The present study evaluated the counselling practices of community pharmacists in Riyadh, Saudi Arabia. Results obtained from the visits using SPs were compared with those obtained in the survey, revealing important discrepancies regarding the frequency of information provided to customers. In the survey, the majority of the respondents claimed that they always provide information on dose, duration of use, and how to use the medication. Nevertheless, actual dispensing practices showed that the majority of SPs were informed about such information only when they started to be inquisitive and probed for information. Others have reported similar inconsistencies between self-reported behaviour of pharmacists in interviews and their actual dispensing practice measured using SPs . It is possible that pharmacists provide more socially desirable responses in the questionnaires. Another possible explanation is that the survey responses may refer to general counselling practice, while the SPs component reflects counselling practice on specific occasions when patients request a medicine by name. Evidence suggests that the latter involves less counselling [15, 21, 22].
Counselling rates reported in international literature vary from 8 to 100 %, depending on the research methods used . The rate of counselling observed in this study is very low (3 %). However, it improved to 43 % when SPs were inquisitive and requested more information. This improvement in observed counselling rate is consistent with previous research reporting an association between patient question-asking behaviour and the provision of information [21, 22]. This improvement in pharmacist-patient communication demonstrates the importance of finding ways to encourage patients to ask questions to community pharmacists.
When dispensing, the majority of pharmacists did not inquire about previous use of the requested medications, concomitant drugs, or history of drug allergy. In a study involving simulated patients visiting community pharmacies in Riyadh with symptoms of specific clinical illnesses, antibiotics were dispensed without inquiring about associated symptoms or history of drug allergy, and only 23 % of pharmacists inquired about pregnancy status . Other studies also report that pharmacists’ assessment of symptoms and questioning concerning medication history are inadequate [15–18, 21, 22]. One explanation for this finding could be that our SPs were asking for specific products. In the context of non-prescription medicines, research suggests that product-based requests result in less information being asked or information elicited by pharmacists than do symptom-based [15, 21, 22]. Another plausible explanation is that consumers might expect to make an OTC purchase without being questioned . However, in this study two medications were POM. For one of these, Amoxil, there was no assessment or request for a prescription. Pharmacists’ assessment with the other, Zocor, was a little better, but still unsatisfactory.
Information regarding dose was the most common type of information provided (97 % of the SPs visits), while a very small proportion of SPs were counselled on precautions. This is consistent with findings in previous research reporting that information on precautions, side effects, interactions, contraindications, and storage is less likely to be given by community pharmacists [7, 12, 13, 17, 18]. Interestingly, in our survey approximately half of respondents reported that they sometimes or never counselled on side effects and drug interactions. Pharmacists may think that too much information could deter patients from taking their medications . However, research suggests that patients want specific information about side effects, duration of treatment, and the range of available treatment options .
Although two of the medications used in the scenarios are POM, pharmacists requested the prescription on only 11 out of 92 SPs visits. This confirms findings from previous research that POMs, such as antibiotics, antihypertensives, and antipsychotics could be obtained easily without a medical prescription in Saudi Arabia [12, 13]. A Saudi study asked pharmacists (n = 60) for the reasons they violated the law and dispensed POM without a prescription . The most common reasons given were that pharmacists do not know the prescription status (i.e. POM or OTC) of many medications, patients ask for medications by name, and patients can only afford the pharmacy visit. Some also reported that ‘if we did not sell it somebody else will’ . These results suggest that the reasons for such malpractice are multifactorial, and multiple approaches are required to correct it.
Implications for policy and research
The intensity of regulatory mechanisms has been proposed as a factor influencing counselling practice . The Saudi Executives Roles for Institutional and Pharmaceutical Products Law  provide no clear regulation on what is expected of community pharmacists during the dispensing of medications. Therefore, the development of legislation or guidelines setting out national standards that clearly stipulate what is expected of community pharmacists during the counselling process is needed. Such guidelines should be supplemented by appropriate strategies for dissemination and implementation.
There should be stringent enforcement of the national regulations that require a valid prescription to dispense a POM in community pharmacies. The Saudi Ministry of Health have published a frequently updated version of the Saudi OTC-Directory since 2000. Additionally, an electronic list of medications licensed in Saudi Arabia, including their prescription status, is available on the Saudi FDA website . However, this seems inadequate and relevant agencies should develop strategies to ensure efficient dissemination of information about the legal status of medications to all community pharmacies. Furthermore, the laws and regulations of the Saudi healthcare system should be part of Saudi Commission for Health Specialties licensing exam for pharmacists. This is especially important given that most community pharmacists in Saudi Arabia are expatriates.
Evidence for effective strategies to improve counselling practices is limited. However, some interventions show promising results, including continuous long-term postgraduate education  and simulated patient visits to assess the current practice followed by feedback [16, 21]. To promote longer-term changes in counselling practices, systematic action is required, coordinated between relevant stakeholders and at different levels. Pharmacy owners and pharmacists will need support and resources to improve existing practice. These include management systems, medicine information systems and databases, and up-to-date basic and continuing education. At the individual pharmacist level, competencies should be updated to meet patient-centred practice requirements.
In this study, we only considered the provision of counselling and not the quality of counselling. Therefore, future studies that examine appropriateness and quality of counselling practices are needed. Future research should also investigate further the factors that hinder community pharmacists from counselling patients. These factors may relate either to the community pharmacists themselves, for example competencies and willingness, or to organizational factors, for example regulations and reimbursements.
Limitations of the study
Some limitations of our study are outlined below. Our results should be generalised with caution to the general population due to our use of convenience sampling, as this method can lead to the under-representation or over-representation of particular groups within the sample. Further limitations include the use of students as simulated patients, who may not have been as convincing or as practiced as paid actors. Furthermore, the SPs were all young females, and generalization of the findings to other populations is not possible. Additionally, SP visits were not audiotaped. Audiotaping can improve the reliability of manually documented data and result in more accurate assessments .
Some have expressed ethical concerns in relation to the SPs method, as pharmacists do not give consent to participate. However, others have argued that it can be a robust method for assessing practice, and may be justified in the wider public interest .
The operational classification we used to assess counselling was originally used within the context of prescription medicines . In such cases, a patient should already have consulted with a medical practitioner and pharmacists’ questioning serves the purpose of meeting specific patient needs only. However, in the present study two scenarios used OTC medications. For OTC medications, pharmacists’ questioning serves a broader purpose. It should not be limited to previous use, allergies, use of other medicines, knowledge of indications, or dosing instructions, but should include an assessment of other aspects, namely nature of the symptoms, treatment duration, and current conditions. The latter were not investigated in this study.
The current study assessed the counselling process only for situations where patients specifically request a medication by name. Other situations, such as counselling for patients with prescriptions and for patients approaching pharmacists for treatment (i.e. explaining their symptoms to pharmacists, who then provide them with the medications), were not investigated. Therefore, our findings cannot be extrapolated to such situations.