**1. Introduction**

Pharmacy technicians (in Denmark called pharmaconomists), with a three-year degree, are the largest group of sta ff at Danish community pharmacies. Their roles are expansive and bear some resemblance to those of pharmacists in some countries. They play a vital role in counselling customers on prescription medication, over-the-counter (OTC) medication and non-medical products. In general, pharmacy technicians perform a broad array of tasks in community pharmacies, except for the more complex pharmacotherapeutic ones. In Denmark, pharmacy technicians can deliver services, such as Inhaler Technique Assessment Service, teaching and quality assurance. Some community pharmacy services, such as medication review and New Medicine Service, are restricted to be delivered by pharmacists. In Denmark, all pharmacy technicians are educated at the Danish College of Pharmacy Practice, Department of Education.

Denmark has a population of 5.7 million people; they are served by 237 community pharmacies, 254 branch pharmacies and two online pharmacies that o ffer prescription medication, OTC medication and a restricted selection of non-medical products [1]. This means that there is a community pharmacy or a branch pharmacy for every 11,600 inhabitants. Furthermore, there are 29 medicine distribution units that offer OTC medication, a restricted selection of non-medical products and pre-ordered prescription medication. Normally, counselling at these units is provided by pharmacy technicians [1]. Finally, there are 750 medicine distribution units, where only pre-ordered medicine is provided. No counselling is offered here as there are no pharmacists or pharmacy technicians, and unskilled staff are not allowed to give information on medicines [1]. Having all these different units ensures easy access to medicines in all regions of Denmark.

Community pharmacies and the appurtenant branch pharmacies in Denmark provide medical supplies, information, counselling and preventive health services by pharmacy technicians, along with pharmacists, to ensure the safe use of drugs [2].

Drug-related problems (DRPs) are common and associated with economic and patient-related costs [3,4]. A drug-related problem is defined by Hepler and Strand as: "an event or a circumstance involving drug treatment that actually or potentially interferes with the patient's experiencing an optimum outcome of medical care" [5]. Examples of DRPs are inappropriate drug use, adverse reactions and non-adherence.

Previous research shows that pharmacists play a role in identifying DRPs for customers at community pharmacies and that they contribute to solving them [6–13]. Research on DRPs focuses on evaluating community pharmacist-driven programmes, mostly at community pharmacies, but also, for example, in care facilities for the elderly [10,11,14,15]. Previous and ongoing research also focus on evaluating counselling, including identification and solving of DRPs in daily practice in community pharmacies. Some of this research also included counselling provided by pharmacy technicians along with pharmacists [13,16,17].

Pharmacy technicians, in general, are being accorded greater scopes of practice in community pharmacies, and, in particular, Danish pharmacy technicians are playing a vital role in counselling customers [18–20]. A previous Danish study on DRPs in self-medication showed that pharmacists and pharmacy technicians identified DRPs for 21% of pharmacy customers presenting a symptom or requesting OTC medication [13]. However, it has, so far, not been documented how pharmacy technicians, in particular, contribute to counselling in general, and handling of DRPs at community pharmacies. It is crucial to document their contribution in order to feed the discussion of their future roles at community pharmacies.

The objective of this study is to map the pharmacy technicians' counselling activities regarding prescription medication, OTC medication and non-medical products at community pharmacies in Denmark and to describe how pharmacy technicians identify and handle DRPs.

This is the first study carried out to specifically analyse how pharmacy technicians contribute to counselling and DRP identification at Danish community pharmacies. The study was carried out in collaboration with the Danish Association of Pharmacy Technicians, the Association of Danish Pharmacies and Pharmakon–Danish College of Pharmacy Practice.

#### **2. Materials and Methods**

The design of the study is quantitative, comprising a descriptive approach.

All community pharmacies were invited to participate in the study through different media, including professional groups on LinkedIn and Facebook, newsletters from the Danish Association of Pharmacy Technicians, the Association of Danish Pharmacies and Pharmakon–Danish College of Pharmacy Practice.

To ensure the representativity of community pharmacies in Denmark, a list of Danish community pharmacies was used, and every fourth community pharmacy on the list was called. The community pharmacies were selected so that the number of recruited community pharmacies in each region reflected the number of pharmacies as much as possible. Seventy-six pharmacy technicians from 38 community pharmacies (two pharmacy technicians from each pharmacy) from all Danish regions were

recruited after responding to a nationwide invitation. Fourteen community pharmacies were recruited by phone by the research group.

The geographic distribution of the included pharmacies is illustrated in Figure 1.

**Figure 1.** Number of community pharmacies included in each region.

The participating pharmacy technicians registered data on all their customer visits to the community pharmacies for five days over a four-week period between January and March 2019. They registered on different days of the week to cover the normal opening hours of most community pharmacies in Denmark.

At the beginning of the study period, the pharmacy technicians were introduced to the study through a webinar and self-study. They received training on registration consisting of an instruction and eight cases, which they were requested to solve before starting the registration process. During the study period, the research group held two question and answer (Q&A) webinars and could furthermore be contacted for support on registration.

The registration was carried out in an electronic survey developed by researchers and representatives from the Danish Association of Pharmacy Technicians and the Association of Danish Pharmacies. It was also pilot-tested by two pharmacy technicians and adjusted afterwards prior to being used in the study. The registration had the following questions: gender and age of the customer, type of errand(s), type of identified DRP(s), counselling subject(s), solving of DRP(s) and whether the counselling saved a visit to the general practitioner (GP). Most of the questions could be answered by clicking on a drop-down menu to save time. All types of DRPs and the counselling subjects were defined by the research group and adjusted after the pilot study. All questions in the registration were answered by the pharmacy technicians and, therefore, the data is self-reported.

In order to document the proportion of customers registered, the pharmacy technicians registered the total amount of customer visits received on the days chosen for registration.

Data was analysed in SPSS version 24 (IBM Corp., Armonk, NY, USA).
