To explore how individual pharmacies manage to engage customers in medicine dialogues, the work of Stevenson et al., which exactly describes five types of interaction scenarios regarding pharmacies’ engagement of customers (if engagement was attempted by staff and what was the customers’ response to this attempt), was used as a theoretical basis to construct coding schemes for observations in Danish community pharmacies.9

Using an operationalized form of Stevenson’s categories, we conducted a pilot study to assess the need to modify the framework for our study. Hence, two times three hours observation was conducted in one randomly chosen pharmacy. Subsequently, it was decided to add a new category that represented customers who purchased a specific product without the staff or the customer trying to initiate a dialogue about the medicine. Further, we merged the two categories of ‘standardized dialogues’ and ‘other dialogues in which the staff encouraged participation and the customer cooperated’ as we in practice found it difficult to distinguish between these.

The final types of staff-customers interactions were:

1. - The customer wants a particular product and does not want to engage in any discussion.

2. - The customer wants advice, and the staff member cooperates.

3. - The staff member encourages participation, and the customer cooperates.

4. - The staff member encourages participation, and the customer does not cooperate (the customer explicitly indicates he does not find counseling relevant).

5. - The customer wants a particular product, and neither the staff member nor the customer encourages participation.

The ‘success rate’ was defined as the sum of encounters where “the customer wants advice, and the staff member cooperates” and “the staff member encourages participation, and the customer cooperates”; both are examples of interactions which resulted in some dialogue about medicine. Similarly the ‘failure rate’ was calculated, defined as the sum of encounters of “the customer wants a particular product and does not want to engage in any discussion” and “the staff member encourages participation, and the customer does not cooperate”; both options are examples of interactions where the customer refused a medicine dialogue.

The type of purchased medicine was also registered, as this aspect has been found important for the customer’s response, and divided into the following categories:6

1. - Purchase of a specific over-the-counter (OTC) product (e.g., asking for a specific OTC product)

2. - Purchase of an unspecified OTC medicine (e.g., wanting something for headache)

3. - Purchase of a first time prescription medicine

4. - Purchase of a refill prescription medicine

5. - Purchase of both OTC and prescription medicine

Overt non-participant structured observations were deemed the most appropriate method. A short observation distance was required in the pharmacies (1-2 meters) for the researcher to register the necessary information. A total of 100 encounters were observed over 1-2 days in each pharmacy of customers purchasing either prescription and/ or OTC medicine. We included both pharmacists and pharmacy technicians because they are both engaged in counter counseling in Denmark. Observations were conducted randomly across different pharmacy counters. When more than one customer was being served, the single observer shifted systematically between customers and staff members at different counters in order to ensure representativity of observations. Observations were conducted during busy and quiet times in the pharmacy. Customers were orally informed about the study by staff, and no customers declined participation. The observations were conducted in November and December 2011.

A purposive sampling frame was set to compare communication of individual pharmacies. To avoid selection bias, the sampling frame included small and large pharmacies (defined by numbers of prescriptions per day) as well as pharmacies located in the capital either centrally or marginally; and pharmacies in provincial and rural areas as earlier studies have suggested that these parameters influence counseling.8,10 Rural areas were defined as pharmacies located in cities with less than 10.000 inhabitants and provincial as pharmacies located in cities with more than 10.000 inhabitants.

Five different pharmacies that met the sampling criteria were sent a letter of invitation and received a follow-up telephone call. Three pharmacies agreed to participate, and two declined. Two additional pharmacies were contacted to obtain a relatively even representation of pharmacies located both within the capital as well as provincial/ rural areas, and both agreed to participate, see Table 1.

Table 1

Size and location of pharmacy

To explore the variation of pharmacies’ engagement of customers, all numerical data were entered into Microsoft Excel. The percentage of ‘success rate’ and ‘failure rate’ for each pharmacy were calculated. The percentages were calculated in relation to each other i.e. to the encounters where either customer or staff displayed a particular interest or disinterest in a medicine dialogue, in order to understand the difference between succeeding and failing (in contrast to none of the parties trying to initiate a dialogue at all). ‘Success rate’ and ‘failure rate’ variation across pharmacies relating to the type of purchased medicine were then calculated using descriptive statistics. The statistical significance of observed differences across the five included pharmacies was analyzed using odds ratios (OR) to measure the probability of successful engagement of customers (event) in relation to type of pharmacy (exposure). The ORs given below thus express the differences in achievement of successful counseling according to pharmacy using the highest scoring pharmacy as control and the remaining four pharmacies as cases. A stringent p-value of ≤ 0.05 denoted statistical significance, and 95% confidence intervals are given for each OR. As the purpose of the study was to detect types of differences between individual pharmacies in their communication practices rather than linking such behavior to specific factors such as size and location, these parameters were not directly included in the statistical analysis.

According to the Danish Data Protection Agency ethical permission for this study was not required because no personal data from the customers were registered.

The average ‘success rate’, i.e., obtaining medication dialogues across all five types of medication purchases, varied considerably between the five pharmacies and ranged from 54% (pharmacy 1) to 82% (pharmacy 3); see Table 2. Notably and unexpectedly (not being the purpose of the study), the two pharmacies with the absolute highest ‘success rates’ (pharmacy 2 (76%) and pharmacy 3 (82%)) were also the pharmacies that served the most customers per day; see table 1 and 2. Very few variations between the pharmacies were identified for customers purchasing first time prescription medicine, and unspecified OTC medicine. On the contrary, large differences were observed for purchase of a specific OTC product and refill prescription medicine. The ‘success rate’ of specified OTC medicine varied from 45% (pharmacy 1) to 84% (pharmacy 3), and the rate of refill prescription medicine from 23% (pharmacy 5) to 57% (pharmacy 2 and 3).

Table 2

Distribution of success rates, failure rates and percentages of ‘encounters where neither staff nor customer encourages dialogue’ distributed by type of purchased medicine.

The difference in average ‘success rate’ between pharmacies was significant when testing the highest scoring pharmacy (pharmacy 3) against the other pharmacies, see Table 3. Pharmacy 3 showed significant better communication pattern skills compared to pharmacy 1 (OR=3.8807 [95% CI 2.04: 7.39] and 5 (OR= 2.6755 [95%CI 1.39: 5.14] but not compared to pharmacy 2 (OR= 1.4386 [95% CI 0.72: 2.86] and 4 (OR=1.7716 [95%CI 0.91: 3.47].

Table 3

Differences between average ‘success rate’/ ‘failure rate’ between pharmacies. Pharmacy 3 used as control.

The percentage of encounters where neither the staff member nor the customer tried to initiate a dialogue varied from 12% (pharmacy 1) to 38% (pharmacy 2), see Table 2. The two pharmacies with the highest ‘success rate’ (pharmacy 2 and 3) were the pharmacies where staff most frequently abstained from attempting to engage the customer in a medication dialogue (pharmacy 2 (38%) and pharmacy 3 (33%)). This difference could not only be explained by pharmacies avoiding engaging refill prescription customers. Pharmacy 2 asked at least as many refill customers as pharmacy 4 (pharmacy 2 (23 customers) and pharmacy 4 (21 customers)). Pharmacy 3 did, however, have the lowest identified number of refill customers whom they tried to encourage to participate in a medication dialogue (No=14). Notably, pharmacy 1 had the lowest average ‘success rate’ (54%) and invited nearly all refill prescription customers to engage in medication dialogues (No=33/34).

Significant variations in pharmacies’ engagement of customers were observed with a two to four-fold higher probability of achieving a successful medication dialogue comparing the highest scoring pharmacy (pharmacy 3) to pharmacy 1 and 5 respectively. No significant differences were observed for the two remaining pharmacies but the results nevertheless confirmed the assumption that communication practices of individual pharmacies vary. Although the study is limited by its sample size and observational design, this variation should be taken into consideration when investigating and trying to improve these practices as the reasons for these differences are still unclear.

As the study showed that variation between pharmacies regards only specific customer groups, the representation of such groups and possible differences between pharmacies in dealing with them ought to be studied further. Similarly, the specific type of purchased refill prescription medicine could play a role; other studies have showed that staff counseling behavior depended on the type of prescription medicine purchased.7,8

The results hinted a possible link between size of pharmacy and ‘success rate’ – however the study was too small and inadequately designed to made distinct conclusions in this regard. Besides, the Hawthorne effect might have generated too positive results regarding the number of customers that staff tried to engage in dialogues.11

A possible link to the size of the pharmacy was identified. Tully et al. in contrast concluded that the number of prescriptions per day did not influence pharmacy counseling.7 Vainio et al. showed that large pharmacies located in commercial centers informed customers more often about the use of medicine than small, however also found that these pharmacies inform more often compared to rural pharmacies.8 This contrasts the findings of Xu et al. who found that rural pharmacies provided more counseling than urban located pharmacies and partly to Ranelli et al. who found that pharmacists in small cities initiated more medicine dialogues.12,13

Puspitasari showed that metropolitan pharmacies gave more verbal information, and rural pharmacies provided more written information.10 Hence, the literature regarding the influence of pharmacy size and location is inconclusive perhaps due to the reason that there are relatively few studies in the area which often explores different practice aspects. However, the possibility that size and location are not primer influential factors of counseling, but rather the culture of the pharmacy including the leadership style of the owner, also exist.14,15

The findings indicated that pharmacies with less pharmacy staff invitations to refill prescription customers had higher ‘success rates’. Abstaining from encouraging refill customers in dialogues could either be considered to be a conservative or a selective communication strategy. Pharmacy 2 and 4 had similar scores regarding the ratio of refill prescription customers that staff abstained from encouragement however the ‘success rate’ differed considerably. This particular result indicates that quality aspects also play a role and that these differ between the pharmacies. According to the literature, future studies in this regard might benefit from studying staff follow-up techniques; a Scottish study found that staff asked questions but failed to tailor their counseling accordingly.16 Studying the interaction at the counter as a ritual has also been recommended.17