**4. Discussion**

#### *4.1. Discussion of the Results*

#### 4.1.1. Proportion of Customers Receiving Counselling

A study mapping Norwegian community pharmacy counselling shows that 60% of the customers receive counselling [17]. Although 80% of the participants in the Norwegian study are community pharmacists, and all of the participants in this study are pharmacy technicians, the proportion of customers receiving counselling in the two studies is comparable.

#### 4.1.2. Counselling Customers Requesting OTC Medication or Presenting a Symptom

In an earlier Danish study mapping DRPs in OTC medication customers, identified by pharmacy technicians and community pharmacists, the most frequent counselling subjects were "counselling on self-medication", "personal care" and "recommendation of a drug/product" [13]. There are similarities between the findings in the two Danish studies because "counselling on self-medication" can cover both of the following subjects: "drug/product use" and "effect of the drug", which were the two most frequent counselling subjects for customers requesting OTC medication or presenting a symptom in this study. In a German study mapping DRPs in OTC medication customers, identified by community pharmacists, the most frequent subjects were "referral to a physician" and "switching to a more appropriate drug" [21]. Pharmacy technicians in this study referred customers to their GP, and they recommended more appropriate drugs/products to some of the customers. However, these two categories were not the most frequent ones. These results show that pharmacy technician counselling is comparable to counselling delivered by community pharmacists, especially in a Danish setting.

#### 4.1.3. Types of DRPs in the Total Study Population

In a German study mapping the DRPs encountered in community pharmacies, identified by pharmacists, the most frequent types of DRPs were "evidence of drug-drug interaction in the literature", "incomplete or unreadable prescription" and "drug not on the market" [7]. It is remarkable that drug-drug interaction is the most frequent DRP in the German study. There are two evidence-based electronic databases in Denmark in which health professionals and patients, respectively, can check for drug-drug interactions. It must be checked if the interactions are clinically relevant; most often only a few of them are. Drug-drug interactions are identified in this study, but are not among the most frequently registered DRPs; but of course, it can be crucial when it is clinically relevant. Otherwise, the next two frequently registered types of DRPs in the German study are similar to the two most frequently registered types of DRPs in this study. Thus, the types of DRPs identified by pharmacy technicians are comparable to those found by pharmacists.

Drug shortage is an international problem and a known and increasing problem in Danish community pharmacies [22,23]. The Association of Danish Pharmacies was contacted by the research group, and they had not detected any extraordinary fluctuation in the frequency of drug shortages in the study period.

A high rate of unavailable prescriptions was shown in this study. A newly published study shows that unavailable prescriptions occur in 1% of all dispensing in Danish community pharmacies. Miscommunication between the patient and GP seems to be the primary source of unavailable prescriptions [24].

#### 4.1.4. Occurrence of DRPs for OTC Medication Customers

DRPs were identified for 15.8% of the total study population and for 12.7% of customers requesting OTC medication or presenting a symptom. The earlier German study documented DRPs in 17.6% of all cases [21]. The earlier Danish study documented DRPs in 21.0% of OTC medication customers [13]. Both studies showed a higher occurrence of identified DRPs in OTC medication customers than this study. It is important to mention that the percentages in the Danish studies are calculated as percentage (%) per customer. The percentages in the German study are calculated as percentage (%) per case or request. So, the Danish results are not comparable with the results from the German study. The percentage in the German study may be lower than 17.6%, as it can be assumed that some of the customers had multiple DRPs. The high occurrence of DRPs identified in the earlier Danish study may be due to extra focus on OTC medication customers during the study period, as it was the aim of the study.

#### 4.1.5. Types of DRPs in Customers Requesting OTC Medication or Presenting a Symptom

The most frequent types of DRPs identified for customers requesting OTC medication or presenting a symptom were "inappropriate drug/product", "symptom that requires a visit to the GP", "adverse reaction" and "duration of treatment too long" (17.6%, 17.3%, 9.4% and 8.8% of customers with DRPs). There are similarities to the German study, which reported that the most frequent DRPs were "self-medication inappropriate", requested drug inappropriate" and "intended duration of drug use too high". In the earlier Danish study, the most frequent types of DRPs were: "the choice of medication is not appropriate/optimal for the condition" (44.8%), "too little of the drug is being taken" (17.0%), "the drug is taken for too long" (15.0%) and "adverse reactions"(13.8%) [13]. The types of identified DRPs are also similar in the two Danish studies. It is remarkable that pharmacy technicians in this study identify symptoms that require a visit to the GP, which probably leads to early diagnosis and treatment, and in this manner, promotes patient safety.

#### 4.1.6. Pharmacy Technicians' Contribution to Counselling and Handling of DRPs

This study documents that pharmacy technicians contribute to counselling in Danish community pharmacies. The subgroup with the highest proportion of customers receiving counselling represents those who request OTC medication or present a symptom (68.0% compared to 58.9% in the total study population). This is probably because most of these customers have not received any prior counselling from a healthcare professional on their OTC medication or their symptom, so they seek counselling at the community pharmacy, and this counselling could be very important for these customers.

Pharmacy technicians have shown that they can identify DRPs for all subgroups. The prevalence of DRPs identified by pharmacy technicians for customers requesting only prescription medication is comparable with the prevalence of DRPs identified by community pharmacists. A Belgian study on the identification and handling of DRPs by community pharmacists in the dispensing process documents that at least one DRP is found in 9869 on a total of 64,962 prescriptions (15%) [25]. The pharmacy technicians in this study solved, or partially solved, DRPs for 70.4% of customers with DRPs. This is also comparable with the Belgian study, where the community pharmacists solved almost 75% of the identified DRPs [25]. Pharmacy technicians contribute to patient safety. In particular, this is

documented by the high extent of counselling provided to customers requesting OTC medication or presenting a symptom, and identification and solving of DRPs for customers requesting non-medical products. These customers would probably not have been counselled on DRPs if they had chosen to buy their products from other outlets than the community pharmacy.

#### *4.2. Method Discussion*

In order to ensure representativity, a couple of initiatives were carried out.

First, the community pharmacies were selected to reflect the number of pharmacies in each region. Second, the participants were instructed to choose five days over a four-week period to register all visits and to choose di fferent days of the week to avoid bias. The collected data do not indicate on which days of the week the registration took place, and we therefore cannot tell if the participants followed this instruction. If we look at the proportion of customers registered, which was 82% on average, it can be assumed that the proportion is high enough to conclude that the collected data is representative.

Third, the participants received training on the registration consisting of an instruction and eight cases, which they were requested to solve before starting the registration process. The participants had access to the correct answers, but it might have been better if they had received feedback on their answers from the researchers before starting their registration.

Due to the study design, the pharmacy technicians collected data on their own counselling activities—self-reported data. Questions, such as whether the counselling saved visits to the GP, were answered by the pharmacy technicians by self-estimation. They were asked to estimate whether the customer would have contacted the GP if they had not received counselling from the community pharmacy, and then, whether the counselling had saved the customer a visit to the GP. There might be a bias here. The wording of the question makes it di fficult to give an answer as the pharmacy technicians are asked to estimate two scenarios at the same time.
