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Journal of Public Health Advance Access originally published online on May 3, 2005
Journal of Public Health 2005 27(3):254-262; doi:10.1093/pubmed/fdi032
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© The Author 2005, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

Use of community pharmacies: a population-based survey



Helen Boardman

Martyn Lewis

Peter Croft
Helen Boardman, Research Assistant, Martyn Lewis, Lecturer in Statistics, Peter Croft, Professor of Primary Care Epidemiology, Department of Public Health, North Staffordshire Health, Heron House, 120 Grove Road, Stoke-on-Trent ST4 4LX.


Paul Trinder

Giri Rajaratnam
Paul Trinder, Public Health Epidemiologist, Giri Rajaratnam, Director of Public Health, North Stoke and South Stoke Primary Care Trusts, Department of Public Health, North Staffordshire Health, Heron House, 120 Grove Road, Stoke-on-Trent ST4 4LX.

Address correspondence to Dr Helen Boardman, Division of Primary Care, 13th Floor, Tower Building, University Park, Nottingham NG7 2RD. E-mail: helen.boardman{at}nottingham.ac.uk

Background Community pharmacies are widely used in the UK, but the services they provide are changing, with pharmacists expected to take on wider roles and responsibilities. The impact of such changes will partly depend on who uses pharmacies and their illnesses.

Methods This was a cross-sectional survey of a stratified random sample of 10 000 adults aged 35 years plus.

Results In the previous month, 59 per cent of respondents had collected a prescription medicine and 40 per cent had purchased an over-the-counter (OTC) medicine from a pharmacy, whereas only 12 per cent had asked for advice. Women were more likely to have obtained medicine or asked for advice (76 per cent), but nearly two-thirds of men had done so (63 per cent). Poor self-rated health was the key factor in obtaining medicine, both on prescription and OTC. Purchasers of OTC medicine were more likely to be younger and from higher socio-economic classes, whereas those who collected prescription medicine were more likely to be older, feel at risk of vascular health problems and non-smokers. Medicines to treat cold and flu symptoms were the most frequently reported purchase type. Only a small number of respondents who asked for advice had not also obtained medicine. Respondents who asked for advice were more likely to have asked about a specific medicine or illness than to have asked for general health advice.

Conclusion Whilst those with poorer health are more likely to visit, a wide range of ages and social classes visit pharmacies each month. This provides an opportunity for public health initiatives to be delivered in pharmacies.

Keywords: community pharmacies, prescription medicines, OTC medicines, advice


   Introduction
TOP
Introduction
Methods
 Outcome measures
 Results
 Discussion
 Acknowledgements
 References
 
Taking medicines is a part of everyday life for many Europeans. Half of the adult respondents reported using medicine in the previous 2 weeks, and more state that they use prescription medicines than over-the-counter (OTC) medicines.1,2 In the UK most people obtain both their prescription and OTC medicines from community pharmacies. Such businesses are widely used by the general public; more than 85 per cent reporting using a pharmacy in 1 year.3,4 Obtaining prescription medicines is the main reported reason for using a community pharmacy, followed by the purchase of OTC medicines.3 By contrast, only a few people reported that their reason for using the pharmacy was to seek advice and fewer than one-third of the population reported that they have received advice in a community pharmacy recently.3,5

Against this background, however, community pharmacy in the UK is changing rapidly as many medicines are moved from prescription-only to OTC purchases, and pharmacists are expected to take on wider roles and responsibilities, including advice about general health promotion as well as about medication.6,7 The initial impact of such changes on the general population will partly depend on the characteristics of those who seek advice or who wish to purchase an OTC product and on the nature of the illnesses they wish to treat or prevent.

We have therefore investigated, in a population-based survey of the use of pharmacies, the pattern of symptoms for which OTC medicines are purchased and the advice sought. We have compared socio-demographic and health variables for those obtaining prescription medicines, buying OTC medicines and seeking advice.


   Methods
TOP
Introduction
 Methods
Outcome measures
 Results
 Discussion
 Acknowledgements
 References
 
The design was a postal survey in a stratified random sample of 10 000 adults aged 35 and over in North Staffordshire. The pharmacy questions formed one section of this questionnaire, the main purpose of which was to determine the use of aspirin in the general population. Ethical approval for the study was obtained from the Local Research Ethics Committee.

The methods have been previously described in a paper that reported on the aspirin results.8 The study population was a random sample of 10 000 adults from the North Staffordshire population, stratified by Primary Care Organization. In brief, 2000 adults were randomly selected in the year 2000 from the registers of each of the five Primary Care Organizations within the North Staffordshire Health Authority area, and mailed self-completion questionnaires. These included a section asking about use of pharmacies and purchase of OTC medicines during the previous month. Sample size was predefined according to the requirements of the aspirin study.8


   Outcome measures
TOP
Introduction
 Methods
 Outcome measures
Results
 Discussion
 Acknowledgements
 References
 
The respondents were asked if they had purchased an OTC medicine in the previous month and, if so, to select conditions for which they had purchased medicine from a list of nine, with the option of ‘other’ (the conditions were: headache, migraine, cold or flu symptoms, cough, indigestion or upset stomach, diarrhoea, skin problems (e.g. eczema), allergies or rash, problems sleeping). They were also asked if they had been to a pharmacy in the previous month for the following reasons: to ask for general health advice (e.g. giving up smoking); to collect a prescription medicine for yourself or someone else; to ask for advice about medicines (e.g. side-effects) for yourself or someone else; or to ask for advice about a specific illness for yourself or someone else.

Potential risk factors
We investigated three categories of risk factors – health, sociodemographic and practical. The first category about peoples’ general health and health awareness comprised four areas. Respondents were asked to rate their current health (on a 4-point categorical scale from excellent to poor). Respondents were also asked if they felt at risk of heart attack, angina, other heart trouble, stroke or mini stroke. Those who replied yes to any of these options were defined as having a ‘perceived vascular risk’. This ‘perceived vascular risk’ was the only potential source of anxiety information in the questionnaire and we used this to provide a proxy measure for health anxiety. They were also asked about physical exercise. To identify the more active respondents we defined those reporting exercise at least once a week in the last month as taking physical exercise. Respondents were also asked if they had smoked regularly in the previous year – those who reported they had were categorized as smokers. For the second category of sociodemographic factor, respondents were asked their date of birth, gender, and current or previous occupation. Social class was categorized into three groups (1 – managerial/professional, 2 – intermediate, 3 – routine/manual) according to their own, or their spouse or partner’s, current or last occupation using the UK National Statistics Socio-economic Classification.9 The third category was a practical question – whether they paid for their prescriptions.

Data analysis
Data analysis consisted of simple frequencies of medicines obtained and advice sought. The prevalences of obtaining prescription medicine, purchasing OTC medicine and advice sought were adjusted to the age and gender of the original mailing sample by direct standardization. Non-response was investigated by comparing percentage estimates of prescription collection, OTC medicine purchase and advice sought between responders to the first, second and third mailings, on the basis that those who deferred their reply until the later mailings might be closer in their characteristics to non-responders. Associations between demographic variables and obtaining prescription medicine, OTC medicine purchase and advice sought were investigated using the {chi}2-test, and estimates of association were summarized by odds ratios. Binary logistic regression was used for all multivariate analyses. The variable ‘pay for prescription’ was omitted from the multivariate analysis because it was so highly correlated with age group (Spearman’s rank correlation coefficient, rs=0.7). Statistical significance is given at the 5 per cent level (two-tailed). Statistical analysis was carried out using SPSS for Windows version 11.0.


   Results
TOP
Introduction
 Methods
 Outcome measures
 Results
Discussion
 Acknowledgements
 References
 
After two reminder mailings 6322 completed questionnaires were received, a response of 67 per cent after excluding deaths and departures. Response to mailings 1, 2 and 3 were 3638, 1100 and 1584, respectively. Non-responders were more likely to be male, younger and live in less affluent areas compared with responders.8 Fifty-six per cent (n=3520) of responders were women and the median age was 56 years (range 35–99 years). Categorization of household social class placed 30 per cent of respondents in class 1 (managerial/professional occupations), 23 per cent in class 2 (intermediate occupations) and 47 per cent in class 3 (routine/manual occupations).

In total, 70 per cent of all responders had visited a pharmacy to obtain medicine or ask for advice in the previous month. Women (76 per cent) were more likely to have done so than men (63 per cent) and there was some modest variation with age ranging from 67 per cent of 35–44-year-olds to 75 per cent of 65–74-year-olds.

Obtaining prescription medicines from pharmacies
Collecting prescriptions was the main reason to use a pharmacy; 3579 (58.7 per cent; 95 per cent CI 57.5–59.9) respondents reported collecting prescription medicine from a pharmacy in the previous month for themselves or someone else (age-gender standardized=57.5 per cent). Prescription collection was most strongly associated with poorer self-rated health (Table 1). Women, older people and those in the routine/manual social class were more likely to collect a prescription medicine, as were those with a perceived vascular risk and those who did not take physical exercise. After statistical adjustment for the other variables in the multivariate analysis, there was no longer an association between prescription collection and social class or physical exercise, and smokers were less likely to collect a prescription medicine, so that poor self-rated health, perceived vascular risk, female gender, and older age were independently associated with collection of a prescription medicine. For respondents aged under 60 years, those who did not pay prescription charges were more than twice as likely to collect a prescription medicine than those who were liable for the charges (ORunadjusted=2.83; 95 per cent CI 2.3–3.4).


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  		Table 1 Prescription collection and associations with demographic and health variables

 

Purchasing OTC medicines from pharmacies
Two-fifths (n=2445, 39.9 per cent; 95 per cent CI 38.7–41.1) of respondents reported buying an OTC medicine from a pharmacy in the previous month (age-gender standardized=39.6 per cent). Women, younger people and those in the managerial/professional social class group were more likely to have purchased an OTC medicine (Table 2), as were those reporting ‘good’ or ‘fair’ general health and those with a perceived vascular risk. No association was found between OTC medicine purchase and physical exercise or smoking. Similar patterns of association were evident after statistical adjustment for the other variables in the multivariate analysis, so that poorer self-rated health, perceived vascular risk, female gender, younger age and higher social class were independently associated with OTC purchase. Respondents aged under 60 years who were exempt from prescription charges were less likely to buy OTC medicine compared with those who would have to pay (ORunadjusted=0.75; 95 per cent CI 0.6–0.9).


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  		Table 2 Over-the-counter medicine purchase and associations with demographic and health variables

 

Respondents who purchased OTC medicine were also more likely to collect prescription medicines than those who had not done so, before and after adjusting for health and demographic characteristics (Table 3). This association was evident across all age–sex strata (data not shown).


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  		Table 3 Association between purchase of OTC medicine and prescription collection

 


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  		Table 4 Associations between purchase of specific OTC medication and demographic and health variables

 
Cold or flu symptoms were the most commonly reported reasons for purchasing an OTC medicine, followed by non-migraine headache and cough (Table 4). Younger people were more likely to buy medicine for cold or flu symptoms, cough, headache and migraine compared with older people, whereas purchases for indigestion, skin problems, sleep problems and allergies showed no clear pattern with age. Women were more likely than men to purchase medicines for all specified symptoms other than skin problems, particularly for sleep problems, headache and migraine. The association between medicine purchase and poorer self-rated health was strongest in purchases for sleep problems, diarrhoea, cough and indigestion.

Asking for advice in pharmacies
A much smaller number of respondents (687, 11.9 per cent; 95 per cent CI 11.1–12.8) recalled asking for advice about general health, medicine or specific illness in a pharmacy during the previous month for themselves or someone else (age-gender standardized=11.7 per cent). Only 39 (6 per cent) of this advice-seeking group did not report also collecting a prescription or buying an OTC medicine during that time. Respondents were most likely to have asked for advice about a specific medicine (n=447), followed by advice about a specific illness (n=371) and general health advice (n=118). Respondents who perceived their health to be poorer, smokers, those with a perceived vascular risk and women were more likely to ask advice (Table 5). Statistical adjustment in a multivariate analysis produced a similar pattern of associations, so that poorer self-rated health, perceived vascular risk, female gender and smoking were independently associated with seeking advice from the pharmacist. However, the associations with perceived health measures were reduced due to their colinearity with the obtaining of medicine (either prescription or OTC).


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  		Table 5 Advice sought about general health, medicines or specific illness in pharmacies and associations with demographic and health variables

 

Investigation of generalizability
Early survey responders were more likely to report collecting a prescription and OTC medicine purchase compared with later responders, but the prevalence of asking for advice was similar across the three mailings. The prevalences for mailings 1, 2 and 3 were: prescription medicine collection – 61, 58 and 55 per cent ({chi}2trend=13.5, p<0.001); OTC medicine purchase – 42, 38 and 36 per cent ({chi}2trend=14.6, p<0.001); and asking for advice – 12, 13 and 11 per cent ({chi}2trend=1.7, p=0.198).


   Discussion
TOP
Introduction
 Methods
 Outcome measures
 Results
 Discussion
Acknowledgements
 References
 
Our survey provides new evidence about the conditions for which people seek treatment or advice from community pharmacies and about the characteristics of people who visit community pharmacies.

Our finding that 70 per cent of respondents had used a community pharmacy to obtain medicine or ask for advice in the previous month was similar to a street survey in Northern Ireland, which found that 68 per cent of the public reported using a pharmacy at least once a month.10 Our study reflected the findings of other studies in that women were more likely to use pharmacies compared with men and use of pharmacies increases with increasing age but declines in the oldest age group.3,11

Collection of prescription medicines from a pharmacy was reported by almost 60 per cent of respondents and 40 per cent had bought an OTC medicine in the previous month for themselves or someone else. Health status appears to be the determining factor in obtaining medicines. After adjustment for other variables, fair and poor self-rated health remained the strongest association with obtaining both prescription and OTC medicines. Our findings that OTC medicines were more likely to be purchased by younger people and those in a higher social class reflect those of previous UK studies of OTC medicine purchase and use.3,12 For those aged under 60 years, prescription charge liability affects how respondents obtained medicines, with those exempt from charges more likely to collect prescription medicine and less likely to purchase an OTC medicine compared with those who are liable for charges. The finding that smokers were less likely to collect prescriptions was unexpected as we would expect smokers to have more illness compared with non-smokers. However, the effect size was small and a possible explanation for this could be that smokers are worried they will be lectured about their smoking when they visit their GP and so attend less often.

Our study has provided information, in a population survey, about the symptoms and illnesses for which people purchase OTC medicines. The profile of medicine purchases – high levels of cough and cold purchases and low levels of allergy purchase – is likely to reflect the study month (March). At another time of the year, a different pattern might have resulted. For some symptoms, the characteristics associated with OTC purchasing were those that are associated with higher prevalence of the symptom in population studies. For example, women are more likely than men to report both headache and migraine, and there is a sharp decline in reported prevalence with increasing age – patterns mirrored in our OTC figures (Table 4).13,14 Sleep problems are commoner in women15 and OTC purchasing of sleep medications was higher in women in our study. Older people were less likely to purchase OTC medications than younger people, which may reflect the availability of free prescriptions or this group being poorer compared with other age groups or being less reliant on medication for common symptoms at that age.

Even at this general population level, there were some specific links between responder characteristics and OTC purchasing – smokers were more likely to buy cough remedies, exercisers to buy skin treatments. However, neither smoking nor exercising were linked with generally higher or lower purchasing across other categories, suggesting that healthy or unhealthy behaviours do not influence OTC purchase. By contrast there was evidence that perceptions of health are linked with OTC purchase. The distinction between ‘excellent’ and ‘good’ self-rated health was sufficient to distinguish a higher prevalence of OTC purchase in the ‘good’ compared with the ‘excellent’ across a range of different symptom categories; and even the presence of a specific ‘perception of vascular risk’ was associated with higher prevalence of OTC purchase for a range of common symptoms.

Our study also examined the extent to which pharmacies are used as a source of advice. The conclusion from our results is that only a small minority consciously do so, with advice principally related to medicines and with few using pharmacies as a source of general health advice. Women were more likely to ask for advice than men, confirming findings from a study in Wales where additionally they found a high level of advice sought on behalf of someone else (30 per cent).16 The low level of advice-seeking suggests that community pharmacies are not being used to their full potential. This has been emphasized in the study by Tully and Temple3 where around half of those obtaining medicines reported they had received advice on prescription or OTC medicines, whilst one in six respondents had wanted advice but did not receive it. Other studies suggest that there is a higher level of advice given out by pharmacists and counter assistants, with around one-third of customers receiving unsolicited advice about their medicines or general health.17,18 However, these studies also showed that people expected advice to be offered more often than it was.

Our study was limited in that we had no data on younger adults (<35 years) as it was part of a larger survey of aspirin use and vascular problems.8 By using data from such a health survey the respondents may also have been biased in that those who completed the questionnaire were more interested in their health and their cardiac health in particular. Furthermore, we did not determine how much of the pharmacy use was for the respondents themselves or for someone else. Previous studies suggest around one-third of community pharmacy contacts are on behalf of another person.10,11,19 The survey had a reasonable response (67 per cent) and age–gender standardization to the original sample did not alter prevalence figures for collecting prescriptions, purchasing OTC medicines and asking for advice. However, the decline in prevalence of prescription collection and OTC medicine purchase across the three mailing responses suggest that non-responders may have lower prevalences of prescription collection and OTC medicine purchase than responders – so the figures presented are probably a slight overestimate of the true prevalences. Our study is also limited in that we only sampled in one health authority and the use of pharmacies may be different in other areas with different population structures. North Staffordshire has a lower proportion of the population from non-white ethnic groups compared with England and Wales, 3.4 per cent compared with 8.7 per cent, and has more people in routine and manual work and less in managerial and professional work compared with the whole of England and Wales.20

Community pharmacy is changing as increasing numbers of medicines are reclassified from prescription-only to pharmacy medicines, and pharmacists are encouraged to take on more roles and responsibilities in looking after patients’ medicines, particularly for those with long-term conditions. The Crown Report21 proposed the widening of prescribing authority to pharmacists in specific clinical areas where this would benefit patient care and safety, and the first supplementary prescribers have now qualified.22 The new contract for community pharmacy23 will also affect community pharmacy with a change in emphasis from prescription numbers to services provided by community pharmacies. Among the essential services that all pharmacies must provide are support for self-care and promotion of healthy lifestyles. The new contract also provides opportunities for pharmacists to have a larger clinical role with the introduction of an advanced level of service to include medication use reviews. These changes are likely to increase the public’s awareness and confidence in pharmacy services. However, the low levels of advice-seeking shown in this study suggest that the British public may need a period of adjustment to a new view of their health professional in the high street. Studies show that general practitioners are the health professional who would be the first choice for general health advice for the majority of the public18,24 and consumers have expressed concerns at pharmacists taking on extended roles.12,18,25,26 At the same time there is also support for the move to more OTC availability.26

Pharmacies are an ideal place to target health promotion and this is reflected in the new contract for community pharmacies23 where promotion of healthy lifestyles is an essential service. Our study suggests that, whilst those who consider themselves to be in excellent health are less likely to visit the pharmacist for OTC remedies than the rest of the adult population, those who do visit represent a wide range of health and social states. Although more women visit, more than half of male respondents to our study had visited a pharmacy during 1 month. Our proxy measure of health anxiety (perceived vascular risk) suggests that many OTC purchasers have the potential to benefit from advice and reassurance about their health. Even smokers, although less likely to collect a prescription, were more likely than non-smokers to ask for advice. However, if the pharmacy is to become an increasingly important arena for health advice and promotion to the general public, it should be borne in mind that we found some evidence also of inequalities in use. After adjusting for levels of ill health, although there were no social class differences in the collection of prescription medicines, those in the lowest social classes were not purchasing OTC medicines to the same extent as those in higher social classes.


   Acknowledgements
TOP
Introduction
 Methods
 Outcome measures
 Results
 Discussion
 Acknowledgements
References
 
We would like to thank Gazala Akram who wrote the pharmacy questions for this survey. We would like to thank the North Staffordshire Health Authority and Joan Bentley for their assistance with the study. We would also like to thank the network team and administrative staff from Primary Care Sciences Research Centre, Keele University for their help and support with the study. The study was funded by North Staffordshire Health Authority.


  
TOP
Introduction
 Methods
 Outcome measures
 Results
 Discussion
 Acknowledgements
 References
 
Primary Care Sciences Research Centre, Keele University, Keele, Staffordshire ST5 5BG.


   References
TOP
Introduction
 Methods
 Outcome measures
 Results
 Discussion
 Acknowledgements
 References
 

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