Management of minor ailments in a community pharmacy setting: Findings from simulated visits and qualitative study in Gondar town, Ethiopia
Management of minor ailments in a community pharmacy setting: Findings from simulated visits and qualitative study in Gondar town, Ethiopia
Asnakew Achaw Ayele 0 1
Abebe Basazn Mekuria 1
Henok Getachew Tegegn 0 1
Begashaw Melaku Gebresillassie 0 1
Alemayehu Birhane Mekonnen 0 1
Daniel Asfaw Erku 0 1
0 Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia, 2 Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar , Gondar , Ethiopia
1 Editor: Mohamed Azmi Ahmad Hassali , Universiti Sains Malaysia , MALAYSIA
Community pharmacy professionals are being widely accepted as sources of treatment and advice for managing minor ailments, largely owing to their location at the heart of the community. The aim of the present study was, therefore, to document the involvement of community pharmacy professionals in the management of minor ailments and perceived barriers that limit their provision of such services. Simulated patient (SP) visits combined with a qualitative study using in-depth interviews was conducted among community pharmacy professionals in Gondar town, Northwest Ethiopia. Scenarios of three different minor ailments (uncomplicated upper respiratory tract infection, back pain and acute diarrhea) were selected and results were reported as percentages. Pharmacy professionals were also interviewed about the barriers in the management of minor ailments. Out of 66 simulated visits, 61 cases (92.4%) provided one or more medications to the SPs. Pharmacy professionals in 16 visits asked SPs information on details of symptoms and past medical and medication history. Ibuprofen alone or in combination with paracetamol was the most commonly dispensed analgesics for back pain. Oral rehydration fluid (ORS) with zinc was the most frequently dispensed medication (33.3%) for the management of acute diarrhea followed by mebendazole (23.9%). Moreover, amoxicillin-clavulanic acid capsule (35%) followed by Amoxicillin (25%) were the most commonly dispensed antibiotics for uncomplicated upper respiratory tract infection. Lack of clinical training and poor community awareness towards the role of community pharmacists in the management of minor ailments were the main barriers for the provision of minor ailment management by community pharmacy professionals. Overall, community pharmacists provided inadequate therapy for the simulated minor ailments. Lack of access to clinical training and poor community awareness were the most commonly cited barriers for providing such services. So as to improve community pharmacists' involvement in managing minor ailments and optimize the contribution of pharmacists, interventions should focus on overcoming the identified barriers.
Data Availability Statement: All relevant materials
and data supporting the findings of this study are
contained within the paper and supporting
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
Abbreviations: CDRSs, community drug retail
outlets; CP, community pharmacist; FMHACA,
food, medicine and healthcare administration and
control authority; NSAIDS, non-steroidal
antiinflammatory drugs; OR, Odds ratio; ORS, oral
rehydration salts; SP, simulated patient; SPSS,
Statistical Package for the Social Sciences; UoG,
University of Gondar; URTI, upper respiratory tract
infection; WHO, World health organization.
Community pharmacy professionals, being one of the most reachable healthcare professionals
among the community, have great potential as a setting in primary health care services. This
characteristic feature of community pharmacies provide a platform for more proactive
contribution in self-care and managing a range of minor ailments [1±3].
Minor ailments are generally defined as medical conditions that will resolve on their own
and can be reasonably self-diagnosed and self-managed with over-the-counter medications.
Examples of minor ailments include headache, back pain, insect bites, heartburn, nasal
congestion, etc. [
]. Majority of developed nations, successfully integrated community pharmacy
professionals into a variety of public-health programs including providing treatment and advice
for managing minor ailments [
]. For instance, the community pharmacist contractual
framework of United Kingdom considered `minor ailment service as one of the enhanced
population health services to be provided by community pharmacy professionals [
Australian community pharmacy professionals are the most accessible health care
professionals for health advice and provision of primary health care services including management of
minor ailments . This is in contrast to community pharmacies in developing countries like
Ethiopia, where pharmacists' role is largely confined to the traditional medication dispensing
practices and seldom provides such public health services [
]. Furthermore, lack of standard
guideline for the management of these conditions is also another problem hindering the
realization of such services in developing countries . Different studies were conducted in
different parts of Ethiopia regarding self-medication and related issues, but most of these studies
utilize consumer's perspective [
], while the role of community pharmacy professionals in
the management of minor ailments and the potential barriers in service delivery are usually
overlooked. The aim of the present study was, therefore, to document the involvement of
community pharmacists in the management of minor ailments and explore potential barriers and
gaps that hindered the provision of such services.
Materials and methods
Study design and setting
A simulated patient (SP) visits and qualitative based in-depth interview were conducted in
selected community drug retail outlets (CDRSs) located in Gondar town, Ethiopia. Gondar
town is located in Amhara regional state, Northwest Ethiopia. According to the 2007
population and housing census report, the town had an estimated population of 206,987 [
town has 20 community pharmacies, 35 drug stores and 2 rural drug vendors. The simulated
study was conducted from January 1-February 30, 2016 and the qualitative study was
conducted from March 16 to June 1, 2016.
The simulated patient study
The quantitative simulated patient visit aimed to document the extent of involvement of
community pharmacists in the management of minor ailments. In Ethiopia, CDROs are mainly
classified into pharmacy (run by a pharmacist with a qualification of bachelor of pharmacy or
equivalent), drug shop or drug store (run by pharmacy technicians or druggists with a
qualification of diploma in pharmacy or equivalent) and rural drug vendor (run by health assistants
or health extension workers). All CDROs in Gondar town were stratified into Arada, Piassa,
Azezo and Lideta sub cities (kebeles) and given a random number through MS Excel random
number generator (RAND). From a total of 55 CDROs in Gondar, 12 pharmacies and 10 drug
stores were selected using a simple random sampling technique and distributed among the
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above stratified kebeles taking into consideration the number of prescriptions filled per day or
patient flow in each kebeles. As each CDRO visited once by each SP, a total of 66 simulated
visits were conducted over a 6-weeks period.
Scenarios and simulated patients
Three different scenarios were developed and enacted by the SPs. The scenarios included
common minor ailments, which are considered to be highly frequent (back pain, acute diarrhea
and upper respiratory infection). Description of the scenarios employed is summarized in
Three graduating (fifth year) undergraduate pharmacy students acted as SPs and each of
them were given a specific scenario to play. After a 5-hour detailed discussion and training of
each scenario with the SPs, one day was given so that they will be familiar and able to perform
the scenarios given. The SPs told not to give and/or ask extra information unless asked in
order to make sure that the information provided is consistent across all visits. The data
collection tool used by the SPs is presented in supplementary (S1 File).
Visit evaluation. All simulated visits were audio recorded so as to avoid counting on the
human cognitive processes, which has been cited as a potential shortcoming of the SP
methodology  Instantly after each simulated visit, the SPs filled the collected data in a form
containing a check list of items that were intended to assess the overall practice of pharmacists
No previous or current medical condition other than the complaint of
fever, cough and nasal discharge.
There is sputum
The symptoms started 4 days ago
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towards management of minor ailments. The check list included questions/patient history
asked, medications and/or counselling provided and duration of the visit. Two of the
investigators independently compared and validated the data from the check list against audio
recordings for the purpose of quality assurance.
The qualitative study
In the second phase of the study, a qualitative approach was employed with the aim of
uncovering the potential barriers to the provision of management services for minor ailments in a
community pharmacy setting.
For the purpose of allowing maximum variation [
], sampling and recruitment was done
considering types of CDROs, geographical area and pharmacist demographics including age,
gender, educational level and experience. Although there is no clear guideline for sample size
determination in qualitative study, there is general consensus that the sample size should be
determined when theoretical data saturation has been attained [
]. Yet, we predetermined
the sample size of community pharmacists for this study so as to allow for the maximal
variation mentioned above, and this type of sampling has been recommended in the literature [
Accordingly, data were saturated after the 13th interview in our study.
The study participants were recruited through food, medicine and healthcare
administration and control authority (FMHACA) of Ethiopia.
Participants were then contacted and invited to take part in the study by telephone. A total
of 15 community pharmacy professionals were identified and approached with 13 successfully
recruited and interviewed. Semi-structured interviews were conducted by the principal
investigator face-to-face at either the respondents' work place or other agreed location such as coffee
houses. The in-depth interview guide was adopted from existing literature with similar topic
and includes open-ended questions probing the potential barrier in the management of minor
ailments in community pharmacy settings and evolved iteratively as discussions proceeded,
along with the use of prompts and cues. The interview took approximately 30 minutes. Minor
ailments are operationally defined as conditions that will resolve on their own and can be
Data analysis and management
Data from the SP visits were entered into and analyzed using Statistical Package for Social
Studies (SPSS) version 20 for Windows and results are presented as frequencies and percentages.
For the qualitative study, thematic analysis was carried out, the transcripts and notes were
read and annotated repeatedly in order to verify the data for accuracy. The audio-recorded
data collected were transcribed and codes were developed by two of the investigators (AAA
and DAE) based on the original terms used, and then matched. After all the data have been
coded, cutting and pasting of codes was done into piles by code and put them together with
other examples of data on the same topic to start looking for patterns across the data. The
patterns and relationships found under the themes were the basis for report. Quotes that would
help in understanding of the content of the theme or sub-theme were identified. Main themes
were illustrated with representative quotations designated as community pharmacist 1 (CP1),
CP2. . .. . .CP3.
Ethical approval to conduct this study was granted by the ethical review committee of School
of Pharmacy, University of Gondar with a reference number of UoG-SoP/089/2016. Written
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Scenario 3 (URTI)
(N = 12)
informed consent from participants of the qualitative study was also obtained prior to
conducting the study. Participant's information obtained were kept confidential.
Outcomes of visit and type of medication (s) recommended
Out of 66 simulated visits (22 each for the three scenarios) presented to CDROs, 61 cases
(92.4%) were provided with one or more medications. Before handing out the medications,
few community pharmacy professionals (26.2%) asked SPs further details of symptoms and
past medical and medication history. Only 9.8% of community pharmacy professionals asked
about possible drug allergies and 36.1% of them informed the SPs about the potential side
effects of the dispensed medications. The average consultation and/or dispensing times were 2
minutes in drug stores and 3 minutes in pharmacies. The detailed actions and advices
provided by the pharmacy professionals is tabulated in Table 2.
A wide variety of pharmacotherapeutic agents were dispensed and/or recommended for 61
of the simulated scenarios in the pharmacies and drug retail outlets (Table 3). Majority of the
medications dispensed for the scenario with back pain were oral analgesics and contained
non-steroidal anti-inflammatory drugs (NSAIDS) alone and/or in combination with
paracetamol. Ibuprofen alone or in combination with paracetamol was the most commonly dispensed
analgesics. A total of five pharmacotherapeutic class of drugs (antiamoebic, antibiotics,
anthelmintic, oral rehydration salts (ORS) and zinc) were given for the scenario with acute diarrhea.
ORS with zinc was the most frequently dispensed medication (33.3%) followed by
mebendazole (23.9%). Finally, Antibiotics were dispensed from 20 out of 22 CDROs in which URTI
symptoms were simulated. Amoxicillin-clavulanic acid capsule (35%) followed by Amoxicillin
(25%) were the most commonly dispensed antibiotics.
Challenges in the management of minor ailments
The results from the qualitative study depicts an in-depth analysis of barriers that hinders
community pharmacists to effectively implement management of minor ailments their
practice settings. Eight of the participants were holders of a bachelor degree in pharmacy and the
rest of them (5) hold a diploma in pharmacy, with a work experience ranging from 2 year to 15
years (with average of 7 years). Results showed that lack of clinical training and poor
community awareness towards the role of community pharmacists in the management of minor
ailments were the main barriers and challenges faced by community pharmacists.
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Abbreviation: ORT: oral rehydration therapy; URTIs, upper respiratory tract infections
Lack of access to clinical training on the management of minor ailments
Almost all of the participant mentioned lack of training as the most barriers that hinders to
provide quality management of minor ailments in community pharmacy settings. According
to the participants, much of the clinical trainings are usually provided for health care providers
having a direct contact with patients in hospitals such as physicians and nurses, with only few
community pharmacists had the chance to take syndrome approach clinical training.
“. . .. I have taken, by chance, a symptomatic approach-based clinical training a couple of years
ago and it helped me a lot for the management of common ailments in my practice. However,
most of the community pharmacists I have known in Gondar have not taken such training,
which I believe, could be the main reason behind the poor management of minor ailments in
many pharmacies and drug stores. . ..º
“. . .. . .. In my point of view, the correct strategy to improve management of common ailments
in community pharmacy is that continuous education and trainings. Lack of knowledge is one
of the gap I observed. For example, if I have not detail knowledge on how to select appropriate
medications for common ailments, I may dispense even wrong medications.”
Poor community awareness
Poor awareness of the community regarding minor ailment management and the role of
community pharmacists in providing these services is another important challenge faced in
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practice setting. According to the participants, some customers have no awareness regarding
generic and brand drugs and they believe that generic drugs are not effective, especially if the
product is from local pharmaceutical factory. To meet the needs of the customers, pharmacist
provide drugs for common ailments and if the patient's willingness to pay is less, they will give
generic drug with low price as alternative.
. . .very few customers see community pharmacies and pharmacists as a whole, as a resource to
be used for the management of any kind of ailments including minor ailments. . .besides, most
of the patients visiting our pharmacy don’t have any idea about brand/generic medications,
and they usually need something better than the usual or generic drugs. For example, patients
usually prefer a more potent and brand analgesics than paracetamol. . .this is also true for
antibiotics. . .instead of amoxicillin, customers prefer to be dispensed amoxicillin-clavulanic
acid drug. . .
The demand for healthcare services within the community settings continues to rise
] and government policies promoting community pharmacy-based minor ailment
management has been advocated and introduced in many developed countries [19±21].
Studies utilizing a simulated patient visit can be used to assess the actual involvement and quality of
care obtained from CDROs within communities. When used in combination with feedback,
they can be a very useful means of promoting proper management of minor ailments in
community setting . To the best of our knowledge, this is the first attempt to document the
involvement of community pharmacy professionals in the management of minor ailments and
barriers in the provision of such services in Ethiopia.
In developing country like Ethiopia where the availability of physicians is very limited,
enabling community pharmacy professionals to treat minor ailments would have significant
advantage from different perspectives such as improving patients' access to a health care,
overall reduction of cost incurred by the patients [
] and alleviate the burden on other health
providers including physicians and nurses, allowing them to focus on patients with more complex
care needs. Results from our study revealed a high rate of dispensing medications with
insignificant queries about past medical and medication history, the potential drug allergies and
side effects. Furthermore, most of the medications were dispensed inappropriately. For
example, antibiotics dispensed for URTI were inappropriate since the simulated case scenario
presented was most likely caused by a virus, not bacterial. Antibiotics are a group of medications
which are highly and irrationally dispensed around the globe. Several simulated case studies
conducted in many parts of the world have also reported that antibiotics can be obtained with
ease from CDROs regardless of laws prohibiting dispensing of these medications without a
valid prescription [23±26]. Frequent and irrational use of these medications, which has been
known to be the main driver of drug resistance, should be minimized as they may predispose
the patient to additional cost due to the need for a broader-spectrum antibiotics and potential
hospitalizations for treatment failures [
The irrational use of analgesic was also reported in our study including provision of
inappropriate dosing and provision of inadequate information. The frequent use of analgesic
combinations in our study is one particular issue, raising many safety concerns. Though
combining paracetamol with various NSAIDS has been shown to produce better pain relief and
], a major fear is unintentional paracetamol overdoses and toxicity by patients,
predisposing to potentially deleterious outcomes [
7 / 11
Generally, pharmacies performed better than drug stores in most of the simulated case
scenarios. This could be due to the fact that drug stores are often staffed by pharmacy technicians,
having inadequate medical and pharmacotherapeutic trainings. This may particularly pose a
serious problem in the management of minor ailments owing to the easy accessibility and high
patronage they receive from the community. Similar studies done elsewhere also reported that
drug stores took the lion's share in the irrational use of medication for several common
ailments such as malaria, diarrhea and respiratory infections [
Understanding the various barriers for the provision of management service for minor
ailments in the community pharmacy settings is a bold step for future improvement in the
provision of such services. In our study, lack of access to clinical trainings was the most commonly
cited reason as a barrier to the provision of such services. Most of the participants also believed
that proper training about how to diagnose, how to select medications for common ailments,
how to counsel the customers coming with symptoms have a significant impact on their
practice. Treating minor ailments seems like an easy task but well trained pharmacist should be
available in community pharmacies to improve the service and to decrease medication therapy
related errors. Providing specific trainings that will fill the knowledge and skill gap required
for the provision of minor ailment services is recommended both in academia and practice
settings as it will result in the delivery of such services in a more skillful way than ever before.
Moreover, lack of community awareness on the role of CDROs in the management of minor
ailments was also noted as one of the main challenge faced by community pharmacy
professionals. It has also been reported that some patients did not accept advice on minor ailments
and its management delivered by the pharmacist. A similar study conducted elsewhere also
reported that lack of knowledge, lack of confidentiality and privacy and lack of awareness of
services are the main barriers preventing young adults accessing pharmacy services [
Improving community awareness regarding the role of community pharmacy professionals in
management of minor ailments could be one potential solution for proper management of
minor ailments. Overcoming the aforesaid barriers also needs restructuring the health care
system of the country in an attempt to integrate community pharmacists into the provision of
a variety of public health services including minor ailment management. Moreover,
considering compensation for service delivery and re-statement of the role and responsibility of
community pharmacy professionals may result in a better service delivery.
Strength and limitations
This study highlights an area of pharmacy practice where there is lack of literature in Ethiopia.
All simulated visits were audio recorded so as to avoid counting on the human cognitive
processes, which has been cited as a potential shortcoming of the SP methodology. Yet, the study
has some limitations that should be taken into account while interpreting the results. It was
conducted in community pharmacies serving a relatively homogenous population. Moreover,
opinions from the public/patient perspective was not collected which might affect the
conclusiveness of some of the findings. Even with the above limitations, this study has significant
implications for improving the involvement of community pharmacists in managing minor
ailments in community pharmacy settings.
Community pharmacy professionals provided inadequate therapy for the simulated minor
ailments. Lack of access to clinical trainings and poor community awareness were the most
commonly cited barriers for providing such services in CDROs. There is a need to ensure that
patients know the role of community pharmacy professionals as a care provider for these
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conditions and the ailments that are appropriate for management in CDROs. Public campaigns
and community sensitization are also recommended to improve community's awareness and
boost the uptake of these services. Large scale studies exploring community pharmacy
professionals' involvement in managing minor ailments on a national scale may also be needed to
identify more barriers and to better inform regulatory bodies.
S1 File. Data collection tool for the simulated study.
The authors acknowledge the Support of School of pharmacy, University of Gondar in
facilitating the data collection process.
Conceptualization: Asnakew Achaw Ayele, Henok Getachew Tegegn, Begashaw Melaku
Gebresillassie, Alemayehu Birhane Mekonnen, Daniel Asfaw Erku.
Data curation: Asnakew Achaw Ayele, Henok Getachew Tegegn.
Formal analysis: Asnakew Achaw Ayele, Abebe Basazn Mekuria, Henok Getachew Tegegn,
Alemayehu Birhane Mekonnen.
Investigation: Asnakew Achaw Ayele, Abebe Basazn Mekuria, Begashaw Melaku
Gebresillassie, Daniel Asfaw Erku.
Methodology: Asnakew Achaw Ayele, Abebe Basazn Mekuria, Henok Getachew Tegegn,
Begashaw Melaku Gebresillassie, Alemayehu Birhane Mekonnen, Daniel Asfaw Erku.
Supervision: Begashaw Melaku Gebresillassie, Alemayehu Birhane Mekonnen.
Visualization: Daniel Asfaw Erku.
Writing ± original draft: Asnakew Achaw Ayele, Abebe Basazn Mekuria, Henok Getachew
Tegegn, Begashaw Melaku Gebresillassie, Alemayehu Birhane Mekonnen, Daniel Asfaw
Writing ± review & editing: Asnakew Achaw Ayele, Alemayehu Birhane Mekonnen, Daniel
9 / 11
Werner JB, Benrimoj SI (2008) Audio Taping Simulated Patient Encounters in Community Pharmacy to
Enhance the Reliability of Assessments. Am J Pharm Educ 72: 136. PMID: 19325956
10 / 11
1. World Health Organization. Good pharmacy practice (GPP) in community and hospital pharmacy settings . Geneva . 1996 ; 1 ± 10 .
2. International Pharmaceutical Federation. Statement of principle self-care including self-medication: The professional role of the pharmacist . 1996 ; pp 1± 5 .
3. Abdu-Aguye SN , Shehu A , Ahmad UI . Management of musculoskeletal pain in retail drug outlets within a Nigerian community: a descriptive study . Pharmacy Practice 2017 Jan-Mar; 15 ( 1 ):873 https://doi.org/ 10.18549/PharmPract. 2017 . 01 .873 PMID: 28503221
4. Sewak NP , Cairns J. A modeling analysis of the cost of a national minor ailments scheme in community pharmacies in England . IJPP . 2011 ; 19 ( s1 ): 50
5. United-Kingdom Department of Health: Choosing health through pharmacy±a programme for pharmaceutical public health 2005 ± 2015 .
6. Pharmaceutical Service Negotiating committee . NHS community pharmacy contractual framework enhanced service: minor ailment service . 2005 ; pp 9± 11 .
7. Benrimoj S , Frommer M. Community Pharmacy in Australia . AustHealth Rev . 2004 ; 28 ( 2 ): 238 ± 246 .
8. Surur AS , Getachew E , Teressa E , Hailemeskel B , Getaw NS , Erku DA . Self-reported and actual involvement of community pharmacists in patient counseling: a cross-sectional and simulated patient study in Gondar, Ethiopia . Pharmacy Practice 2017 Jan-Mar; 15 ( 1 ): 890 . https://doi.org/10.18549/ PharmPract. 2017 . 01 .890 PMID: 28503225
9. Erku DA , Mekuria AB , Surur AS , Gebresillassie BM . Extent of dispensing prescription-only medications without a prescription in community drug retail outlets in Addis Ababa, Ethiopia: a simulated-patient study . Drug, Health care and Patient Safety . 2016 ; 8 : 65 ± 70 .
10. Sumia S , Mohamed A , Mahmoud AA . The role of Sudanese community pharmacists in patients' self-care . Int J Clin Pharm . 2014 ; 36 : 412 ±419 https://doi.org/10.1007/s11096-013 -9911-8 PMID: 24442644
11. Ayalew Mohammed Biset. Self-medication practice in Ethiopia: a systematic review . Patient Preference and Adherence 2017 : 11 401 ±413 https://doi.org/10.2147/PPA.S131496 PMID: 28280312
12. Hailemichael W , Sisay M , Mengistu G . Assessment of the knowledge, attitude, and practice of selfmedication among Harar Health Sciences College students, Harar, eastern Ethiopia . J Drug Deliv Ther . 2016 ; 6 : 31 ± 36 .
13. Complete report on 2007 Ethiopian census . Central statistical agency . http://www.csa.gov.et/index. php/census-report/census-tables/category/301-census-tables
15. Creswell JW , Clark VLP . Designing and Conducting Mixed Methods Research . 2nd ed. Thousand Oaks, California: Sage Publications, Inc; 2011
16. Sandelowski M. Sample size in qualitative research . Res Nurs Health 1995 ; 18 : 179 ±183 PMID: 7899572
17. Guest G , Bunce A , Johnson L . How many interviews are enough? Field Methods 2006 ; 18 : 59 ± 82
18. Manolakis PG , Skelton JB . Pharmacists' contributions to primary care in the united states collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers . Am J Pharm Educ . 2010 ; 74 ( 10 ): S7 PMID: 21436916
19. Coelho RB , Costa FA . Impact of pharmaceutical counseling in minor health problems in rural Portugal . Pharmacy Practice 2014 Oct-Dec; 12 ( 4 ): 451 . PMID: 25580167
20. Cardol M , Schellevis FG , Spreeuwenberg P , van de Lisdonk EH. Changes in patients' attitudes towards the management of minor ailments . Br J Gen Pract 2005; July 2005 ; 55 ( 516 ): 516 ± 21
21. Campbell MK , Silver RW , Hoch JS , Østbye T , Stewart M , Barnsley J , et al. Re-utilization outcomes and costs of minor acute illness treated at family physician offices, walk-in clinics, and emergency departments . Canadian Family Physician 2005 ; 51 ( 1 ): 82 ± 93
Watson MC , Cleland JA , Bond CM . Simulated patient visits with immediate feedback to improve the supply of over-the-counter medicines: a feasibility study . Fam Pract . 2009 ; 26 ( 6 ): 532 ± 542 . https://doi. org/10.1093/fampra/cmp061 PMID: 19828574
23. Kagashe GAB , Minzi O , Matowe L . An assessment of dispensing practices in private pharmacies in Dar-es- Salaam , Tanzania. International Journal of Pharmacy Practice . 2011 ; 19 : 30 ±35 https://doi.org/ 10.1111/j.2042- 7174 . 2010 . 00075 . x PMID : 21235657
24. Contopoulos-Ioannidis DG , Koliofoti ID , Koutroumpa IC , Giannakakis IA , Ioannidis JP . Pathways for inappropriate dispensing of antibiotics for rhinosinusitis: a randomized trial . Clin Infect Dis . 2001 ; 33 ( 1 ): 76 ±82 https://doi.org/10.1086/320888 PMID: 11389498
25. Alvarez-Uria G , Seeba Zachariah S , Thomas D. High prescription of antimicrobials in a rural district hospital in India . Pharmacy Practice 2014 Apr-Jun; 12 ( 2 ):384 PMID: 25035714
26. Llor C , Cots JM . The sale of antibiotics without prescription in pharmacies in Catalonia , Spain. Clin Infect Dis . 2009 ; 48 ( 10 ): 1345 ±9. https://doi.org/10.1086/598183 PMID: 19361303
27. Bartoloni A , Cutts F , Leoni S , Austin CC , Mantella A , Guglielmetti P , et al. Patterns of antimicrobial use and antimicrobial resistance among healthy children in Bolivia . Trop Med Int Health . 1998 ; 3 ( 2 ): 116 ± 23 . PMID: 9537273
28. Larsson M , Kronvall G , Chuc NT , Karlsson I , Lager F , Hanh HD , et al. Antibiotic medication and bacterial resistance to antibiotics: a survey of children in a Vietnamese community . Trop Med Int Health . 2000 ; 5 ( 10 ): 711 ± 21 . PMID: 11044266
29. Ong CK , Seymour RA , Lirk P , Merry AF . Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain . Anesth Analg . 2010 ; 110 ( 4 ): 1170 ± 1179 . https://doi.org/10.1213/ANE.0b013e3181cf9281 PMID: 20142348
30. Molloy P , Chambers R , Cork T. How well are national guidelines relating to the general sales of aspirin and paracetamol, adhered to by retail stores: a mystery shopper study . BMJ Open . 2016 ; 6 ( 1 ): e010081. https://doi.org/10.1136/bmjopen-2015 -010081 PMID: 26781508
31. Okeke TA , Uzochukwu BS , Okafor HU. An in-depth study of patent medicine sellers' perspectives on malaria in a rural Nigerian community . Malar J . 2006 ; 5 : 97 . https://doi.org/10.1186/ 1475 -2875-5-97 PMID: 17078875
32. Uzochukwu BS , Onwujekwe OE , Okwuosa C , Ibe OP . Patent medicine dealers and irrational use of medicines in children: the economic cost and implications for reducing childhood mortality in Southeast Nigeria . PLoS One . 2014 ; 9 ( 3 ):e91667. https://doi.org/10.1371/journal.pone. 0091667 PMID: 24621618
33. Edwards R , Dymoss M , Hesslewood J. Improving the use of community pharmacies among 16±24 year olds in the Dudley borough . IJPP . 2011 ; 19 ( S2 ): 31 ± 2