In many parts of the world most drugs are dispensed without a prescription 1–4. Excluding antibiotics, anabolic steroids, narcotics, and controlled drugs, patients may self-select their medications without a visit to the physician, 4. Over-the-counter (OTC) drugs are those drugs that are available to consumers without a prescription 5.
The widespread use of OTC drugs can be attributed to the need to save time and money and because patients perceive their symptoms to be minor, not requiring physician consultation 1,3. Individuals with higher literacy skills are more likely to self-medicate 3. Other factors responsible for not seeking physician advice have been reported to be inconvenient access or dissatisfaction with healthcare 6.
Benefits of nonprescription medications include decreased frequency of physician visits, increased patient autonomy, and reduced costs 7,8. However, the use of such products can delay or mask the diagnosis of serious illnesses 9, increase the risk of adverse effects or drug interactions, and delay appropriate medical attention 10,11. There is also a potential for misuse and abuse of such products 12. Uncertainty about the indications for the drug and therapy failure are the two main problems identified among customers purchasing nonprescription products 13. In such a case customers need to be well informed about the nonprescribed medications they are using, and thus education about such drugs is considerably important. Among healthcare professionals, pharmacists have a key role in providing information and helping customers make a safe choice of nonprescription medicines 14. Pharmacists are the most often used source of information for minor illnesses and OTC medication 15. They are more accessible 14 and most nonprescription medicine purchases are from pharmacies 14,16. The main factor found to influence the public choice of OTC medicines was pharmacist recommendation 16. The pharmacist is the individual who is expected by the population to provide information on medications in an understandable and competent way 17. The pharmacy may become the sole source of support and education for patients with respect to their choice of medication 18. This potential source of information and support may be underutilized, the customer–pharmacist interaction being often short and perfunctory because of lack of time 14.
The Royal Pharmaceutical Society of Great Britain has published guidelines in their Code of Ethics indicating how medicines should be dispensed from community pharmacies 19. The guidelines require the involvement of a pharmacist in consultations where appropriate. For example, the guidelines recommend that sufficient information be obtained during consultations to enable a suitable product to be recommended. It is also recommended that particular care be taken with specific patient groups (such as the elderly) and specific drugs (such as newly reclassified drugs). The extent to which current practice complies with these guidelines is unknown, but there is evidence that nonprescription medicines are sometimes supplied or used inappropriately 20–22.
Because of the growing use of such medications and their importance we aimed to measure the attitudes and beliefs of the community pharmacists toward the use of nonprescription medications by the Egyptian customers.
Subjects and methods
The study was conducted at community pharmacies in Alexandria.
This study was cross-sectional and descriptive in design.
The study comprised pharmacists working at community pharmacies in Alexandria. The total number of pharmacies at the time of the study was 4388, distributed in eight regions.
Assuming 44% inappropriate use of OTC medication 23 (precision of 7, α level=0.05), the minimum sample size required was calculated to be 334 pharmacists.
- Sampling technique: A total of 335 community pharmacies were selected by proportional allocation according to the number of pharmacies in each region. Only one pharmacist was included from each pharmacy (a total of 335). In each region the researcher visited the required number of pharmacies until he had obtained the required sample size.
- Data collection: Data were collected using a self-administered questionnaire that was previously used in the USA to study the attitudes and beliefs of the medical professionals toward OTC medications 23. Only questions that could be directed at pharmacists were included. The questionnaire was used after translating it into Arabic. The collected data included personal data of pharmacists such as age, sex, number of filled prescriptions per week, and years of practice.
At the beginning of the questionnaire, a definition of OTC medications and their groups was provided. Pharmacists were questioned about the current use of OTC compared with their use 4 years ago and if the inappropriate use of nonprescription medicine is extremely, very, somewhat, or not at all serious. The extent of the different forms of inappropriate use of nonprescription medicine was questioned when eight items were included, and for each item five responses were provided (extremely, very, moderate, rarely, or not widespread at all). The pharmacists were asked to rate five contributing factors to inappropriate use of nonprescription medicine as extremely, much, moderately, little, or not contributing at all. Pharmacists were asked how often they discuss with their patients/customers the use of different categories of nonprescription medications. For each category five responses were provided (all of the time, most of the time, sometimes, few times, or not at all). Pharmacists were also asked about the frequency of consultations for nonprescription medications and the main reasons why patients/consumers do not seek consultation for nonprescription medicines. The pharmacists’ sources of information about nonprescription medicines were interrogated.
Data were fed to the computer using the Predictive Analytics Software (PASW Statistics 18, SPSS Inc., Chicago, Illinois, USA; 2009) 24. Quantitative data were described using measures of central tendency, mean and SD, and minimum and maximum values. Qualitative data were described using frequency and percentage Pharmacists were ensured that the information they gave would not be used for any purpose other than scientific research. Also administrative approval from the ministry of health in Alexandria was obtained.
Women constituted 60% of the sample. The mean age of the pharmacists was 31.1 years. The pharmacists had a mean number of 9.3 years of practice and dispensed medicines for a mean number of 159.8 prescriptions per week. The use of nonprescription medicine among patients/consumers was reported by 66.9% of pharmacists to have increased in the past 4 years, whereas 10.4% reported a decline in their use and 22.4% reported no difference. The use of nonprescription medications was considered as a very serious problem by 56.4% and somewhat serious by 37.9% of pharmacists.
According to pharmacists, the most common reasons for inappropriate use of nonprescription medications were as follows: long-term or chronic use (76.7%), use of nonprescription medicine for prescription indications (68.7%), taking nonprescription medicine that does not treat the problem (39.1%), taking doses of nonprescription medicine too frequently throughout the day (37.7%), taking too high a dose at one time (36.1%) (Fig. 1).
The most common factor that contributes to inappropriate use of nonprescription medications was thought to be lack of knowledge on the part of patients/customers about the active ingredient in a branded product, as reported by 82.4% of pharmacists. The second common factor was the fact that many nonprescription medicines contain the same active ingredient, as reported by 64.5% of pharmacists. Misunderstanding the information provided on the medication label was considered by 55.8% to be extremely or significantly contributing to inappropriate use (Fig. 2).
The most common medications for which patients/consumers consulted pharmacists were those for cough, cold, or sore throat (73.5%), heartburn, indigestion, or other stomach problems (66.5%), and skin problems (59.4%). Medications for allergy or sinus relief, constipation and diarrhea, and pain relief were discussed by 55.5, 52, and 51.3% of the pharmacists, respectively, with their patients/consumers, and 42.7% discussed medications against infection (Fig. 3).
The most common enquiries made by patients/consumers to pharmacists were with respect to the manner in which nonprescription drugs should be used (79.4%), what nonprescription medicine should be used to treat a problem (50.2%), and whether they can take more than one nonprescription medicine at a time (49%) (Fig. 4).
The main reasons for nonconsultation by patients/consumers on nonprescription medicines were stated by pharmacists to be as follows: patients believed that nonprescription medicines were safe (60.0%); they considered consultation unnecessary (52.5%); they did not have access to pharmacists (37.6%); and patients/consumers were embarrassed to discuss the situation in detail (28.1%) (Table 1).
The study showed that 93.7% of pharmacists turned to drug product labeling to learn about nonprescription medicine; 74.6% asked pharmacist colleagues; and 68.4% asked colleagues in other health professions. A significant proportion of pharmacists used drug manufacturers, advertisments in newspapers, internet, magazines, radio, TV, or reference books as sources of information about nonprescription medicines (42.7, 40.9, and 40.9%, respectively) (Table 2).
In the present study 66.9% of pharmacists reported that nonprescription medicine use has increased over the past 4 years. This result is comparable to that reported in America (2001) 23, where 73% of medical professionals including physicians, pharmacists, and nurses believed that patients/customers are taking more nonprescription products today than they were 5 years ago. High levels of self-medication practices with OTC medicines have been reported 25,26.
Most pharmacists who participated in the present study considered inappropriate use of nonprescription medicines to be a serious problem. Similarly, about one-third of American medical professionals (32%) believed that inappropriate use is very or extremely serious and 47% believed that it is somewhat serious 23.
Inappropriate use of many forms of nonprescription medications was reported to be very or extremely widespread. Long-term or chronic use, use of it for prescription indications, taking a medicine that does not treat the problem, taking doses too frequently throughout the day, and taking too high a dose at one time were considered to be very or extremely widespread problems (Fig. 1). These results are comparable to that of the American medical professionals’ survey in which long-term or chronic use of nonprescription medicine, taking doses of nonprescription medicine too frequently throughout the day, and taking too high a dose at one time were considered by 44, 35, and 33% of American medical professionals, respectively, to be a very or extremely widespread problem 23. Also, about 29.5% of pharmacists in this study considered concurrent use of nonprescription and prescription medicines to be a very or extremely widespread problem. A higher percentage (51%) of American medical professionals considered this concurrent use as a very or extremely widespread problem 23. In Italy, about half (55.3%) of the customers of community pharmacies reported that they have been taking at least one prescription drug along with nonprescription medication 14.
Pharmacists considered many factors as contributing to the inappropriate use of nonprescription medicines – for example, lack of knowledge on the part of patients/customers about the active ingredient in a branded product, the fact that many different nonprescription medicines contain the same active ingredient, finding the label confusing, not bothering to read the label, and not asking pharmacists’ advice (Fig. 2). Such factors were considered by a high percentage of American medical professionals to contribute a great deal to inappropriate use of nonprescription medicines 23. Considering these factors, promoting knowledge about OTC medicines among patients/consumers can improve nonprescription medicine use, which emphasizes the pharmacist’s role as the patient’s assistant in the selection of appropriate drug therapy 27.
OTC medications include more than 80 therapeutic categories 28. The most common nonprescription medications that the participating pharmacists were asked about by patients/consumers were those for cough, cold, or sore throat medication, heartburn, indigestion, or other stomach problems, skin problems, and allergy or sinus relief (Fig. 3). In Italy the most frequently purchased nonprescription medicines by adults were NSAIDs, paracetamol, and medicines for gastrointestinal problems 14. Among the elderly, the most common OTC drugs used are analgesics 25,29, laxatives, and nutritional supplements 25.
In Jordon, patients’ choice of nonprescription medication was based on advice received from pharmacy staff, friends/relatives, or informal advice from other healthcare professionals 1. As a result, pharmacists need to be well informed about several aspects pertaining to nonprescription drugs. The present study showed that 79.8% of pharmacists were asked about how OTC should be used. Also they were asked about what nonprescription medicine they should use to treat the problem and whether they could take more than one nonprescription medicine at a time (Fig. 4).
The advice given by a community pharmacist is almost wholly focused on product indications and use. Advice giving varies according to whether consultations concern prescription or nonprescription medicines. When the latter are involved, advice is mostly consumer-led. Consumers’ major ‘need’ for pharmacy services appears to be for information on the effectiveness of products they buy, whereas pharmacists and pharmacy assistants concentrate on providing advice on the safety of medicines. OTC discussions need to be more open and conversational in nature than counseling on prescribed medicines 30.
Pharmacists see patient counseling as their professional obligation. They try to give basic information regarding drug usage to the patient. In India, the reasons stated by pharmacists for providing patient counseling are professional satisfaction, patient satisfaction, observed increase in sales, and improved patient compliance 31.
The present study showed that pharmacists believed that patients/consumers did not ask about nonprescription medicines because they believed that nonprescription medicines are safe, they did not think it necessary to seek consultation, or they did not have access to a pharmacist (Table 1). The American pharmacists assumed that patients/customers do not ask about nonprescription medicine because they have enough information or because patients do not want to bother them 23.
Pharmacists have many sources of information about nonprescription medicines. Most pharmacists (93.7%) in the present study turned to drug product labeling to learn about nonprescription medicine. Only 34.3% of pharmacists used continuing professional education to obtain information about nonprescription medications (Table 2). Similarly, for 42% of American medical professionals, drug labels were the most used source of information 23. These results showed the importance of improving the information provided in OTC labels and the need for continuing professional education. Labels of OTC medications should be reviewed and should follow the regulations set forth by Food and Drug Administration 32. In the UK, pharmacists underwent 30 h of continuous professional education on drugs, which contributed substantially to behavioral change 22. In India, pharmacists agreed that patient information leaflets certainly help in counseling, but available information leaflets are company generated and prescriber focused. Restrictions on doctor dispensing, legalization of patient counseling, and regular continuing professional development programs are factors that motivate pharmacists to offer patient counseling 31.
Use of nonprescription medications has increased over the past few years and pharmacists consider it a serious problem. Long-term or chronic use of nonprescription medicine is the most common reason for inappropriate use of nonprescription medications, and lack of knowledge on the part of patients/customers about the active ingredient in a branded product is the most common factor contributing to inappropriate use. Patients/customers do not ask about nonprescription medicines because they think that nonprescription medicines are safe. Most pharmacists turn to drug product labeling to learn about nonprescription medicine; hence, special attention should be paid to improving the existing legislations on its use.
Pharmacists should receive continuing professional education to improve their knowledge on and practice of dispensing nonprescription medication. Information on OTC drugs label should be consistent with the regulations laid down in the Food and Drug Administration-published OTC Drug Facts Label, as the majority of pharmacists use the drug label as a source of information about OTC.
Conflicts of interest
There are no conflicts of interest.
1. Yousef AM, Al-Bakri AG, Bustanji Y, Wazaify M.Self-medication patterns in Amman, Jordan.Pharm World Sci2008;30:24–30.
2. Awad A, Al-Rabiy S, Abahussain E.Self-medication practices among diabetic patients in Kuwait.Med Princ Pract2008;17:315–320.
3. Saeed AA.Self-medication among primary care patients in Farazdak clinic in Riyadh.Soc Sci Med1988;27:287–289.
4. Wilbur K, El Salam S, Mohammadi E.Patient perceptions of pharmacist roles in guiding self-medication of over-the-counter therapy in Qatar.Patient Prefer Adherence2010;4:87–93.
6. Alghanim SA.Self-medication practice among patients in a public health care system.East Mediterr Health J2011;17:409–416.
7. Brass EP.Changing the status of drugs from prescription to over-the-counter availability.N Engl J Med2001;345:810–816.
8. Sinclair HK, Bond CM, Hannaford PC.Long term follow-up studies of users of nonprescription medicines purchased from community pharmacies: some methodological issues.Drug Saf2001;24:929–938.
9. Hughes CM.Monitoring self-medication.Expert Opin Drug Saf2003;2:1–5.
10. Bradley CP, Bond C.Increasing the number of drugs available over the counter: arguments for and against.Br J Gen Pract1995;45:553–556.
11. Hughes L, Whittlesea C, Luscombe D.Patients’ knowledge and perceptions of the side-effects of OTC medication.J Clin Pharm Ther2002;27:243–248.
12. Hughes GF, McElnay JC, Hughes CM, McKenna P.Abuse/misuse of non-prescription drugs.Pharm World Sci1999;21:251–255.
13. Westerlund LOT, Marklund BRG, Handl WHA, Thunberg ME, Allebeck P.Nonprescription drug-related problems and pharmacy interventions.Ann Pharmacother2001;35:1343–1349.
14. Cuzzolin L, Benoni G.Safety of non-prescription medicines: knowledge and attitudes of Italian pharmacy customers.Pharm World Sci2010;32:97–102.
15. Volmer D, Lilja J, Hamilton D.How well informed are pharmacy customers in Estonia about minor illnesses and over-the-counter medicines.Medicina (Kaunas)2007;43:70–78.
16. Wazaify M, Shields E, Hughes CM, McElnay JC.Societal perspectives on over-the-counter (OTC) medicines.Fam Pract2005;22:170–176.
17. Major C, Vincze Z.Consumer habits and interests regarding non-prescription medications in Hungary.Fam Pract2010;27:333–338.
18. .Report on the council meeting of the Royal Pharmaceutical Society.Pharm J1992;248:219.
19. .Medicines, ethics and practice2005.London:RPSGB.
20. Sinclair HK, Bond CM, Hannaford PC.Over-the-counter ibuprofen: how and why is it used?Int J Pharm Pract2000;8:121–127.
21. Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, Litaker MS.Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis.Obstet Gynecol2002;99:419–425.
22. Watson MC, Bond CM, Grimshaw JM, Mollison J, Ludbrook A, Walker AE.Educational strategies to promote evidence-based community pharmacy practice: a cluster randomized controlled trial (RCT).Fam Pract2002;19:529–536.
23. .Attitudes and beliefs about the use of over-the-counter medicines: a dose of reality2002.USA:National Council on Patient Information and Education, Harris Interactive Inc.
24. .PASW Statistics 18, release version 18.0.02009.Chicago, IL:SPSS Inc..
25. Hanlon JT, Fillenbaum GG, Ruby CM, Gray S, Bohannon A.Epidemiology of over-the-counter drug use in community dwelling elderly: United States perspective.Drugs Aging2001;18:123–131.
26. Bradley C, Blenkinsopp A.The future for self medication.Br Med J1996;312:835–837.
27. Hepler CD, Strand LM.Opportunities and responsibilities in pharmaceutical care.Am J Hosp Pharm1990;47:533–543.
29. Goh LY, Vitry AI, Semple SJ, Esterman A, Luszcz MA.Self-medication with over-the-counter drugs and complementary medications in South Australia’s elderly population.BMC Complement Altern Med2009;9:42.
30. Hassell K, Noyce P, Rogers A, Harris J, Wilkinson J.Advice provided in British community pharmacies: what people want and what they get.J Health Serv Res Policy1998;3:219–225.
31. Adepu R, Nagavi BG.Attitudes and behaviors of practicing community pharmacists towards patient counselling.Indian J Pharm Sci2009;71:285–289.