve privacy conditions in pharmacy .

Strengths and weaknesses

A major strength of the study was that we included the perspective of both CPs and PAs. Furthermore, we found enough CPs and PAs from various backgrounds (e.g. pharmacy types, location, pharmacist positions and years of experience) willing to cooperate during this strenuous period. The number of interviews was sufficient to reach data saturation [11]. In general the perceptions on barriers and facilitators from CPs and PAs aligned well which added to the data saturation.

The most important weakness of the study was that the topic guides were not piloted with CPs and PAs. Since the first six interviews only led to changes in the order of starting questions, we included all interviews in the analysis.

CPs should strive for an optimal environment in pharmacy to improve the quality of self-care advice by arranging training and assessing knowledge and skills for themselves and their team, providing sufficient time for advice by minimising environmental stressors. CPs should improve cooperation with GPs and raise awareness of the importance of appropriate use of self-care products with consumers.

Acknowledgements

The authors thank the community pharmacists and pharmacy assistants who were willing to share their views on provision of self-care advice.

Funding

No funds, grants, or other support was received.

Conflicts of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

CRediT authorship contribution statement

Rian Lelie van der Zande: Methodology, Conceptualization, Formal analysis, Writing - original draft, Writing - review & editing,

Ellen S. Koster: Methodology, Writing - review & editing.

Martina Teichert: Methodology, Writing - review & editing.

Marcel L. Bouvy: Methodology, Writing - review & editing.

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Barriers and Facilitators for Evidence-Based Self-Care Counselling in Community Pharmacy, a qualitative study

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