Parental decision-making for over-the-counter plant-based products used in children: A Bulgarian cross-sectional survey with implications for community pharmacy

Pharmacia 73: e193614 DOI 10.3897/pharmacia.73.e193614 Research Article Parental decision-making for over-thecounter plant-based products used in children: A Bulgarian cross-sectional survey with implications for community pharmacy Bozhidarka Hadzhieva1 , Kristina Kilova2 , Milen Dimitrov3 1 Medical College, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., Plovdiv 4002, Bulgaria 2 Department of Medical Informatics, Biostatistics and Electronic Learning, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., Plovdiv 4002, Bulgaria 3 Department of Pharmaceutical Technology and Biopharmacy, Medical University of Sofia, 2 Dunav Blvd., Sofia 1000, Bulgaria Corresponding author: Milen Dimitrov () Received 30 March 2026 ♦ Accepted 12 April 2026 ♦ Published 4 May 2026 Citation: Hadzhieva B, Kilova K, Dimitrov M (2026) Parental decision-making for over-the-counter plant-based products used in children: A Bulgarian cross-sectional survey with implications for community pharmacy. Pharmacia 73: e193614. https://doi. org/10.3897/pharmacia.73.e193614 Abstract Background: Over-the-counter (OTC) plant-based medicinal products are widely used in pediatric self-care, yet evidence on what drives parental product choice remains limited, particularly in Central and Eastern Europe. Understanding these decision drivers matters not only for counseling quality and safer self-medication but also for clarifying how community pharmacies function as real-world points of guidance in routine child self-care. Aim: To identify the main determinants of parents’ decisions when purchasing OTC plant-based products for children, with particular emphasis on the roles of physicians and pharmacists. Methods: A cross-sectional anonymous online survey was conducted using Google Forms among parents in five Bulgarian cities (Sofia, Plovdiv, Ruse, Pazardzhik, and Dobrich) between December 2023 and April 2024. Descriptive statistics were calculated; associations were assessed using Pearson’s chi-square test with Cramér’s V, and multivariable logistic regression was applied for key decision factors. Results: A total of 1305 respondents completed the questionnaire. Previous experience and physician recommendation were the strongest drivers of product choice. Pharmacist recommendation was also influential, with 64.0% of respondents rating it as moderately or very important; 92.5% reported purchasing these products from pharmacies, and 76.9% reported trusting pharmacists’ advice. Advertising had the weakest influence (6.8% rated it as very important). Several apparent demographic differences attenuated after multivariable adjustment. Conclusion: In this large Bulgarian convenience sample, parental decisions were shaped mainly by familiarity and professional advice rather than promotional messaging. The findings highlight community pharmacies as a practical setting for improved OTC counseling, safer pediatric self-care, and more evidence-aligned use of plant-based products, while also offering a useful country-specific reference point for future work on parental self-medication behavior in regulated pharmacy settings. Copyright Hadzhieva B et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 2 Hadzhieva B et al.: Parental decision-making for OTC plant-based products Graphical abstract Keywords Bulgaria, children, community pharmacy, counseling, herbal medicinal products, OTC medicines, parental decision-making, pediatric self-care, self-medication, survey Introduction Over-the-counter (OTC) plant-based medicinal products are widely used in pediatric self-care, yet relatively little is known about how parents weigh previous experience, professional advice, availability, price, and promotional cues when selecting these products for children. International evidence suggests that parent-directed medication choices are shaped by prior experience, perceived safety, convenience, symptom interpretation, and the credibility of professional advice rather than by any single factor alone (Seth et al. 2023; Tarciuc et al. 2023; Aydın Aksoy et al. 2024; Haq et al. 2025). Country-specific analyses, therefore, remain important because the balance between self-care, physician input, pharmacist counseling, and retail access is influenced by the local OTC market, regulatory framework, and community-pharmacy culture. In Bulgaria, recent work has documented both the substantial pediatric availability of plant-containing OTC medicines and the active role of community pharmacists in supporting more responsible self-medication (Hadzhieva and Petkova-Dimitrova 2024; Hadzhieva et al. 2025). Earlier Bulgarian work on OTC market practices likewise suggests that nonprescription product selection is shaped by more than product characteristics alone, which reinforces the relevance of market-facing and point-of-purchase influences in this field (Petkova et al. 2014). The regulatory positioning of herbal medicinal products also deserves attention because parents may interpret plant origin as a marker of mildness or safety, even when age-related restrictions, indication boundaries, and evidence limitations still matter in practice (European Parliament and the Council 2004; Hadzhieva et al. 2023; European Medicines Agency 2023; European Medicines Agency 2024; European Medicines Agency 2025). Evidence from neighboring and other international settings further suggests that parents may prefer plantbased options because they are viewed as familiar, natural, or gentler, while still turning to healthcare professionals when uncertainty or perceived risk increases (Seth et al. 2023; Petran et al. 2024; Haq et al. 2025). Against that background, the present study aimed to identify the main factors influencing parents’ decisions when purchasing OTC plant-based products for children in Bulgaria, with particular emphasis on the relative roles of physicians, pharmacists, and non-professional influences. By clarifying which decision drivers matter most at the point of choice, the study provides practice-relevant evidence for community-pharmacy counseling and a useful comparative reference for future work on pediatric self-care, parental health behavior, and OTC decision-making in regulated pharmacy settings. Pharmacia 73: e193614 Materials and methods Study design and setting A cross-sectional survey design was employed. Data were collected using an anonymous online questionnaire administered via Google Forms between December 2023 and April 2024. The survey targeted parents residing in five Bulgarian cities: Sofia, Plovdiv, Ruse, Pazardzhik, and Dobrich. 3 adjusted associations between respondent characteristics (gender, age group, education, and city) and higher importance ratings (scores 3–4 vs. 1–2) for key decision factors (physician presc (...truncated)