How well informed are pharmacy customers in Estonia about minor illnesses and over-the-counter medicines

Summary. Objective. To determine how knowledgeable pharmacy customers are regarding their own health and information about minor illnesses and over-the-counter medicines. Methods. A written questionnaire was sent in the period of January to April 2003 to a sample of pharmacies in different regions of Estonia. Questionnaires were then distributed to randomly selected pharmacy customers. Of 886 questionnaires given out, 727 were answered and returned; a response rate was 82%. Results. Half of the respondents assessed their health as good or excellent. When minor illnesses occurred, most used home remedies or over-the-counter medicines. Their knowledge of such illnesses was better than that of over-the-counter medicines. In both cases, the pharmacist was the most frequently used information source. Drug administration, which preparation should be chosen for which illness, and the drug price were the three most often asked questions in the pharmacy. The information about over-the-counter medicines given in the pharmacies was regarded as sufficient by 51% of the respondents. Conclusion. Although lay people do know about over-the-counter medicines and especially about minor illnesses, pharmacists play a very important part in providing information about medicines. However, drug communication by healthcare professionals regarding over-the-counter medicines should be given more attention in the future.


Introduction
Health and health indicators. One of the most important indicators of quality of life is health status. Health, as defined by the World Health Organization, is the state of complete physical, mental, and social well-being (1,2).
In Estonia, several of the factors influencing the health of the population have altered in recent years. Changes in the socioeconomic system in the past decade have influenced the environment, living conditions, the organization of the health care system, and the health of population. As in other countries, lay people have to take care of their own health (3)(4)(5).
In Estonia, studies examining health and factors affecting health began 15 years ago. The Health Interview Survey, the first large-scale investigation (n=4711) on the health of the Estonian population, was undertaken in 1996 and was based upon data provided by the individuals interviewed. This study found that 65% of respondents between 15-39 years of age perceived their general health as good or excellent, 55% of those aged 35-59 years assessed their health as average or satisfactory, and 30% in the group aged 65-79 years said their health was poor or very poor. No differences between genders were detected (6,7).
In 2003, a further study analyzed the nation's satisfaction with its health care system. The biggest problems for Estonian patients were the length of time it took to see a physician and the high costs of health care services and medicines. However, the respondents appreciated the attentive and caring behavior of the physicians and dentists. At the same time, only one in three Estonians visited a dentist because it was so expensive (8).
Minor illness and self-care. What is meant by a "minor illness" and by "self-care" ?
A minor illness can be defined as a self-limiting condition, e.g., a cold, which does not require referral to a clinician or other health professional (10). Selfcare was defined by L. S. Levin et al. as "a decisionmaking process which involves self-observation, symptom perception and labeling, judgment of severity, and choice and assessment of treatment options" (11). Self-medication is one of several possible selfcare actions including use of nonprescription medicines by people on their own initiative (12).
In treating minor illnesses and stable health care problems, there has been an international move away from the use of primary care facilities to a reliance on self-care, a change supported by drug policies worldwide. For government institutions, this can decrease health care costs and allow health care professionals to focus on more serious health problems. For the ordinary person, it means that he/she has to be more of a decision maker as it regards his/her own health. However, satisfactory lay decisions in a medical perspective are connected with individual self-responsibility and knowledge of illnesses and/or medicines (13).
A study carried out in Wales concerning patients' knowledge and perceptions of the side effects of overthe-counter (hereinafter OTC) medications reported a good understanding of their illnesses by the participants. Their willingness to take responsibility to begin self-treatment using OTC medicines was high. There were no problems in adjusting the dosage levels of their medication. However, their knowledge of side effects was inadequate. Participants identified most subsequent unexpected symptoms as side effects; a conclusion arrived at without any specific knowledge of the medication they had been taking (14). A similar study undertaken in Sweden showed that two main problems related to OTC medicines were uncertainty about the indications for the drug (33.5% of incidents surveyed) and therapy failure (19.5%) (15). Both studies demonstrated the need for professional intervention by health care professionals at different stages of self-medication.
However, today we must face the fact that the majority of medical symptoms experienced by the public are not presented to the health care professionals (what is known as the "iceberg symptom") (16). Many people now use self-treatment or ignore/tolerate illness. According to British Market Research Bureau data, many respondents waited two weeks before questioning the following conditions: tiredness, 40%; headache, 33%; muscle aches or pain, 29%; and sleeping problems 23%. Nearly half of the participants surveyed (46%) did not take anything to relieve symptoms. One-fourth of respondents (25%) treated their illness with OTC medicines, 14% used prescription drugs they already had at home, 10% visited a physician, and 9% tried homemade remedies (17,18). A study carried out among families with children in Jyväskylä, Finland, showed that OTC medicines were not the first choice of treatment. More popular were homemade remedies, rest, and sleep (19). Similar results were obtained from a survey undertaken in Tartu, Estonia, eight years ago. Majority of the respondents (90%) had used home remedies for treating minor illnesses while 70% had taken OTC medicines (20).
In a more recent study, it was found that more than 75% of Estonians had OTC medicines at home, mostly analgesics, anti-inflammatory preparations, and medications to be used in case of respiratory and alimentary tract illnesses and skin problems (21).
In self-care treatment, patients must assess the severity of their illness and the results to be expected from treatment with OTC medicines. This means that they must have an elementary knowledge of symptoms, about administration routes, and about possible side effects of OTC medication. To get this information, they can use different sources of information: the mass media, professional sources, family, friends, and point-of-sale information (22). In the above-mentioned study carried out in 1997 in Tartu, 60% of respondents assessed their knowledge of OTC medicines as sufficient, 31% as insufficient, and 9% considered this type of information as unimportant. The three most frequently used information sources were physicians (91%), pharmacists (85%), and package information leaflets (67%) (20).
Objectives of the current research. The survey discussed in this paper is the first large-scale study in Estonia where opinions of pharmacy customers concerning health, minor illnesses, and OTC medicines have been gathered and assessed. The study focuses on the following factors: self-assessment of health; behavior in the case of minor illnesses; knowledge of OTC medicines and minor health problems; and what people want and expect by way of drug or medical information.

Method
A structured multiple-choice questionnaire was distributed in January-April 2003 to 31 pharmacies and one center of family physicians in Estonia. Although it was not possible to achieve an entirely random sample, the aim was to reach pharmacy custo-Knowledge of Estonian pharmacy customers about minor illnesses and over-the-counter medicines mers of different ages, sex, area of residence, and social background.
Firstly, we selected the regions. There are 15 official regions in Estonia, and 8 of these were included in the survey. In the eight regions, we chose pharmacies from three groups: big cities (urban areas with a population more than 90 000), small cities (urban areas with a population between 10 000 to 90 000), and in rural areas (areas with no town with a population more than 5000). In the rural area pharmacies, 150 questionnaires were distributed. In the small city pharmacies 300 questionnaires and in the big city pharmacies 436 questionnaires were given out. Thus, 886 questionnaires in total were distributed with 727 being returned, i.e., a response rate was 82%.
The questionnaires were distributed to the customers on working days in the morning (8:00 AM -noon) and evening (5:00 PM -8:00 PM). No distinction was made between customers buying prescription and OTC medicines, and participation was always voluntary. In the pharmacies after getting their medicine, one of nine different pharmacy students (all female) who all looked like regular pharmacy staff (they wore the same white coat) asked each customer to fill in the questionnaire. In the family physicians' center, however, the patients were asked to fill in the questionnaires at the registration desk. Here, the student who distributed the questionnaires did not wear any formal clothing.
The survey period lasted two to four weeks depending on the region.
In the questionnaire, there were 20 questions with optional answers. There were between 2 and 11 different reply options depending on the question. With all the questions, however, it was possible for respondents to add a personal opinion.
The questionnaire was divided into five parts: 1.Self-assessment of health; 2.Minor illnesses, knowledge and action; 3.OTC medicines, knowledge and action; 4.Information to be expected from the pharmacy; 5.Background data of the respondents.
The raw data were analyzed using SPSS 11.0 for Windows. Statistical associations between regions, sex, age, education of pharmacy customers, and respondents' answers to the questions were examined by cross tabulation and the Pearson's chi-square test.
Results are presented and discussed only when a statistical significance was observed (P<0.05). Calculated percentages are mostly presented in tabular form with statistical associations being discussed as text below the tables.

Background data of the respondents
Of the pharmacy customers who participated in the study, 69% were women and 31% men. Men and women had the same age distribution. For both men and women, the most common age was in the range of 30-39 years (22% of men, 23% of women).
Of the respondents, 24% of men and 32% of women had gone on to higher education; 13% of the men and 12% of the women had had only elementary school level education. The rest of the sample (63% of men and 56% of women) had received a formal education somewhere between elementary school standard and university.
Approximately two out of three of the respondents were working, and close to 20% were retired. The others were students, mothers taking care of the baby at home, etc.

Self-assessment of perceived health and factors influencing health
According to Table 1 more than half of the respondents assessed their health as excellent or good, one in four as satisfactory, and one in six as bad. Men were more likely to assess their health as excellent or good; women more inclined to give a rating of satisfied or poor (P<0.05). People with higher education, those living in the big cities, and younger respondents were more positive in their assessment of their health (for all associations P<0.01).
The most frequent response (68%) to the next question concerning important factors influencing health was self-responsibility and a sensible lifestyle.
To some extent, sufficient information about health (63%) and medicines (59%) was also regarded as Daisy Volmer, John Lilja, David Hamilton important. Younger people and those who had had higher education were more certain of the importance of their own role in maintaining good health (for both associations P<0.05). People living in the big cities regarded the information concerning drugs as more important than did those from the small cities and the countryside (P<0.05).

Minor illnesses, knowledge, and action
Approximately half of the respondents used different self-care methods to get well. For one in four of the respondents, minor illness was regarded as a serious problem and, if necessary, they visited a family physician. Quite a few people took no action ( Table 2).
The use of home remedies and prescription drugs was statistically associated with age, education, and gender (for all associations P<0.05). Both kinds of preparations were mostly used by older respondents. Men and people with higher education were more likely to use OTC preparations they had at home.

Knowledge and information sources of minor illnesses and OTC medicines
To assess the self-perceived knowledge of minor illnesses and OTC medicines, two separate scales were used. The respondents regarded their knowledge of minor illnesses as better than that of OTC medicines (Table 4).

Table 2. Attitudes toward minor illness
There were statistical associations between attitudes towards minor illnesses and place of residence (P<0.05) and gender (P<0.01). More respondents in smaller cities or countryside and men in comparison to those living in the bigger cities and women took no action to treat minor illnesses.
Half of the respondents had a minor illness once a year, and 33% four times per year. Every month 6% of the participants suffered from a minor ailment; 11% mentioned that they had a minor illness rarely, i.e., less than once per year.
The respondents were asked to indicate whether they had had very recently any of the following 12 minor conditions: headache, toothache, fever, cough, cold, sleeping difficulties, indigestion, heartburn, muscle pain, arthritic stiffness, skin irritation, or something else. Women had more trouble with headache and sleeping difficulties than men (P<0.01). Older people suffered more from sleeping difficulties, muscle pain, and arthritic stiffness (P<0.01 for all these conditions).
The most popular ways to treat minor illness (described in Table 3) were home remedies and OTC medicines. No treatment at all 4 Table 4.

Knowledge of minor illnesses and over-the-counter medicines
Knowledge concerning minor illnesses was associated with place of residence, gender, and education (for all associations P<0.01). Those in the big cities and women knew more about minor illnesses than those in the countryside and men. More respondents who had been in higher education selected the option "sufficient" than did those with less formal education.

Knowledge
Minor Over-the-counter A higher percentage of respondents with elementary school education assessed information concerning minor illnesses as unnecessary compared with respondents with higher education.
With regard to knowledge of OTC medicines, there was an association with gender (P<0.01). Women rated their knowledge higher than men.
The results regarding information sources about minor illnesses and OTC medicines are presented in Table 5. Pharmacists and family physicians were the sources most often used for information about minor illnesses and treatments with OTC medicines.

Information sources about minor illnesses
Contact with pharmacist. Information obtained from the pharmacist was associated with place of residence (P<0.05), gender (P<0.01), and education (P<0.05). Advise from the pharmacist was mostly used by those from small cities and the countryside, by women, and by those with only elementary school education.
Contact with family physician. No statistically significant associations were observed.
Contact with known health care professional. Information from a known health care professional was associated with education (P<0.05); presented source of information was used more by people with higher education.
Contact with family/friends. Information from the family and friends was associated with place of residence (P<0.01) and gender (P<0.01). Respondents from big cities and men tended to use this source more often than those from other places and women Personal experience. Personal experience was associated with age (P<0.05) and education (P<0.05). Older people and those with higher education trusted their own experience more than younger folk and those with less education.

Information sources about OTC medicines
Contact with pharmacist. Information from pharmacist was associated with gender (P<0.01) and age (P<0.01). Women and older people more often turned for advice to pharmacists than men and younger respondents did.
Contact with family physician. An association was observed between information obtained from pharmacist and place of residence (P<0.05) and age (P<0.01). In the big cities, 82% of respondents got information from physicians. Elderly respondents referred to their doctor more than younger people did.
Contact with known health care professional. Information from a known health care professional was associated with education (P<0.01); respondents with a higher education more often sought information from a known health care professional than those with less education.
Contact with family/friends. Current variable was associated with gender (P<0.01) and age (P<0.01). More men (51%) asked family or friends for information than women (28%). The same source of information was used more by younger respondents than older people.
In addition, the respondents were asked to evaluate the importance of package information leaflet (PIL) as a source of information. Before taking a medicine for the first time, 76% of respondents always read the PIL, and 22% said they did so sometimes. Women read the PIL more often than men (P<0.01). Those who considered that information about medicines is important to maintain their good health more often read the PIL compared with those who did not regard such information as important (P<0.01).

Information to be expected from the pharmacy
The most important pieces of information sought

Daisy Volmer, John Lilja, David Hamilton
Women were more interested in the administration, indications, side effects, interactions, and the price than men (for all associations P<0.01). Elderly respondents asked more about which preparation to select for a particular condition, about any interactions, and about the price than younger people (for all associations P<0.05). Those with higher education were more concerned about administration, interactions, and side effects (for all associations P<0.01).
The respondents had to answer to the question concerning satisfaction with the information provided in pharmacies regarding OTC medicines. About half of the respondents were always satisfied. A few were dissatisfied with the kind of information given about OTC medicines, and hardly anyone felt that way when they sought additional information (Table 7).
In the big cities, people were less pleased with what they were told than those in the small cities and in the countryside (P<0.01). Also, older respondents (P<0.01) and people with an elementary school education (P< 0.05) were more satisfied with information from the pharmacy than younger folk and those with higher education.
The respondents were asked to evaluate the importance of the pharmacist as a skilled communicator. It was an important characteristic of women (P<0.01) and elderly pharmacy customers (P<0.05).
The respondents were asked whether in the future they wanted information for specific types of preparation. The highest positive responses were for OTC medicines and herbal preparations ( Table 8). about OTC medicines were details of drug administration, which preparation to select for a particular illness, the price, indications, and side effects. Respondents were less interested in interactions and active ingredients (Table 6). Respondents living in the big cities wanted to know more about OTC medicines (P<0.05) and herbal preparations (P<0.01) than those living elsewhere. It was noted that, in comparison to men, women would like to know more about herbal preparations (P<0.01) and also about prescription drugs (P<0.01) which was something about which elderly people as compared to young people also wanted more information (P<0.05).

Discussion
This research was a baseline study to determine the attitudes, knowledge, and behavior of Estonian pharmacy customers regarding minor illnesses and OTC medicines. The used selection process did not include any known bias. From a practical perspective, the sampling process corresponds to a random process. The high response rate (82%) strengthens the reliability of the results.
In the sample surveyed, almost one in three were men (31%), and more than two in three were women (69%). Half of the respondents perceived their health to be good or excellent. Approximately 20% of respondents in each age group from 20 to 60 years believed their health to be satisfactory. In many ways, this was unexpected that the same percentage of people, who if not in old age were at least in the final stages of late middle age, should consider themselves as healthy as youngsters just out of their teens. The questions were asked in winter and early spring, times of the year for minor illnesses. This could have affected the responses to certain questions, e.g., the incidence of certain minor illnesses such as the common cold.
Estonians often treat minor illnesses by home remedies. There is a tradition of using different types of herbal tea and options rather than drugs. If that treatment is not effective, then they might turn to a pharmacy or to a physician. The percentage of those who use prescription drugs in their medicine cabinet is surprisingly high. The degree to which this might constitute a risk to health is something worthy of future study.
The respondents' knowledge of minor illnesses and OTC medicines varied considerably, but their knowledge of minor illnesses was perceived to be better than of OTC medicines where one in three noted that they do not know enough ("insufficient" knowledge). This concern over their lack of awareness of what was available over-the-counter might be explained by the considerable growth in the number of different preparations on the Estonian drug market in recent years. This hypothesis is supported by the results from a similar, older study performed in 1997 where 60% of respondents (half more than according to the current study) rated their knowledge of OTC medicines as sufficient (20).
This survey showed pharmacists to be the most often used information source for minor illnesses and OTC medication.
Approximately half of the respondents were always satisfied with the quality of service in the pharmacy. However, in future they would like to have more information about OTC medicines and herbal preparations. Pharmacy customers are interested not only in the price of the medicines. They want to know more about which preparation to select for specific medical conditions or symptoms and they would like more information about how to administer their drugs and drug indications. Questions about side effects and interactions with other medicines, food, and drink were not asked so often. However, it does not mean that pharmacy customers are not interested in these issues. A study, undertaken in Finland 10 years ago, showed different opinions between pharmacists and customers about information available in the pharmacy. Pharmacists considered dosage instructions and storage conditions as the more important information. Customers in contrast wanted to know more about the side effects and interactions of the medicines (23).
In future, more in-depth research concerning factors influencing the choice of OTC medicines by pharmacy customers and pharmacists is planned. In addition, reasons for dissatisfaction with the OTC information received from the pharmacy, opinions about herbal preparations sold in the pharmacy, and the need for additional information/training among pharmacists will be studied.
One problem in Estonia today, and it is not unique to this country, is that pharmacists often do not have enough time and are not sufficiently motivated to talk to their customers. Similar problems could be found in the study carried out among 98 community pharmacists in East London, United Kingdom. In addition, the pharmacists' perception that they were neither valued nor appreciated, work-related stress, and a lack of professionalism in community pharmacy were among the other concerns mentioned (24). All these factors may serve as barriers to communication with pharmacy customers. However, even with limited time available, communication in the pharmacies could be improved. Questions like "Are you familiar with how to take this drug?" or "Do you need any additional information?" might encourage a customer to ask for "missing" information. No less attention should be paid to the pharmacy customers asking for a medicinal product by trade name. N. M. Katajavuori et al. proved in their study that Finnish pharmacy customers needed counseling concerning medicines that were familiar to them (25).
In this study, many respondents regarded the communication skills of the pharmacist as an important factor influencing the quality of the interchange between pharmacist and patient. Good communication is essential in establishing a trusting relationship. The importance of skilful communication by the pharmacist has been the main outcome of different researches all around the Europe (4,14,15,23,(25)(26)(27)(28).
Our study revealed remarkable differences in the behavior between men and women. Men rated their health as better and were less interested in treating minor illnesses than women. Their knowledge of minor illnesses and OTC medicines was lower than women, and they were less willing to seek out information in these areas.
Respondents living in the big cities displayed greater self-responsibility in looking after their own health. Their knowledge of minor illnesses was better than those in rural areas. But as it can be seen from the Daisy Volmer, John Lilja, David Hamilton answers, their contact with health care professionals could not be said to be satisfactory -in cases of minor illness, they turned more often for advice to family or friends and they were not always satisfied with the information on OTC medicines received from the pharmacy.
People who had gone through the higher education system stressed the importance to their health of their lifestyle and the need to be well informed about medicines. In cases of minor illness or information about OTC medicines, this group mostly asked advice from a known health care professional and/or trusted their own knowledge or previous experience.
Older respondents were more concerned about their health and in cases of minor illness started treatment immediately. Besides home remedies and OTC medicines, their use of prescription drugs for treatment of minor diseases was remarkably high. Elderly people used both information sources, pharmacist and physician, equally and expressed satisfaction with the information received from the pharmacy. Skilful communication by the pharmacist was very important for them.

Conclusion
This survey of pharmacy customers' opinions and behavior regarding minor illnesses and over-the-counter medicines was the first national large scale study in Estonia. In general, the respondents who were all customers in pharmacies assessed their health as good. They tended to be interested in taking care of their own health. They recognized that a healthy lifestyle could help to prevent minor illnesses. They said that they mostly turned for advice to pharmacists and then to the family physician and known health care professionals. They did, however, indicate that they were not always satisfied with the information concerning over-the-counter medicines provided in pharmacies.
The quality of the pharmacy information service could probably be improved on two levels. At undergraduate level, more attention should be paid to the teaching of better effective communication techniques between pharmacist and customer. At postgraduate level, a more appropriate organization of the work in the pharmacies and improved communication skills obtained at professional training sessions would support a sustainable development of Estonian pharmacists. Metodai. 2003 m. sausio-balandžio mėnesiais grupei vaistinių skirtinguose Estijos regionuose išsiųstas klausimynas. Šie klausimynai išdalyti atsitiktinai atrinktiems vaistinių klientams. Iš 886 klausimynų į 727 atsakyta ir jie grąžinti; atsako dažnis -82 proc.