Accepted Manuscript Self-medication and non-prescription drug counseling: Illustrating profession uncertainty within Turkish pharmacy practice Afonso Miguel Cavaco, Bilge Sozen Sahne, Elif Ulutas Deniz, Selen Yeğenoğlu PII:

S1551-7411(17)30177-8

DOI:

10.1016/j.sapharm.2017.09.006

Reference:

RSAP 957

To appear in:

Research in Social & Administrative Pharmacy

Received Date: 1 March 2017 Revised Date:

14 July 2017

Accepted Date: 5 September 2017

Please cite this article as: Cavaco AM, Sahne BS, Deniz EU, Yeğenoğlu S, Self-medication and nonprescription drug counseling: Illustrating profession uncertainty within Turkish pharmacy practice, Research in Social & Administrative Pharmacy (2017), doi: 10.1016/j.sapharm.2017.09.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT TITLE Self-medication

and

non-prescription

drug

counseling:

illustrating

profession

uncertainty within Turkish pharmacy practice.

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RUNNING TITLE Turkish pharmacists’ OTCs and self-medication practice uncertainties.

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Afonso Miguel Cavacoa (corresponding author), Associate Professor of Social Pharmacy, Faculty of Pharmacy, Av. Prof. Gama Pinto, 1649-003 Lisbon, Portugal.

[email protected]

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+351 217 946 456

Bilge Sozen Sahneb, Assistant Professor of Pharmacy Management, Faculty of Pharmacy, 06100 Sihhiye, Ankara, Turkey. [email protected]

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+903 123 054 226

Elif Ulutas Denizb, Research Assistant of Pharmacy Management, Faculty of Pharmacy, 06100 Sihhiye, Ankara, Turkey.

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[email protected] +903 123 054 226

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Selen Yeğenoğlub, Full Professor of Pharmacy Management, Faculty of Pharmacy, 06100 Sihhiye, Ankara, Turkey. [email protected] +903 123 052 349 a

University of Lisbon

b

Hacettepe University

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ABSTRACT Background. Recommending effective minor ailment treatments and using non-prescription or over-the-counter (OTC) medicines is a pharmacist’s duty. Although common in most European

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countries, self-medication counseling practices may differ from country to country.

Objectives. This study explored Turkish community pharmacists’ attitudes concerning the present self-medication market, professional responsibilities toward patients’ self-care, and the

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usefulness of e-learning for patients’ counseling education.

Methods. The study was comprised of three phases: initially, a document content analysis

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searched for relevant OTC regulatory and/or practice frameworks; secondly, qualitative individual interviews on self-medication with purposively selected Turkish community pharmacists were performed; finally, a focus group with practitioners and continuing education experts was conducted to deepen previous results. A thematic data analysis, based on the attitudinal theory, was conducted, supported by MAXQDA v12 software.

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Results. Sixteen documental sources allowed the extraction of three initial main themes: selfmedication, classification of medicines and pharmacists’ role. Individual interviews outlined four themes that informed the focus group discussion, which produced four new themes. Themes and their codes reflected dissimilar practitioners’ cognitions towards OTCs, OTC usage and self-

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medication, particularly if compared to other European conceptualizations. Contradictory feelings towards the value of OTCs for professional development, e.g., patient counseling

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influenced by profit-based expectations, were identified.

Conclusion. Turkish community pharmacists and their minor ailments treatment competences have yet to thrive as a relevant professional intervention. There are risks of missing the best pharmacy practice standards, thus losing their contribution to rational self-care. Besides weakening the societal recognition of the profession to help individuals’ everyday health decisions and well-being, there might be a reduced active role in public health.

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Keywords: self-medication; non-prescription medicines; pharmaceutical services; community

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pharmacy; Turkey

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INTRODUCTION Self-care and self-medication: the Turkish context It is widely accepted that in most countries, especially European countries, healthcare policies promote citizens’ empowerment and responsibility concerning their own health and well-being.1

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This relies on self-care, which was defined by the World Health Organization (WHO) as “what people do for themselves to establish and maintain health, prevent and deal with illness.” Selfmedication, i.e., the administration of any medicine without a medical prescription, is an important part of self-care.2–4

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Different European organizations, such as the Association Européenne des Spécialités Pharmaceutiques Grand Public (AESGP) and the European Union’s (EU) physician representatives, have jointly defined the scope for responsible self-medication, recognizing a

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number of reported advantages and risks.5,6 General benefits are an increase in patients’ relief, better use of professionals’ clinical skills and the contribution towards reducing prescribed drug costs associated with publicly funded health programs.5,6 AESGP market data confirms its importance: one out of two packages of medicines sold in Europe is a non-prescription product. These products are generally called over-the-counter (OTC) medicines, which have been

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continuously expanding in line with the long-standing reclassification of pharmacological active ingredients in most EU countries, i.e., there is a steady switch of legal status from prescriptiononly medicines (POM) to non-prescription ones.7,8 In Turkey, as well as most countries, OTCs are medicines licensed at national pharmaceutical

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markets to be purchased without a medical prescription, usually from community pharmacies.9 The Turkish national pharmaceutical market, as with the EU, comprises a list of approved

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medicines with both POM and OTC status.10–12 OTCs have had growing sales in recent years, mainly as a result of an increasing public awareness about health as well as from pharmaceutical companies’ promotion.13,14 However, only 3% of all brands correspond to medicines registered as an OTC in Turkey.

A screening of the currently available OTCs in Turkey disclosed products with active ingredients that are mainly nutritional or classified in the EU as food supplements, alongside certain chemical compounds for external use (e.g., skin disinfection). Active pharmaceutical substances, long-standing as OTCs in most EU countries (AESGP data), are not approved as such in Turkey. Conversely, several medicines approved in Turkey as POM are dispensed without a previous

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medical prescription in Turkish community pharmacies.15,16 Moreover, according to the present Turkish law, all products registered as medicines, including OTCs, are to be sold exclusively in

Turkish pharmacy practice and self-medication

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community pharmacies.17,18

Worldwide, community pharmacists are considered some of the most accessible healthcare professionals.19 They can recommend not only medicinal products but also provide nonpharmaceutical (e.g., lifestyle) counseling,20 while maintaining an emphasis on overall patient

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care.21 This professional responsibility is relevant knowing that consumers still use medicines without being aware of the benefits and risks or treatment options, e.g., frequency and/or

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duration.22,23 This patient counseling role involving clinical activities, such as advice giving on minor ailments, including physician referral when needed, has been clearly accepted as advantageous in many countries.24–26

In Turkey, the number of community pharmacists per 100,000 inhabitants is now 33.1, and this figure is close to the EU average (31).27–30 Turkish pharmaceutical education follows the general competencies framework in place for most EU practitioners,31 including pharmacists’ advisory

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role in minor ailments treatment. In fact, the relevance of responsible self-medication has been recognized by Turkish pharmacists2,32–34 as well as by the public and patients.35,36 This is also a general trend in neighboring Middle Eastern countries, although to a varying degree.22,37,38 Nonetheless, patient counseling activities rely on technical aspects of the pharmacists’

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consultation, i.e., the ability to recommend an effective OTC treatment.39 Self-medication protocols and OTC clinical guidelines have been regarded as preferential tools to help with this process.40 Although protocols may be considered basic or limited according to recent

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research,41,42 they provide structure to rational clinical decisions and OTC medicines use. In Turkey, where professionals work in a less organized OTC market,13,25,43 means to increase practice quality and standardization seem to be relevant.44

Effective self-medication counseling Patient counseling tools and activities, including the use of OTC protocols, require adequate communication abilities45 central to the provision of humanistic and individualized healthcare.46 Different methods have been used for communication skills training in pharmaceutical

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education.47 Patient simulation is being used in clinical interview training, and there are encouraging simulation experiences regarding the provision of OTCs and patient counseling for minor ailments.48–50 Virtual environments, created through computer simulation, have also produced positive outcomes in undergraduate communication skills training,51 while the overall

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benefit of using virtual patients in healthcare education has been recognized.52

It is known that the Turkish OTC market does not include many medicines, usually classified as non-prescription, that pharmacists are educated to provide for minor ailments counseling; and self-medication practices exists amongst the Turkish population, particularly for professionals

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working in dense urban areas.53,54 All previous factors, strongly suggest the need to investigate professionals’ attitudes towards non-prescription medicines activities, including further training,

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such as simulation and computer-based learning.

Study objectives

The main objectives of this study were to explore Turkish practitioners’ views and attitudes on self-medication, including the usefulness and feasibility of non-prescription counseling training supported by self-medication protocols as well as communication skills learning through virtual

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patient software. Although relevant, this study did not intend to explore Turkish healthcare and medicines policies, related burdens or outcomes but to investigate community pharmacists’

METHODS

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positions on the present self-medication system and educational solutions.

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The study followed an exploratory qualitative design, using a threefold methodology as described:

1. An initial documental search and analysis aimed to collect and integrate information on the legal and professional framework of the present Turkish pharmaceutical practice, including education issues related to non-prescription medicines. 2. An intermediate research phase with Turkish practicing pharmacists gaining insights into OTC-related topics and the role of e-resources for continuous professional development, including computer simulation.

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3. A final phase with Turkish pharmacists responsible for continuous professional education aimed to confirm and provide additional interpretation of emerging views and attitudes and to reach, when possible, an informal agreement on how to develop Turkish pharmacists’ role in

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self-medication.

Populations and sampling

The initial documental review included the following general search strategy for all online open access documents:

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(a) Identification of search terms and keywords definition: concepts and synonyms in Turkish (and English), i.e., over-the-counter, OTC, non-prescription, self-medication,

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minor illnesses/ailments, pharmacy counseling, patient consultation and pharmacist– patient communication. These strings were used with the Boolean operator “OR” to search the bibliographic sources described next.

(b) Bibliographic sources: all available Turkish national online resources related to pharmaceutical and OTC markets, comprising of governmental and official Web portals (e.g., laws and bylaws), professional organizations’ websites (e.g., documents from

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regional pharmacy chambers and the National Pharmaceutical Association), international bodies’ websites (e.g., reports by consultancy companies), Turkish academic online databases (e.g., published research papers and doctoral and master’s theses) as well as universities’ and schools’ webpages offering pharmacy degrees (e.g., official syllabi).

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(c) Inclusion of the extracted documents: to confirm the relevance of the extracted documents, the term “Turkey” or “Turkish” was searched as well as other terms related to

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the country, language, culture and/or population. The document search was accomplished independently by two local researchers (BS and EU), and all emerging documents were used for analysis, discussed and agreed on by the research team (AC, SY, BS and EU).

To address the second study phase, community pharmacists from greater Ankara were purposively sampled following a sampling matrix from the Ankara Pharmacists Chamber database and its chairman’s informed decisions. This matrix contributed to increasing participants’ heterogeneity through inclusion criteria balanced by gender, varying years of experience, practice location (i.e., near hospitals, the city center, the outskirts and shopping

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malls) and the number of supporting staff, the last being used as a proxy measure of business flow. Interviewees were contacted by phone and visited in their pharmacies. Data saturation, or the redundancy rule, was used to achieve an adequate sample size.55–57 In qualitative research, the number of participants depends on the study purpose, which in the present case, the thematic

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analytical approach and the searching for commonalities rather than uniqueness or comparisons, anticipated a sample size no larger than 20.56,57

In the final study phase, the participants targeted were rich-information cases, actively involved with continuing professional education and local policy-making regarding community

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pharmacists’ counseling. The inclusion criteria comprised of all pharmacists belonging to the Lifelong Learning Commission of the Ankara Chamber of Pharmacists, who are professionals

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particularly dedicated to continuous education development.

DATA COLLECTION AND ANALYSIS

The initial study phase followed the documentary analysis as proposed by Bowen,58 searching for relevant legal and/or practice frameworks on OTCs and/or self-medication through content analysis, i.e., an objective systematization of self-medication and OTC-related concepts without

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any quantification. This was accomplished by the same two Turkish team members (BS and EU), providing the basis to develop the individual interview topic guide, which was designed to capture emerging ideas as well as explore the level of acceptance regarding concepts and resources, such as computer practice simulation.

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The second phase of the study used a semi-structured interview schedule, which also included previous work developed by the local members of the research team.19,26,59 The schedule

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comprised of three main domains: general aspects of Turkish community pharmacy practice concerning the role of pharmacists in healthcare; the Turkish OTC market and pharmacists’ intervention in patient counseling; and opinions on communication skills training and the role of computer simulation in Turkish practice (Annex 1). Themes emerging from the individual interviews were subsequently used to choose the topics for the final study phase, a focus group discussion (Annex 2). Individual and focus group interviews were conducted between May and June 2016 in Ankara. All interviews were conducted by the Turkish-speaking researcher (BS) and audiotaped after informed written consent was obtained from all participants. Additional field notes were taken when necessary (by EU). Tapes were transcribed verbatim by one

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researcher (BS), sampled for transcription checking by another research team member (SY), translated by two researchers (BS and SY) and imported into a qualitative data analysis software (MAXQDA v12). Using a qualitative thematic approach, all interviews were coded by a single researcher (BS) in

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an inductive manner based on the attitudinal theory. Attitudes can be defined as the individual's predisposed state of mind regarding the value of the attitude object (a person, place, thing or event), precipitated through a responsive expression of a cognitive, psychomotor/behavioral and affective nature, which in turn influences the individual's thoughts and actions.60 Therefore,

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participants’ accounts were initially sorted according to three possible domains, i.e., their cognitions, behaviors and emotions regarding self-medication and OTC medicines. Codes were

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developed in English with the recurrent ones, as well as other analytic products organized by constant comparison, and compiled into a coding frame. The development of the coding frame and emerging themes was periodically discussed within the research team (AC, SY, BS and EU), ultimately producing an explanatory conceptual diagram (Figure 2). The present study closely followed the research principles described in the checklist of the consolidated criteria for

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reporting qualitative research (COREQ).61

Ethical approval

The research project was approved by The Scientific and Technological Research Council of Turkey (TUBITAK, Program No. 2221-1059B211503110) and received ethical approval (No.

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431-1375) from the Hacettepe University Ethics Board. All research practices at each step were

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respected, from data collection and handling to results dissemination.

RESULTS

Documental analysis

The documental online search retrieved 21 relevant documents, comprising of laws, regulations, mission statements, legislatorial documents, reports, white papers, information notes and other grey literature (see Annex 3). After an initial search for content and relevance, 16 sources were selected for an in-depth analysis, which supported the themes and codes presented in Figure 1 and are discussed next.

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(Figure 1 to be inserted here. Themes and codes from the documental analysis.)

Individual interviews

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The next study phase comprised of individual interviews, followed by a focus group meeting. Twelve individual interviews and one focus group interview with 14 pharmacists were conducted. Basic demographics from both individual and group participants are presented in

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Table 1.

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(Table 1 to be inserted here. Characteristics of the individual and focus group interview’s participants.) Figure 2 presents the themes (A to H) emerging from individual interviews. The first four themes (A to D) emerged from individual interviews and were comprised of a total of eight codes and nine sub-codes, which subsequently informed the focus group schedule. The group meeting produced four new themes (E to H) and eight codes. Individual participants’ accounts are

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presented and discussed below, with participants (P) and their quotations (Q).

(Figure 2 to be inserted here. Themes and codes from individual and focus group interviews.)

A. Behaviors

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When questioned about their self-perception as consulting pharmacists (A1: Q1 and Q2), participants assumed they were capable of responding to patients’ requests, including minor

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ailments and/or OTC products. Relevant daily activities (A2: Q3 and Q4) include dispensing prescriptions.

Q1. “We provide consultations here. We meet the requests of our patients properly.” (P4) Q2. “If you recommend a high-quality OTC, it will be good both for the patient and for us economically...Giving the requested OTC properly is also important in terms of patient care and income.” (P8) Q3. “My main job is to provide the prescribed medicines that doctors recommend.” (P5)

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Q4. “First, I must provide prescription medicines properly. Then, I have to manage my pharmacy.” (P3)

One basic tool for performing daily activities is “good communication”; this was mentioned by

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participants.

Q5. “…Communication is everything for expressing ourselves, to maintain the profession, to be

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trustworthy.” (P6)

B. Emotions

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Participants disclosed emotional comfort and self-confidence in relation to their practice (B1: Q6–Q9). There were other positive emotions (B1: Q9), such as a feeling of mutual trust between professionals and customers.

Q6. “I love this job.” (P2)

Q7. “The pharmacy is where I'm [most] happy after my home.” (P10)

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Q8. “They come in because of my experience, [which works] in our favor.” (P12) Q9. “We know most of our patients from their childhood...They counsel us on most issues because they trust the pharmacy...To be a reliable person is very important.” (P1)

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Negative emotions were also expressed (B2: Q10–Q14), comprising of conflicts between patients and pharmacists as well as individual dissatisfaction. This might also emerge from other

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pharmacies’ service that clients experience.

Q10. “Discussions between our patients and us about financial things are a cause of ethical breakdowns. Also, their [patients’] attitudes are against us when money is involved.” (P1) Q11. “...People think that they know everything. I want to counsel my patients, but they don’t want advice. They always say, “I know, I know.” (P10) Q12. “I’m not satisfied with my profession because I can’t earn money.” (P3) Q13. “...Bureaucratic work is also hard. You are always dealing with banks [and the] Social Security Institution.” (P7)

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Q14. “As we have so many financial problems, we cannot act freely. [With fewer monetary concerns] we could have a chance to counsel our patients properly.” (P11)

C. Cognitions

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Self-medication and OTC conceptualizations (C1: Q15–Q18) were provided by participants. Some of these concepts disclosed a fertile field for discussion, both regarding the nature of OTC substances, actual role in healthcare and regulatory issues.

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Q15. “An OTC is a supplement.” (P3)

Q16. “According to new concepts, [self-medication] is preventive public health. With the

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entrance of OTC products onto the market, the aim is to live without getting sick.” (P4) Q17. “The need to increase the income of a pharmacy encourages many pharmacists to [sell] OTCs…Pharmacists are forced to do something about OTCs. Firstly, it is important for income. Secondly, these kinds of products are extremely important for public health.” (P6) Q18. “They [OTCs] don’t have any standards, and standards from the Ministry of Agriculture are

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not enough.” (P2)

Participants recognized that some limitations on conceptualizing these products might result from their education (C2: Q19 and Q20). This included social skills training, and the advantages

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of experiential learning through simulation (C2: Q21 and Q22).

Q19. “The curriculum of [pharmacists’] education is not enough. I didn’t learn much from the

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school [on self-medication and OTCs].” (P3). Q20. “I don’t think I have enough knowledge about non-prescription products...Even if you participate in vocational [i.e., postgraduate and specialization] trainings, they aren’t sufficient for us.” (P2)

Q21. “Communication education during undergraduate education is very important but inadequate...Establishing dialogue and proper counseling must be the core points of communication education.” (P9) Q22. “You should maybe practice it [communication and counseling] with role-playing...Virtual patients could be a time-saving method.” (P5)

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D. Expectations Individual interviewees expressed the wish for a change in the Turkish OTC market, with an increase in medicines licensed as OTCs (D1: Q23) as well as certain changes in counseling-

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related practice (D1: Q24).

Q23. “The amount of OTCs in the pharmacy must also be increased for public health.” (P1) Q24. “I don’t have OTC requests from my patients, but I want to counsel them about OTCs.”

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(P10).

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Focus group interview

The focus group meeting comprised of all members of the professional development committee from the Ankara Pharmacists Chamber, a group of advanced practitioners directly involved with pharmacists’ continuous education who are all female, and echoed the individual pharmacists’ attitudes towards self-medication, OTC use and pharmaceutical education, including lifelong and vocational learning, e.g., communication skills training.

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Experts were asked to provide their conceptualization of OTCs and self-medication to establish a baseline comparison with individual participants and international definitions. Experts confirmed the view of OTCs mainly as “mild” substances used for prevention (E1: Q25 and Q26), mainly

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justified by cultural and administrative particularities (E2: Q27 and Q28).

Q25. “I believe that OTCs are both supplements and protective [of well-being].” (FG3)

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Q26. “OTC products are beneficial as a supplement, not for treatment…[OTCs are not real medicines since they] must be used under the control of pharmacists and physicians, not on the recommendation of someone else.” (FG6) Q27. “If the degree of culture is lower, then OTC misuse is common.” (FG5) Q28. “In foreign countries, OTC products are commonly used for the flu. But in Turkey, all of these are reimbursed.” (FG10).

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Again, communication skills were expressed as significant for practice (F1 and F2: Q29). This might be improved by continuous (i.e., vocational) education through computer-based training, excluding virtual reality for communication improvement (Q30–Q32).

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Q29. “The main aim of communication is to be able to counsel patients, informing them about medicines. Because we know what happens if they are used incorrectly. It also contains patients’ satisfaction…Because of the economic problems of the community, they [patients] can’t always buy OTCs, but they truly want to know about them.” (FG1)

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Q30. “Vocational training must be obligatory. We can’t complete this with a certificate because of certain legislative issues.” (FG10).

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Q31. “...For becoming more practice oriented, computers can be used…at the beginning of the profession.” (FG8)

Q32. “…E-platforms aren’t useful for teaching communication.” (FG13)

In summary, the main findings are as follows: (a) There might be too few registered OTC medicines available in Turkey; (b) there is a view by pharmacists that OTC medicines are much

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less effective and therefore inferior to prescription medicines; (c) there is little training for pharmacists in dealing with and supporting self-care; (d) there is a tension between physicians and pharmacists, who might see self-medication as a competitive role; and (e) there is little political action by pharmacy bodies to lobby the government towards adopting or enforcing this

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DISCUSSION

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policy.

This study comprised of three main research phases: a documental analysis, individual interviews and a focus group discussion. All contributed to address the study aim, i.e., searching for Turkish community pharmacists’ attitudes towards self-medication and their potential role in providing patient counseling.

Documental analysis 1. Self-medication

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The definition of self-medication was not found in the searched Turkish legislatorial documents. An explanation was found in a report from the Turkish Pharmacists’ Association, stating that “self-medication is the use by patients of non-prescription medicines for symptoms and minor ailments,”62 recognizing minor ailments as potentially hazardous to one’s health, particularly if

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OTC medicines are not available.63 The association between the three concepts is acknowledged,13,64,65 while valuing patients’ autonomy in their well-being. Patients’ empowerment concerning their health is recognized: “It has become widely accepted that selfmedication has an important place in the [Turkish] healthcare system.”66 By recognizing the

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responsibility of individuals for their own health, i.e., patients’ autonomy, professional organizations seem to justify the reduced pharmacists’ counseling in minor ailments. However, it

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is recognized that varying levels of health literacy exist in Turkey and that it is the professional duty of pharmacists to contribute to optimizing drug therapies.

Other entities, such as the Association of Research-Based Pharmaceutical Companies (AIFD), believe in an expansion of this area as a result of preventive healthcare: “As the trend for preventive and protective treatment methods persists, the use of the drugs sold without prescription will continue to rise.”67 This illustrates that OTCs and self-medication are not only

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seen as a treatment option for an existing minor ailment but also as a prophylactic solution; this opinion emerged as a pivotal point in the next study phase. 2. Classification of medicines

Health authorities in Turkey follow an EU equivalent regulatory framework in relation to

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medicines classification, i.e., “Human medicinal products can be divided into two categories: prescription only medicines (POM) and non-prescription medicines (over-the-counter or

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OTC).”10 The status is decided according to EU usual procedures, i.e., “When a marketing authorization is granted, the competent authorities shall specify the classification of the medicinal product (into POM or OTC).”68 OTC medicines are defined as “drugs which can be used without a prescription and to treat minor illnesses for a short term…They can be sold everywhere,

including

pharmacies.”63

Regulations

seem

to

be

contradictory, 69

“…pharmaceuticals are [to be] dispensed only through private pharmacies,”

since

which reinforces

the explicit definition of OTCs as medicinal products recognized as having an equivalent position regarding the EU healthcare market. Turkish legislation also admits statutory switches: “POM can be switched to OTC after required evidence according to the regulations.”12

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Nonetheless, a certain degree of ambiguity in relation to how OTC medicines are conceptualized seems to exist, which is explored in the next study phase. Additionally, the pharmaceutical market evolution (2015 data) comprised of a decrease in the value of POMs and OTCs, with an increase in non-pharmacological health product sales.70 This

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was another topic for individual interviews, concerning a possible devaluation or threat to pharmacists’ counseling role. 3. Pharmacists’ role

The documental analysis also found equivalent expectations to most EU countries regarding

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pharmacists’ role in OTC counseling: “…Most patients respond well to [OTC] treatments; sideeffects are infrequent, and compliance is high…,” and therefore, “…Pharmacists are able to

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make an important contribution to public health.” Pharmacists should establish “communication that considers the sensitivity [i.e., individuality] of many patients,” while being the gatekeepers to the healthcare system, i.e., referring patients to doctors for well-described cases (e.g., firsttime sufferers, pregnancy, repeat attacks, children and more serious symptoms).66 Therefore, communication and clinical skills are additional topics for interviews with professionals.

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Individual interviews A. Behaviors

Participants assumed to be able to respond to clients’ requests. This professional self-perception seems to be permeated with a business orientation, i.e., pharmacists assume a counseling role

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focused on the profits associated with dispensing OTCs. It would be important to determine in the future the clinical qualities of the service provided, i.e., the actual level of intervention

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requested by patients and the level of professional response. Regarding prescription dispensing, this was also infused by a focus on financial management, with a reduced focus on healthcare provision, while considering minor ailments counseling as a less important daily task. Communication skills were in general considered as a central component of the pharmacy profession, following the WHO statement of pharmacists as “communicators.”71 In the context of a strong business orientation, it was not clear how communication skills were conceived to be relevant to practice. Usually, these skills are needed to assure the understanding of patient health and medication needs; here, the primary communication goal might be service management and financial objectives.

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Daily practice of the study participants is based on product dispensing and information provision, the latter perceived as a competitive advantage. This indicates that other pharmacists may not provide essential information routinely, while most practitioners seem to be distant from

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cognitive clinical services or therapy management.

B. Emotions

Some participants demonstrated a strong emotional engagement with daily practice and a feeling of mutual trust between professionals and customers based on long-standing relations, including

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family members. This allows a good opportunity for pharmacists to provide structured counseling on minor ailments as well as therapy follow-ups. Essentially, patient loyalty is an

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important prerequisite for an advanced level of practice and pharmaceutical care.46,72–74 Conflicts between patients and pharmacists seem to mainly emerge from a public perception of pharmacists as businesspeople instead of healthcare professionals. Pharmacists might be missing the right balance between patient-centered healthcare and management issues. The previous negative feelings were also linked to low professional gratification: while some colleagues put profit first, being less satisfied with their income, others seemed frustrated with the

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administrative burden that limits other duties. Negative feelings also resulted from the attitudes of fellow colleagues who are not performing as they are legally obliged to, e.g., they are absent from the pharmacy and dismissive of patient care. This leaves the service to others, who may not

pro bono.

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C. Cognitions

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understand or accept the “extra” time provided to patients by pharmacists, particularly when it is

Self-medication and OTC conceptualizations were aligned with current definitions, again towards a business rather than a healthcare perspective. Offering information and selling products were conceived as a means to keep and attract customers, rather than showing a true concern for patients’ well-being. In fact, participants even expressed that if pharmacies were financially sound, recommending and selling OTCs might not be needed. Self-medication and its OTC-related ambiguity seem to be misaligned with the concepts prevailing in most European practices, such as those of the WHO/FIP (World Health Organization/International Pharmaceutical Federation).75 In Turkey, many OTCs are classified as

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food supplements as well as certain herbal products that are registered as medicines, which are perceived as being “preventive/supportive,” instead of “curative” (C3). OTCs are not considered as xenobiotics but reinforcements of the body’s functional qualities, equivalent to natural products. This conceptualization may lie in the available OTCs in the Turkish market, which

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excludes common active substances with a long-standing OTC status in most European countries. Additionally, some of the products that may be considered by pharmacists as OTC medicines are also under inadequate regulation from the Ministry of Food, Agriculture and Livestock’s legislation. This removes these pharmaceutical products, which are also being sold

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through other retailers, such as herbal shops, from the normal medicines circuit and OTC legal status.76 Hence, these products tend to be neglected by practitioners, who question their quality while defending a regulatory framework, comprising all OTC medicines to be sold only at

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community pharmacies.77

Another reason for having a limited conceptualization of OTCs as medicinal products is linked to the limited undergraduate education in minor ailments and non-prescription medicines. Participants were clear regarding the lack of education on patient counseling and selfmedication, believing there to be a general mismatch between undergraduate education and

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actual practice. Turkish pharmacy degrees usually present a clinical pharmacy subject, although learning to respond to minor ailment symptoms is limited when compared to self-medication handbooks published in pharmacy practice education, and this is confirmed by the low level of patient intervention at community pharmacies.78,79 Therefore, adding to the reduced number of

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OTCs available on the market, education might not yet be at the forefront in proving the clinical skills necessary to develop the professional roles found in other European practices. Turkish

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academia and professional organizations should cooperate to improve minor ailment treatment competencies adjusted to the actual practice setting. Another example of unmet educational delivery was reported in relation to reduced or ineffective communication skills and patientinteraction training. Participants expressed that simulation might be a good solution in counseling development, including the use of virtual patients.

D. Expectations Participants’ citations acknowledge the underdevelopment of the Turkish market, which needs a reduction of legal and economic opacity, recognizing the public health benefits and business

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advantages mentioned in previous codes. Participants also expected to improve minor ailment counseling, expanding their work in self-medication, depending on public awareness and patient demand. This was another question for the focus group discussion: How can pharmacists

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promote their role as self-care advisers amongst the population?

Focus group

The group interview was aimed at providing a deeper understanding of the major constructs emerging from the individual accounts. Experts confirmed the view of OTCs mainly as

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preventive products, limiting the scope for developing pharmacists’ intervention in self-care and self-medication. The role of pharmacists was assumed to be centered on curative prescription

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medicines in a market where self-medication with OTCs is driven by patients’ full autonomy. Pharmacists’ contribution to individuals’ well-being through, for example, professionals’ ability to help customers differentiate minor ailments from major diseases, seems less relevant in the current Turkish practice. Again, a major tension was found between dealing with a commercial role (involving product sales) and a (free of cost) healthcare advisory role. Experts explained the lower level of OTC acceptance in the country based on cultural differences

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from other European countries. It was mentioned that the Turkish population’s access to existing non-prescription substances, such as those in other European markets, raises public health hazards. In fact, most of these medicines are under prescription and reimbursement in Turkey. Although pharmacists’ self-medication counseling was considered less relevant to daily practice,

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communication skills were assumed to be important amongst the expert group, given the need for patient information and counseling. In recognizing the communication skills normally used in

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running the pharmacy services, business advantages seem to prevail over a healthcare orientation.

Continuous professional development (i.e., vocational training) was consensually considered to be essential and mandatory, almost equivalent to having an education degree or certification status. However, the use of computer simulation and distance learning was not considered the best option, especially when communication skills training is involved. Virtual patients (VPs) could help novice pharmacists in initial training and before working with real patients. For example, the use of simulation was not recommended as a possible way to verify fitness to practice. Finally, exercising clinical competencies through simulated patient consultations

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unveiled a conservative attitude. This was somewhat reinforced by a hierarchical and passive position in relation to physicians, contradictory to the inter-professional collaboration and teamwork in primary care. Aside from all the aforementioned Turkish features, the development of pharmacists’ competencies in minor ailments treatment seems confined by

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cultural and social values. It should be added that no clear agreement existed on distance learning and virtual reality solutions as valuable education resources for patient counseling.80,81 This should be further researched, taking into consideration the need to advance self-medication and

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the present boundaries of Turkish practice. Study limitations

As a study of a qualitative nature, the results are not representative of all Turkish practices.

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Although an effort was made to assure most results’ transferability by reaching data redundancy and themes’ saturation, the present study was conducted with a relatively small sample of pharmacy practitioners in their workplaces, who were usually busy and therefore potentially limited in their ability to provide more in-depth contributions. Moreover, knowing that new themes had emerged at the focus group meeting, additional research steps should have been taken to address these themes’ saturation, although the initial focus meeting aim was

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explanatory/confirmatory rather than exploratory. The documentary phase was not designed as a full systematic search; therefore, other relevant documentation might have been missed. Regarding language, issues might also exist along

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transcription and coding: the extent to which all translation subtleties were addressed was

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unspecified, although the team members were highly proficient in the English language.

CONCLUSIONS

Present Turkish community pharmacists follow a traditional medicine dispensary role, where prescribed medicines and information strongly prevail when compared to an active and tailored patient counseling role for minor ailments. Practitioners seem hesitant in their role regarding rational self-medication, defending their attitude by recognizing cultural issues and the lower health literacy in Turkey compared to other European countries. Turkish community pharmacists seem ambivalent in relation to their role in patient self-care: professionals believe in the

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advantages of patients’ autonomy towards better public health; however, helping with minor ailments seems to be less important, with OTCs regarded as less essential medicines or health products. The diverse OTC conceptualization and low practice significance placed on pharmacists’

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intervention in minor illnesses can be explained through the lack of directed education, both undergraduate and postgraduate, but mainly from the lack of adequate therapeutic resources, i.e., there is a shortage of non-prescription medicines available on the market, limiting the scope of pharmacists’ intervention when compared to other European countries, even if similar population

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literacy issues might exist (e.g., Eastern Europe). Furthermore, government reimbursement of most medicines does not facilitate the establishment of a self-medication market, restraining

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patients’ choices and pharmacists’ informed intervention beyond palliative options. However, the financial burden of healthcare already exists in Turkey because of a global increase in healthcare expenditures and local heavy migration fluxes.

Putting into practice a greater number of counseling skills also requires augmented relational and communication abilities. Appreciation was shown for these competencies, although this did not favor the recognition of additional solutions for training non-prescription counseling techniques,

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including computer-based and virtual reality simulation.

Finally, political and educational forces should promote Turkish pharmacists’ minor ailmentrelated competencies as a key professional area. Otherwise, Turkish practice is at risk of falling behind best world practices and losing societal recognition of pharmacists’ relevance in

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supporting individuals’ everyday health decisions and long-term well-being.

ACKNOWLEDGMENTS

The authors would like to thank the Ankara Pharmacists Chamber for its contribution as well as all of the community pharmacists for participating in this study.

COMPETING INTERESTS The authors declare that they have no competing interests.

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a

Obs. CPe CPe CPe CPe CPe CPe CPe

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Ho.a Cen.b Ne.c Cen.b Ne.c Ne.c Ne.c Ne.c Sh.d Ho.a Cen.b Sh.d Cen.b Ho.a Ne.c Ne.c Cen.b N/A Cen.b Ho.a N/A Cen.b Cen.b Cen.b Ne.c Ne.c

Number of technicians 0-2 >2 0-2 >2 0-2 0-2 0-2 0-2 >2 0-2 >2 >2 0-2 >2 0-2 >2 >2 N/A >2 >2 N/A 0-2 0-2 0-2 0-2 0-2

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Region

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Years of Experience >15 >15 >15 >15 >15 0-15 0-15 0-15 >15 >15 >15 >15 >15 0-15 >15 >15 >15 >15 0-15 >15 >15 0-15 >15 0-15 0-15 >15

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M M M M F M F M M F F F F F F F F F F F F F F F F F

CPe CPe CPe CPe CPe CPe CPe CPe CPe CPe PSf CPe CPe PSf CPe CPe CPe CPe CPe

near Hospital, b Centre, c Neighbourhood, d Shopping mall, e Community pharmacist, Public servant; N/A not available

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f

Gender

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Participant s I1 I2 I3 I4 I5 I6 I7 I8 I9 I10 I11 I12 FG1 FG2 FG3 FG4 FG5 FG6 FG7 FG8 FG9 FG10 FG11 FG12 FG13 FG14

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Self-medication and non-prescription drug counseling: Illustrating profession uncertainty within Turkish pharmacy practice.

Recommending effective minor ailment treatments and using non-prescription or over-the-counter (OTC) medicines is a pharmacist's duty. Although common...
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