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Consumers’ Perceptions About Pharmaceutical Care Provided by Community Pharmacists in China in Relation to Over-the-Counter Drugs: A Qualitative Study

While patient-centered care is highly anticipated nowadays, investigation of consumers’ perceptions and expectations about pharmacist’s pharmaceutical care when providing over-the-counter (OTC) drugs is sparse. This article aimed to explore consumers’ perceptions regarding the pharmaceutical care that community pharmacists provide in relation to OTC drugs. Semistructured interviews were conducted with consumers recruited (N = 97) in Yinchuan City, China. The 4 main themes that emerged were expectations on pharmaceutical care, attitude toward pharmacist’s competence, experience of self-medication, and suggestions for improving pharmaceutical care. Most participants had high expectations on community pharmacists to recommend the right medicines, to advise them about the effective use of drug, to advise them about the safe use of drug, and to recommend economic drugs. However, their previous experiences at community pharmacy were far from satisfaction reportedly, leading to a general distrust in pharmacist’s certification and qualification, knowledge, communication skills, and attitude. As a result, the participants turned to self-medication based on their personal experiences, their relatives’ experiences, the information on drug label, and the information distributed in the mass media. Realizing the need to improve pharmaceutical care, the participants also made improvement suggestions specific to community pharmacist, community pharmacy, and the government.


What do we already know about this topic?
Pharmacists should understand consumers' concerns and demand in order to ensure quality of pharmaceutical care. How does your research contribute to the field? This research identified consumers' expectations on community pharmacists and found the reasons why consumers avoided seeking pharmaceutical care from community pharmacists. What are your research's implications toward theory, practice, or policy? Collective actions of pharmacists, community pharmacies, and government should be taken to rebuild consumers' trust in the competence of community pharmacist to order to improve the safe and appropriate use of OTC drugs at community pharmacy.

Background
Around the world, more and more people use over-thecounter (OTC) drugs for self-medication. 1,2 With the increasing usage of OTC drugs, irrational drug use and adverse drug reactions are also becoming significant health care problems. For example, in a study by Schmiedl et al, among 266 adverse drug reactions, 143 cases were related to OTC drugs. 3 A national survey in the United States in 2008 also showed that about 1 million (5.3%) people abused cold-cough OTC drugs in a year. 4 As OTC drugs can be readily purchased by consumers at community pharmacies, it highlights the importance of pharmaceutical care provided by community pharmacists. 5 In China, the OTC drug market reached RMB 128 billion in 2012, of which RMB 78.266 billion (61%) originated from community pharmacies. 6 However, pharmaceutical care at community pharmacies was developing very slowly. [7][8][9] To establish a standard for pharmacists to practice appropriately, scholars had highlighted the importance of understanding consumers' needs for pharmaceutical care. 10 International Pharmaceutical Federation (FIP) and World Health Organization (WHO) also urged that pharmacists should understand consumers' concerns and demand to ensure quality of pharmaceutical care. 11 However, the amount of research work targeting consumers' perspective about pharmaceutical care is relatively limited, most of which emphasized particularly on consumer satisfaction with community pharmacy services. Although the findings helped to shed light on the continuous need for improvements, empirical results showed that the levels of consumer satisfaction with community pharmacy service varied. [12][13][14][15] Other scholars also tried to investigate consumers' understanding of community pharmacists' professional role. While most consumers agreed that community pharmacists should play the professional role more rather than just drug dispenser, the conceptualization about community pharmacist's professional role is neither specific nor consistent. [16][17][18] At present, limited information has been provided from the literature to specifically guide the improvement process based on their consumers' needs.
This study aims to explore consumers' perceptions regarding the pharmaceutical care that community pharmacists provide in relation to OTC drugs. The findings will provide empirical evidence to supplement the current findings supporting the development and improvement of pharmaceutical care provided by community pharmacists in China and also enrich the academic field of understanding consumers' role in pharmaceutical care.

Ethics Approval
Ethical approval was obtained from the Ethics Committee of the University of Macau (MYRG2015-00072-ICMS-QRCM) and the Ethics Committee of Beijing Jiaotong University (Project No. 14BRK027).
Study design and setting. To enable the researchers to explore the unique opinions of individual consumer, semistructured interview was chosen as the method for this study. 19 We chose interview method for 2 reasons. First, this study aims to "explore" but not to "measure" consumers' perceptions, which demands more qualitative design. Second, it is considered that the interview method can offer distinctive advantages to this particular study allowing exploration of the interviewee's opinions more thoroughly through interactions between interviewer and interviewee. 20 Therefore, interview method was adopted.
The study was conducted in Yinchuan City, northwest China, which was the provincial city of the Ningxia Hui Autonomous Region. Until the end of 2014, there were about 2 million residents in Yinchuan City, among which 52% residents were male. For age composition, 16% residents in Yinchuan City were less than 14 years; 75% residents' age was between 15 and 59 years; and 9% residents were older than 60 years. Comparatively, the population of residents in Yinchuan City was slightly younger nationally as the overall age composition in China for the same age groups were 17%, 70%, and 13%, respectively. In 2014, the gross domestic product (GDP) per capita of Yinchuan City was USD 10 909 which was significantly higher than the national GDP per capita (USD 7575). There were about 700 community pharmacies in the Yinchuan City, indicating a relatively high pharmacy density of 350 community pharmacies per 1 million residents as compared with the national figure of 205:1 000 000 in 2012. 21,22 With such kind of pharmacy density, residents were encouraged to not only buy OTC drugs but also seek professional advice at community pharmacy to support their self-medication.
Participants. Participants were selected through systematic planning. First, it was designed to recruit participants from all the 3 districts of Yinchuan City (Xingqing, Jinfeng, Xixia) to ensure that participants included in this study allowed optimal generalization. Second, the demographic composition of population in Yinchuan City was considered for participant recruitment to get a diverse range of perspectives.
In practice, people walking by the community pharmacies during daytime (9 am-5 pm) in the 3 selected districts were randomly approached. Participants were recruited from 10 community pharmacies in each district. By having consumers recruited from the different community pharmacies from all the 3 districts in Yinchuan City, the diversity of demographic composition was appropriately considered for and the findings of this study were sufficiently representative of the city population.
For each interview, the researcher showed her identity card and explained the research purpose to the person when inviting him or her to participate. People who were older than 18 years and had bought OTC drugs at community pharmacy in the past 6 months were eligible to participate. The study did not set up a target sample size but stopped recruiting when theoretical data saturation was reached. 23 Finally, a total of 97 interviews were completed.
Data collection. The field interview was conducted from January to March 2015. Each interview lasted for 12 minutes on average (range: 10-15 minutes). All the interviews were conducted in Chinese and audio-taped following written consent.
To ensure interview validity, necessary measures were taken when designing the interview guide before the formal field interview. First, the interview topics was originally developed from current academic literature and documents about community pharmacies in China, which resulted in the first version of interview guide. Second, it was reviewed by 3 community pharmacists and 7 consumers, which led us to revise the interview guide. Third, another 10 consumers were invited to test the feasibility of the second version of the interview guide. Fourth, after minor modification, a final version of interview guide was decided.
The final guide mainly covered the following topics: expectations on pharmaceutical care of OTC drugs at community pharmacy; attitude toward pharmacist competence; experience of self-medication with OTC drugs at community pharmacy; and their suggestions to improve pharmaceutical care of community pharmacists. All the questions were designed in an open-ended manner (see Appendix).
Data analysis. A thematic analysis approach was applied in this study. 24 Microsoft Excel 2013 was used for data analysis. Necessary measures were taken to ensure coding validation and language validation. First, all the interview transcriptions in Chinese were reviewed to mark out recurring themes and subthemes by reading and rereading, which was undertook by 2 researchers individually. Second, their coding results were exchanged for discussion. When there were differences in coded themes and subthemes, another researcher participated to review the interview transcriptions again to make decisions. Third, all the themes and subthemes were formulated with reference to literature work to generate a complete thematic framework that integrated all the findings. The thematic framework was then translated into English. Fourth, the researcher did the back translation of the final thematic framework to ensure translation validation. During the whole data analysis, 2 researchers played the leading role, while other researchers were involved in reviewing the coding structure and interpretation regularly as "peer debriefing." 25

Results
As shown in Table 1, among the 97 participants, 54 participants were female (56%). In terms of education, 56% participants had received bachelor degree or postgraduate education; 91% participants were younger than 50 years old.
The thematic analysis reached 4 main themes with associated subthemes (see Table 2).

Expectations on Pharmaceutical Care
Most of the participants had high expectations on pharmacists to provide pharmaceutical care regarding the use of OTC drugs. In their view, satisfactory pharmaceutical care Advise about the effective use of drug. How to take OTC drugs effectively was also a main concern of participants. The participants generally wanted to know more details about effective use of drugs from community pharmacists, such as Recommend economic drug. Compared with therapeutic efficacy, the participants showed less sensitivity to price. But they still wanted community pharmacists to suggest economic drugs, as I hope they could recommend some effective and inexpensive drugs, not the most expensive drugs that are not covered by medical insurance. (C069: 42, female, college)

Attitude Toward Pharmacist Competence
While the participants had high expectations on community pharmacists' pharmaceutical care, they did not tend to seek pharmaceutical care from community pharmacists in reality. The main reason was their distrust in pharmacist competence, which was composed of 4 subthemes:

Distrust in pharmacist's certification qualification; Distrust in pharmacist's knowledge; Distrust in pharmacist's communication skills; and Distrust in pharmacist's attitude.
Distrust in pharmacist's certification and qualification. Some participants did not trust the service by community pharmacists because they did not know whether the community pharmacists were licensed: Distrust in pharmacist's attitude. Some participants were affected by the bad service and attitude of pharmacist, which led to their distrust in pharmaceutical care provided by the pharmacist: It feels that he was just careless, not professional at all. (C076: 36, female, bachelor)

Experience of Self-Medication
Because participants had general distrust in community pharmacist's competence, they would turn to self-medication with OTC drugs and: Rely on personal experiences; Rely on relatives' experiences; Rely on drug label; and Rely on media.
Rely on personal experiences. For many participants, the first choice was to rely on their own experiences to decide which OTC drugs to buy at community pharmacy. They generally thought that they knew the drugs well enough from experiences to use them for treating their diseases: I only bought the drugs that were often used. I knew them well. (C019: 47, female, bachelor) Rely on relatives' experiences. If the participants could not make their own decision, they would seek advice from family members and friends who recommended drugs based on their experiences: Usually the drugs were suggested by family relative and friends. (C082:37, female, bachelor) Rely on drug label. If their own or relatives' experiences could not provide satisfactory guidance, the participants would actively read the drug label or package insert to decide which drugs they needed: Rely on media. Some participants said they would choose the OTC drugs by following the information from media. In particular, along with the popular use of smartphones among young consumers in China, they tended to search online information to guide their purchase of OTC drugs at community pharmacy, as

Improvement Suggestions
The participants thought collective actions of pharmacists, community pharmacy owners, and government were needed to improve the quality of pharmaceutical care provided by community pharmacists. Their suggestions could be categorized as suggestions to community pharmacist, suggestion to community pharmacy, and suggestions to the government.
Suggestions to community pharmacist. Some participants thought that community pharmacists needed to improve their professional knowledge and communication skills, as Suggestions to community pharmacy. The participants also suggested that community pharmacy needed to take actions to facilitate the provision of pharmaceutical care by pharmacists. Some participants thought community pharmacy needed to change the floating salary structure and provide fixed remuneration to community pharmacists: In addition, some participants thought consumers might have other questions at home when taking the drugs. However, community pharmacy did not provide any convenient after-sales service, so Community pharmacy should have the idea of after-sales service. Don't deny anything after selling the drugs. (C057: 32, male, bachelor) Suggestions to the government. Some participants thought that the current disorder of community pharmacy was due to lack of government regulation, then Government should have effective monitoring mechanism, complaint mechanism, etc. Now it feels that no one takes charge.

Discussion
This study found that participating consumers expected community pharmacists to provide pharmaceutical care. Similar to findings in previous research, consumers' most expectations on pharmaceutical care were recommendation of proper drugs and professional medication counseling. 26 Moreover, the participants in this study showed explicit interests in knowing further details about drug ingredients and their pharmacological actions. As OTC drugs in the same therapeutic group often have similar medical effects, consumers would like to know more information about alternative drugs to help them make informed choices. This finding implies that community pharmacists have to realize consumer's growing demand for professional service of providing specific drug information to consumers.
This study also identified distrust in pharmacist competence as a key issue for consumers to seek pharmaceutical care from community pharmacists. Literature had indicated that experiences of unsatisfactory interactions with pharmacists would discourage consumers to take in pharmacists' advice. 27,28 As shown in this study, bad experiences had resulted in distrust in pharmacists' competence in terms of certification and qualification, professional knowledge, communication skills, and attitude. Once consumers lost trust in pharmacists, it would be difficult for community pharmacists to provide pharmaceutical care. This finding implies that consumers' trust (or distrust) in community pharmacist plays significant role in determining the quality of pharmaceutical care.
Another significant consequence of distrust in pharmacists' competence was consumers' increasing practice of self-medication with of OTC drugs. As shown in this study, without consulting with community pharmacists, participating consumers relied on their personal experiences or their relatives' or friends' suggestions when choosing OTC drugs. They generally regarded OTC drugs as safe and lacked the respect for the potential risks of self-medication with OTC drugs. 29,30 While consumers thought they could get enough information by reading drug label or package insert, technically the drug information is difficult for consumers to fully comprehend and understand. 31 This study also found that consumers would let media guide their choice of OTC drugs, especially when it came to drug information on the Internet. Internet information which includes a lot of direct-to-consumer advertisement may not subject to stringent regulation and can be highly confusing and even misleading. 32 Without professional and reliable advice from pharmacist, consumers' self-medication with OTC drugs could easily result in increased drug risks.
In addition, the demographic impact on consumers' requirements on pharmaceutical care of OTC drugs by community pharmacists needs to be noted. As shown in this study, the residents in Yinchuan City who were relatively younger, at better economy status and better educated, anticipated a higher level of pharmaceutical care. For example, they wanted to know more specific details about different OTC drugs and were more proactive to find out more about the drugs via various means. It is not surprisingly as higher education level allows greater consumers' autonomy in selftreatment. 33 Accordingly, it will impose greater pressures on community pharmacists to improve their competence.

Practice Implications
Mutual understanding between consumers and pharmacists is crucial for the provision of pharmaceutical care at community pharmacy. [34][35][36] On the contrary, if pharmacists lost trust from consumers, they would meet consumers' avoidance to their professional service. Therefore, how to build (or rebuild) consumers' trust in pharmacist competence is key for promoting pharmaceutical care regarding the use of OTC drugs at community pharmacy. From this perspective, collective efforts by pharmacists themselves, community pharmacy owners, and policy makers should be taken to realize this objective. First, policy makers need to legitimize the professional role and qualifications of community pharmacists as health care providers in public health. Second, community pharmacy owners should recognize pharmaceutical care provided by pharmacist as one necessary and distinguished feature of their pharmacy service and provide resources to support. Third, pharmacists need to improve their own professional knowledge, communication skills, and attitude. Particularly, pharmacists need to learn to communicate with consumers in a lively instead of scientific way to attract consumers' attention and increase their acceptance. 37 At the same time, public education is necessary to help increase consumers' health literacy and awareness about health risks associated with irrational drug use and their recognition of pharmacists' professional role in safeguard their drug safety.

Limitations and Future Research
This study provides exploratory evidence about consumers' opinions about community pharmacist's pharmaceutical care in relation to OTC drugs in China. The findings could be advanced in the future study in 3 aspects. First, large scale survey with consumers in other regions of China could be conducted to retest the findings from this study. Second, further qualitative study with key stakeholders as policy makers, business leaders of community pharmacy, and key representatives of community pharmacists could be conducted to collect their opinions to provide comparative materials. Third, while this study explored consumers' opinions about the pharmaceutical care that community pharmacists should provide in relation to the use of OTC drugs, future study can explore the proactive behaviors that consumers can take to interact with pharmacists to get more effective pharmaceutical care, which will significantly contribute to the field of studying pharmaceutical care from the view of consumers.

Conclusion
Consumers expected pharmacists to provide professional service about OTC drugs at community pharmacies. However, they were not keen on seeking pharmaceutical care from community pharmacists due to distrust in pharmacists' competence. Consumers' reliance on self-medication with OTC drugs caused them higher drug risks. Collective actions of pharmacists, community pharmacies, and government should be taken to rebuild consumers' trust in the competence of community pharmacist to improve the safe and appropriate use of OTC drugs at community pharmacy.