Editor-in-Chief Hatice Kübra Elçioğlu Vice Editors Levent Kabasakal Esra Tatar Online ISSN 2630-6344 Publisher Marmara University Frequency Bimonthly (Six issues / year) Abbreviation J.Res.Pharm. Former Name Marmara Pharmaceutical Journal
Journal of Research in Pharmacy 2010 , Vol 14 , Num 1
The pharmacy practice of community pharmacists in Turkey
Hale Z. Toklu1, Ahmet Akici2, Şule Oktay2, Sanda Cali3, Sena F. Sezen1, Meral Keyer-Uysal1
1Marmara University, School of Pharmacy, Department of Pharmacology, Istanbul, Turkey
2Marmara University, School of Medicine, Department of Pharmacology & Clinical Pharmacology, Istanbul, Turkey
3Marmara University, School of Medicine, Department of Public Health, Istanbul, Turkey

Sule Oktay; EmeritusPresent adress: KAPPA Consultancy Training Research Ltd, Istanbul
Sena Sezen; Present address: Johns Hopkins Medical Institutions, Baltimore, USA
Meral Keyer Uysal; Emeritus DOI : 10.12991/201014464


Serbest eczanelerdeki (SE) iyi eczacılık uygulamaları akılcı ilaç kullanımı (AİK) açısından oldukça önemli bir basamağı oluşturmaktadır. Bu çalışmada serbest eczacılık uygulamalarının AİK ilkeleri açısından incelenmesi amaçlandı. Bir müdahale araştırmasının bir bölümünü oluşturan bu çalışmada, 2002 yılında İstanbul, Ümraniye'deki 84 SE'nin eczacılık uygulamaları, yüz yüze görüşme yoluyla yapılan anket ve simüle senaryo uygulaması ile değerlendirildi. Bir reçetenin ortalama karşılanma süresi, reçete karşılama davranışı, ilaç kutusuna gerekli işaretlemenin yapılması gibi AİK parametreleri değerlendirildi. Bulgularımıza göre simüle çalışmalar sırasında eczacıların %32,0'ı eczanelerinde bulunmuyordu. Reçetelerin sadece %40,5'i eczacılar tarafından karşılandı. Eczacı kalfalarının % 44,5'inin eğitim düzeyi ilkokul mezunu düzeyinde idi. Eczacılar, hastalarının yaklaşık yarısının herhangi bir reçetesi olmadan eczaneye başvuran kişilerden oluştuğunu beyan etti. Reçetenin karşılanma süresini ankette eczacılar ortalama 287 saniye olarak ifade etmesine karşın, bu sürenin simüle reçete senaryolarında 149 saniye olduğu saptandı. Tüm eczacılar ilaçların nasıl kullanılacağı konusunda hastalarını bilgilendirdiklerini ifade ederken, simüle reçete senaryolarında reçetelerin sadece %43,0'ının yeterli işaretlemelerinin ilaç kutusuna yapıldığı ve sadece %6,5'ine eczanede ilacı kendilerine sunan tarafından ilaçları ile ilgili etkileşimler konusunda bilgi verildiği saptandı. Sonuç olarak, iyi eczacılık uygulamaları açısından İstanbul'da araştırmanın yapıldığı bölgedeki SE'de yapılan eczacılık uygulamalarının yetersiz olduğu görülmektedir. Reçeteli ya da reçetesiz çoğu hastanın ilaçları konusunda sıklıkla başvurduğu yerin SE'ler olduğu dikkate alındığında bu araştırmanın bulguları, eczacıların ve diğer eczane çalışanlarının sürekli eğitim kapsamında AİK ilkeleri doğrultusunda eğitim almalarının gerekli olduğunu ortaya koymaktadır.


In the last century the pharmacy profession consisted of compounding and dispensing medicines. As the compounding functions were significantly reduced in the last decade, the new role of the profession needed to be developed[1]. The role of the today’s pharmacists needs to be expanded to include pharmaceutical care concepts, making the pharmacist into a healthcare professional rather than a shopkeeper in a commercial enterprise[2]. The mission of a pharmacy practice is to provide medications and other health care products and services and to help people and society to make the best use of them[3,4].

Effective therapy with prescribed medicines requires a collaborative process that includes physicians and pharmacists. Possible errors about the medication can be detected and reduced by pharmacists’ interventions[5-10]. The pharmacist is often the last member of the health care team to see the patient, before the patient starts using the drug. Additionally, pharmacists are accessible to patients, often seeing them on several occasions between routine physician visits. Therefore, it is the pharmacist’s responsibility to ensure the safe and appropriate use of the medication by the patient[11-14].

The prescription order is a part of the professional relationship between the prescriber, the pharmacist and the patient[15]. Correct prescribing does not guarantee that the drugs are used properly. Reasons for non-adherence may be inadequate drug information, inadequate labelling, lack of money, and cultural perceptions about drugs[16]. Information is as important as the appropriateness of the medicines themselves. The pharmacist must provide the necessary information and guidance to assure the patient’s compliance in taking the medication properly[15].

Providing healthcare should now include provision of appropriate information, explanation and emotional understanding of the patients[17]. More effective, fact-based information on drugs could possibly bring a more positive attitude towards drugs, leading to better compliance[18]. The responsibility for noncompliance should be directed at the physician and/or pharmacist if they fail to give the patient adequate instructions or present them in a manner he does not understand[19].

Irrational use of drugs is a common problem in many countries, especially in developing countries[20], since in many developing countries community pharmacies are the main source of drugs. Rational use of drugs (RUD) requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time and at the lowest cost to them and their community[21]. Since pharmacists are an important part of the integrative health system, their role should be emphasised in promoting rational use of drugs[14]. In many countries the pharmacist has a changing role as patient counsellor/educator and as an intermediary to affect patient outcomes in ambulatory settings. Thus, pharmacists have an important role in the safe and effective use of pharmaceuticals by providing sufficient and accurate information to patients and monitoring the drug therapy. Good pharmacy practice in community pharmacies is essential for a proper dispensing process thereby promoting a rational use of drugs[22,23].

Formally, the dispenser is a person who has had a special training in the art of preparing and giving medicines. In many countries (especially developing countries) dispensers without a formal pharmaceutical training exist. An effective dispenser needs besides marketing skills, knowledge about drugs and the ability to communicate and consult with public and other health care professionals[23].

Although the dispensing process seems to be a simple one, it should be noted that proper dispensing takes time. The quality of dispensing increases with the time spent. The dispensing behaviour is influenced by many factors, i.e. training and knowledge, professional compensation, lack of communication skills, dispenser-prescriber relationships, social status of a dispenser in the healthcare system, public versus private sector, promotional and marketing techniques and availability of supply[14].

In addition to the information provided, the quality of information is also important. The information must be scientifically accurate, unbiased and up-to-date. One FDA study in 2001 showed that although most patients received prescription drug information, the quality of information needed improvement[24].

Community pharmacies in Turkey are private enterprises and are required by law to be managed and owned by pharmacists. Turkish law allows a pharmacist to own and/or run only a single pharmacy. All owners and managers must be registered with the regional Board of Pharmacists. All the regional boards fall under the guidance of the Turkish Pharmacists Association [TEB]. Pharmacists are required to be present in their pharmacies during opening hours, but this is not strictly adhered to. The dispensers are either pharmacists or pharmacy employees. There are numerous untrained employees dispensing without the required supervision.

The aim of the present study was to evaluate the dispensing habits of the community pharmacists in one region of Istanbul from the perspective of RUD.


The following study involves a part of the data of an interventional study in which 84 community pharmacists in the Umraniye district of Istanbul were evaluated by a face to face questionnaire and a simulated case scenario in 2002.

Study population:
The questionnaire was conducted with 84 community pharmacists (total number of pharmacies in the district was 104) who had consented to participate in the study. However, 4 of them could not be reached after the third visit and 9 of them dropped after a few questions and 71 pharmacists completed the questionnaire.

Questionnaire: The questionnaire consisted of 30 structured questions which were prepared to determine the sociodemographic characteristics of the pharmacists and pharmacy employees and the dispensing habits of the pharmacists. The structured statements were strongly agree, agree, no idea, disagree and strongly disagree.

Simulated Case Scenario: A 25 year-old patient enters the pharmacy with a constant prescription of a tetracycline capsule (Tetralet®) twice a day. Before leaving the pharmacy, (s)he asks the dispenser, if (s)he could take this antibiotic with an antacid or milk, because (s)he has gastritis.

The simulated patients (undergraduate students of Marmara University School of Pharmacy) visited the pharmacies two days after the questionnaire. After leaving the pharmacy, they filled out a form about the dispensing behaviours of the dispensers (pharmacist or pharmacy employee), who had evaluated their prescription.

Rationality indicators

The rationality indicators evaluated in the study were average dispensing time, stock availability and adequate labelling of the drug. The average dispensing time (starts with entering the pharmacy and ends with leaving the pharmacy) was recorded by the use of stopwatches. The data in the questionnaire and practice results of the simulated scenario were matched for each pharmacy.

Average dispensing score

An average dispensing score was calculated for each dispenser. The maximum dispensing score was 16 for the dispensed drug. The dispensing score was based on the given verbal and written information (Table 1).

TABLE 1: Calculation of the total dispensing score (Maximum score = 16)

Statistical Analysis: The data were subjected to frequency analysis by the Statistical Package for Social Sciences® (SPSS) software version 11.0 for windows. A frequency analysis and Student’s t test were performed for the statistical analysis. The level of statistical significance was accepted as p<0.05.


The questionnaire was conducted with 80 community pharmacists, (total number of pharmacies in the district was 104) who participated in the study. However, 9 of them dropped after a few questions and 71 pharmacists completed the questionnaire. The overall response rate was 76.9% (80/104). The majority of the community pharmacists were female (79.2%) and middle-aged. The average age for all pharmacists was 38.8 ± 10.6. The average years since graduation was 15.5 ± 9.1 and the experience as a community pharmacist was 11.1 ± 9.0 years. 12.7% had a post-graduate education and 41.8% had another professional experience in a drug company or a hospital pharmacy.

All the pharmacists stated that they used a computer for online connection to the web-sites of social insurance organisations for reimbursement applications of the prescriptions. There was at least one non-pharmacist employee working in 87.5% of the pharmacies. The average number of employees was 2 per pharmacy. Almost half (44.5 %) of the pharmacy employees had a primary school degree and 90.5 % of the pharmacists believed their employees were satisfactory in dispensing drugs on their own.

The pharmacists stated that the proportion of the patients who had a prescription was similar to the patients applying without a prescription. Most of the pharmacists said that they served up to 30 patients with/without prescription per day. The reported number of patients applying at a pharmacy in a day is shown in Table 2.

TABLE 2: The reported daily number of applications to a pharmacy by the prescription status

The statements of pharmacists about the items they checked on a prescription are shown in Table 3. All the pharmacists claimed to have checked the instructions about dosing and medication dosage. 97.2% of pharmacists checked the duration of medication and 90.1% checked the pharmaceutical dosage forms. The diagnosis and date of prescription were checked by 81.7 and 88.7% respectively. The name and age of the patient seemed to be checked less frequently (64.7 and 69.0% respectively).

TABLE 3: Statements of pharmacists about the points they check in a prescription

Table 4 shows the type of problems pharmacists reported that they had to face on a prescription. The three most common problems were illegible prescriptions (83.1%), unavailable drugs (73.3%), and inadequate instructions about the medication (56.4%) (Table 4). The other problems included: being unable to persuade the patient or doctor about an equivalent drug, high cost of the drugs, prescriptions being written by brand-name/lack of the generic drugs in the prescriptions.

TABLE 4: Statements of pharmacists about the problems they face on a prescription

Pharmacists reported that in the case of a prescription problem, their approach was to call the doctor (95.8%), ask a colleague (43.7%), use their own knowledge/ judgement (93.0%), check a reference book or drug index etc (21.1%), (Table 5).

TABLE 5: Pharmacists’ approaches to prescription problems

All the pharmacists reported that they informed the patients about the diagnosis, the dosing of the drugs and the instructions for administering the drug (Table 6). Other information given was the duration of medication (95.8%), equivalent drugs (91.6%), storage conditions (91.6%), food interactions (78.9%), diagnosis (77.4%), compliance (76.0%), possible side effects (74.6%) and drug interactions (66.2%).

TABLE 6: Statements of pharmacists about the information they provide to the patients about their prescriptions/ medications

Sixty nine percent of pharmacists believed that the patients do clearly understood the information they were given. Half of them confirmed and clarified the understanding of the patients (Table 7).

TABLE 7: Statements of pharmacists about their attitudes in providing information

According to their statements 74.6% of pharmacists were unsatisfied with their profession. Only a small percent (15.5%) was satisfied, while 9.9% had no idea/were unsure about this.

The results of the simulated case scenario
Sixty seven point nine percent of the pharmacists were present in their pharmacies at the time of the study and 90.4% stated that they spent more than 6 hours a day in their pharmacies. 40.5 % of the prescriptions were dispensed by the pharmacists.

The availability of the prescribed drug, another rationality indicator, was 81.0% for our study. The prescription given by the simulated patients was dispensed in 93.0 % (n=78) of the 84 pharmacies whereas six dispensers (7.0%) refused the prescription because the drug was not available. In other pharmacies, the prescribed drug was replaced by an equivalent after informing the patient (5.0%) or without informing the patient (6.0%). Overall, 92.0% of the patients had access to the prescribed drug or its equivalent. In one pharmacy (1.0%) tetracycline capsules were unavailable and it was replaced by doxycycline capsules.

The declared average dispensing time (287 ± 241 seconds) for a prescription of a single drug was almost twice the time measured (149 ± 72 seconds) by the simulated patients.

Adequate labelling of the drug is another patient care indicator for RUD. The number of drug packages adequately labeled was 43.0%, whereas 10.0% were unlabeled. Moreover, 47.0% of the labeled packages were mislabeled or inadequately labeled.

In spite of the pharmacists’ statements about informing the patients (Table 6), it seems that their statements were only partially consistent for the instructions about medication. The information about the duration of medication, drug interactions, possible side effects, contraindications and storage instructions was not given at all. The other information given was the name of the drug (20.0%), diagnosis/ purpose of the drug (8.9%), pharmaceutical dosage form of the prescribed drug (3.8%) and dosing of the drug (6.3%). 1.3% of the simulated patients were misinformed about the dosing schedule (Table 8).

TABLE 8: Information given by pharmacists to the simulated patients about prescriptions/ medications

Some of the pharmacists claimed that they warn their patients about potential drug and food interactions (66.2 and 78.9% respectively) (Table 6), but only a few patients (6.5%) in the simulated case scenario were warned about both interactions by the dispensers. When asked by the simulated patients, half of the dispensers (50.6%) approved that tetracycline capsule could be taken together with an antacid or milk (Table 9).

TABLE 9: The dispensers performance about the warnings to antacid and dairy product interactions with tetracycline in the case scenario

The average dispensing score for the pharmacists was 3.7 ± 1.8 (n=32) while it was 2.9 ± 1.0 (n=45) for the non-pharmacist dispensers (p<0.01). The average dispensing score of the pharmacists was not influenced by the factors such as sex, age or workload. On the other hand the dispensing score was found to be significantly higher for the pharmacists whose experience as a community pharmacist was 5 years or less (Table 10).

TABLE 10: Factors influencing the dispensing score


√ Average dispensing time should be longer so that there will be enough time for counselling.

√ The dispensing score may be a useful method for the assessment of the quality of dispensing and intervention studies aimed at improving the quality of dispensing may be carried out using this score.

√ The dispensing scores of pharmacists are significantly higher than those of the non pharmacist dispensers. Therefore, only trained health staff should be allowed to provide dispensing services. Although TEB has been active in organizing training programs for the non pharmacist employees in recent years, no formal training is required by law.

√ The average dispensing score of the pharmacists was not influenced by factors such as sex, age or workload but is closely associated with experience.

√ It is essential that undergraduate and postgraduate education of pharmacists and other health care professionals aim to improve the quality of dispensing.

The authors would like to thank Hedef-Alliance Holding A.Ş. who supported this study as well as the pharmacists who participated for their time and cooperation. The authors are also grateful to R. W. Guillery for English editing.

Conflict of Interest:
None declared.


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