Self-Medicating for Pain: A Public Health Perspective.

BACKGROUND: Pain is one of the symptoms for which any man is willing not only to go to the doctor but also to resort to any means, including self-medication, to "get rid" of it. Self-medication is not only a current practice but also a public health problem, under the circumstances that it can influence the way in which a disease is diagnosed and/or treated in a timely manner, and, consequently, repercussions may occur on the cost of treatment, in the case of severe forms. Pain is a vital symptom, and the diminution until the disappearance of pain is a fundamental right of each individual; the analysis of ethical issues in the case of self-administration of analgesic medication has not been a major concern. AREAS OF UNCERTAINTY: Understanding the problem is important to realize whether self-medicating for pain is a necessity or an abuse, and in this respect, we review scientific articles from international databases: PubMed and ProQuest. DATA SOURCES: The study is based on the consultation of scientific articles from international databases-PubMed and ProQuest, the main keywords in the search being pain and self-medication, to which a stigma or public health is sequentially added. RESULTS: Pain is becoming more and more a global problem and the extent of its spread can substantiate our assertion about pathology with pandemic impact. Under the pressure of patient associations, of the media, and of nonmedical authorities, the opinion about the need for a stoic approach to pain has long become an outdated theory, and chronic pain, beyond a multidimensional approach, is increasingly considered not only a useless element but also even a destructive one. CONCLUSIONS: Pain and self-medication must be addressed, including in medical practice, starting from their multidimensionality from the following perspectives: medicobiological, sociocultural, instructive-educational, legal-political, and especially ethical. They are not only individual health problems but also become, when connected with a stigma, a public health problem.

A comparison of usual care, a patient-centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting.

AIM: To compare medication adherence and readmissions in patients who received usual care vs. patient-centred interventions. BACKGROUND: Medication adherence is a complex behaviour that may be improved with patient-centred strategies. METHOD: A non-concurrent convenience sample of 303 hospitalised patients received either usual care (n = 98) or patient-centred interventions (n = 205). Intervention patients received teach-back and medication tools (n = 137) or motivational interviewing (n = 68). Data were collected at discharge (T1), at 48-72 hours (T2) and 30 days after discharge (T3). RESULTS: No significant differences were found in medication adherence, therapeutic alliance, patients' experience and readmissions between groups. Patients in the motivational interview group reported lower confidence with medication adherence at T1 (P = 0.01) and T2 (P = 0.00) than the patient-centred intervention group. Motivational interviewing was a significant predictor (ß = -1.55, P = 0.01, OR 0.21, 95% CI 0.06, 0.72) of fewer readmissions. CONCLUSION: Overall, patients reported very low levels of non-adherence and very high levels of confidence and importance of medication adherence. IMPLICATIONS FOR NURSING MANAGEMENT: Medication adherence continues to be an important area for clinical inquiry. For those patients who lack confidence for medication adherence, comprehensive patient-centred strategies such as motivational interviewing may improve treatment outcomes.

[Household storage and use of medications in a population served by the family health strategy in Brazil]. / Estoque doméstico e uso de medicamentos em uma população cadastrada na estratégia saúde da família no Brasil.

OBJECTIVE: To identify families served by the family health strategy (FHS) storing medicines at home, to evaluate storage conditions, and to investigate medicine use practices. METHODS: The study was conducted in a municipality in the state of São Paulo with two FHS units serving 1 867 households. The sample was selected by means of stratified random sampling. Data collection was conducted through semistructured interviews from July to October 2008. RESULTS: One resident was interviewed in each of the 280 households visited. Medicines were found in 255 households (91.1%). Of 326 storage locations, 217 (75.8%) were inadequate (easily accessible to children or exposed to moisture, light). Of the 2 578 medicines identified, 2 059 medicines (79.9%) in 236 (84.3%) households had safety or identification problems. Of the 280 respondents, 179 (63.9%) used medications. Of these, 24 were self-medicating, only one with an over-the-counter drug. Only 44 users had the prescription for their medication, and 21 did not follow the prescription in terms of dosage or had interrupted the treatment. CONCLUSIONS: Non-adherence to recommended treatment can lead to negative outcomes, such as inefficiency (using dosages lower than prescribed), poisoning (using dosages higher than prescribed), and other adverse reactions.

[Family pharmacy: survey of a sample of patients in Midi-Pyrénées]. / La pharmacie familiale : enquête auprès d'un échantillon de patients en Midi-Pyrénées.

OBJECTIVE: Possession of drugs at home in the family pharmacy and self-medication are at risk. METHOD: Appraisal based upon an analysis of 247 questionnaires completed by patients and 116 questionnaires completed by general practitioners in the French department of Haute Garonne (Southwestern, France). RESULTS: Two hundred and forty-four patients were involved in the study. In 80% of cases, women were in charge of family pharmacy who was located in 66% of cases in a unsecurise room and could be reached by children in 17% of cases. Drugs most frequently found: antiseptics (97%), paracetamol (91%), anti-inflammatory drugs (68%), anti-diarrhea (60%). For the physicians 52 useable questionnaires, 80% of physician were confronted with one of three risks: self-medication, drug autolysis, poisoning in children. CONCLUSION: Women are the referent of the family pharmacy. The doctors seem best placed to a message of prevention through minimal advice.

Self-medication of migraine and tension-type headache: summary of the evidence-based recommendations of the Deutsche Migräne und Kopfschmerzgesellschaft (DMKG), the Deutsche Gesellschaft für Neurologie (DGN), the Österreichische Kopfschmerzgesellschaft (ÖKSG) and the Schweizerische Kopfwehgesellschaft (SKG).

The current evidence-based guideline on self-medication in migraine and tension-type headache of the German, Austrian and Swiss headache societies and the German Society of Neurology is addressed to physicians engaged in primary care as well as pharmacists and patients. The guideline is especially concerned with the description of the methodology used, the selection process of the literature used and which evidence the recommendations are based upon. The following recommendations about self-medication in migraine attacks can be made: The efficacy of the fixed-dose combination of acetaminophen, acetylsalicylic acid and caffeine and the monotherapies with ibuprofen or naratriptan or acetaminophen or phenazone are scientifically proven and recommended as first-line therapy. None of the substances used in self-medication in migraine prophylaxis can be seen as effective. Concerning the self-medication in tension-type headache, the following therapies can be recommended as first-line therapy: the fixed-dose combination of acetaminophen, acetylsalicylic acid and caffeine as well as the fixed combination of acetaminophen and caffeine as well as the monotherapies with ibuprofen or acetylsalicylic acid or diclofenac. The four scientific societies hope that this guideline will help to improve the treatment of headaches which largely is initiated by the patients themselves without any consultation with their physicians.

Healthcare-seeking strategies among displaced children in war-ridden northern Uganda: the case of malaria.

A field study was performed to examine suffering and treatment seeking from the perspective of children aged 8-16 years living in war-affected northern Uganda. Various techniques for collecting qualitative and quantitative data were used, including a semi-structured questionnaire about illness experiences and medicine use over a 1-month recall period. The 165 children who were interviewed were attending primary schools for displaced children and/or commuters' night shelters. The children frequently attributed their common febrile ailments to malaria and used a variety of pharmaceuticals and herbal remedies, as self-medication, for their self-diagnosed malarial episodes. Misdiagnosis of febrile illnesses by the children (as well as by the local healthcare providers) and frequent misuse of medicines in the treatment of these illnesses appeared to be very common. Improvement of the health conditions of these children requires a change of focus. Firstly, children above the age of 5 years who are not under adult care and who are often no longer welcome in the local hospital's paediatric ward need to be accepted at the outpatient clinics currently intended for adults. Secondly, the local diagnostic system needs to be improved, not only so that malaria can be reliably diagnosed but also so that alternative diagnoses can be confirmed or rejected, otherwise the current over-consumption of antimalarial drugs may simply be replaced with an over-consumption of antibiotics.

Self-medication practices in riverside communities in the Brazilian Amazon Rainforest.

OBJECTIVES: to analyze the practice of self-medication and the associated factors in the riverside population of the Middle Solimões river region - Amazon rainforest. METHODS: a cross-sectional population-based study conducted between April and July 2015, through interviews at home. RESULTS: the prevalence of self-medication among the riverside population was 76.3%. Analgesics and antibacterials were the main therapeutic classes used in self-medication. Self-medication proved to be associated with the male gender, young people, not having sought the health service in the last month, longer commuting from the community to the urban area and the habit of consuming allopathic medicines on their own. CONCLUSIONS: self-medication among the riverside population of Coari - Amazon may reflect the need to seek self-care by people, with the use of allopathic medicines without prescription, mainly due to the restricted access to health services.

The role of pharmacists in community education to promote responsible self-medication in Indonesia: an application of the spiral educational model.

Background Community empowerment is one key strategy to improve the health of Indonesians. In 2015, the Government initiated the 'Smart Use of Medications Campaign' to empower Indonesians to practice responsible self-medication. Analysis of a pilot training program established in 2016 identified that improvements were needed in the content and organisation of the module. Objective To evaluate a revised module (applying a spiral model approach) to guide community training as part of the 'Smart Use of Medications Campaign'. Setting The Ngawi District, Indonesia in May 2018. Method Eight pharmacists (trainers) and 39 community representatives (participants) were involved in the training based on the revised module. The module adopted the spiral approach and consisted of three progressive steps: (1) understanding basic concepts of information on the label/package of one medication product; (2) re-enforcing that concept to understand medication classification (applied using three products); and (3) expanding the concept to understand medication classification (applied using a pack of 40 products). Pre-/post-test scores were used, and Focus Group Discussions were conducted to explore the participants' knowledge gain. Main outcome measure: participants' and trainers' views on the spiral process. Result Participants' mean overall knowledge gain increased from 12.53/15 to 13.44/15 (p = 0.001). Six focus groups of participants and two focus groups of trainers perceived that both trainers and participants found the spiral model better facilitated understanding, as it involved step-by-step learning. They also indicated the importance of the role of pharmacists as suitably qualified trainers as well as the development of appropriate training aids/media and arrangements. Conclusion Training based on the spiral model has the potential to be implemented in community training to improve self-medication literacy among the Indonesian public. Support from pharmacists as well as the relevant national and professional bodies is essential for successful implementation of the training.

Is reliance on self-medication and pharmacy care adequate for rhinitis patients?

INTRODUCTION: Many people with rhinitis choose to self-medicate, frequently relying on pharmacy advice. We have investigated the effectiveness of such a treatment. METHODS: To obtain data regarding treatment and outcome of individuals with rhinitis who have not consulted a physician in the past 2 years, a cross-sectional survey was performed. A random sample of the French, German and United Kingdom general population (n = 15,085) was screened, resulting in 818 individuals with rhinitis. Each of these respondents was sent a postal questionnaire. RESULTS: A total of 610 (74.6%) individuals returned the questionnaire. A sum of 42% (256) respondents described their symptoms as moderate and 5% (31) as severe. Multiple triggers were reported by 442 (72.5%) and 30% of respondents reported sleep disturbance (increased to 44% in sedating antihistamine users) > or = 8 nights/month, resulting in reduced cognition and productivity loss in 14.5%. Individuals stated that they did not attend the physician because their symptoms were too trivial (378 - 63.9%) or over-the-counter (OTC) medication was adequate (341 - 57.6%). Only 217 respondents reported currently taking OTC medication (France 30; Germany 82; UK 105). In all countries, antihistamine was the main treatment taken (non-sedating in 38% and sedating in 23% of subjects). Intranasal corticosteroid use (18 - 8.3%) was mainly in the UK where it is available OTC. CONCLUSION: Individuals with rhinitis who do not consult a physician report multiple sensitization, reduced sleep and cognition. Drug utilization appears suboptimal, particularly for those reporting moderate or severe symptoms. Reliance on pharmacy or self-medication may not be adequate for some people.

Prevalence of migraine and tension-type headache among adults in Jordan.

Here, we investigated the prevalence of headache among adults in Jordan. The study was conducted from January 2007 to November 2008. A sample of 4,836 participants were permitted to complete a self-conducted screening questionnaire. As much as 82.3% of participants complained from headache at least once per year. 36.1% were tension-type headache and 59% of the participants had other family members who suffered from headache. Headaches affected everyday activities in 51.6% of the participants; 82.7% of participants did not seek medical attention for their headaches. Among those who used analgesics (75.6%), acetaminophen was the most common (91.43%). In conclusion, headache and overuse of analgesics were prevalent in a significant part of the society. Thus, there is a need to educate the public to ensure safe practices and to make the use and selling of analgesics more stringent.

Keys to successful self-management of medications.

Medication use by community-dwelling elderly accounts for a significant portion of all U.S. drug use. Many elderly manage over three prescriptions a day. Recent evidence indicates that non-adherence to prescribed drug regimens can lead to symptoms that result in hospitalizations. The study's purpose was to explore self-management of medications as perceived by community-dwelling elderly. Guided by Orem's Self-Care Deficit Nursing Theory, 19 older adults were interviewed about their medication self-management practices. Inductive data analysis revealed three major themes: successful self-management of medications, living orderly, and aging well. Success in establishing individual management systems may be the result of developing and maintaining orderly lifestyles.

Revealing undetected problems with medication therapy management services.

Implementation of Medication Therapy Management (MTM) services under the Medicare Modernization Act of 2003 has highlighted the innovative roles that pharmacists are assuming in progressive, community-based practice settings. MTM underscores the vital role that community pharmacists have in helping patients achieve desirable therapeutic outcomes and reduce health care expenses. Pharmacists can: 1) obtain detailed medication histories, 2) assess patient adherence and the development of side effects, 3) educate patients on their medications and disease states, and 4) perform cost-effective therapeutic interchanges in collaboration with prescribers. This case describes an MTM session with a 68-year-old Caucasian male who is a regular prescription customer at a local grocery-store chain pharmacy. The patient was screened and identified by his Medicare Part D plan as one who qualifies for MTM services. He has a history of dyslipidemia, depression, and epilepsy. The patient was contacted by the pharmacist to participate in a MTM appointment to discuss his current medications and disease states. After obtaining a detailed history, the pharmacist identified significant medication-related problems including inappropriate prescribing of medication, self-treatment, and the patient's lack of knowledge concerning his medications. After discussions with the patient and his health care providers, a medication plan was created for the patient to follow. Open communication among the patient, pharmacist, and prescribers is a crucial component to ensure the success of MTM services.

Use of herbs among adults based on evidence-based indications: findings from the National Health Interview Survey.

OBJECTIVE: To examine the extent to which US adults use herbs (herbal supplements) in accordance with evidence-based indications. PATIENTS AND METHODS: The Alternative Health supplement of the 2002 National Health Interview Survey (NHIS) is part of an annual, nationally representative survey of US adults. It contains data on adults' use of the 10 herbs most commonly taken to treat a specific health condition in the past year (January 1 to December 31, 2002). The Natural Standard database was used to formulate evidence-based standards for herb use. These standards were applied to the NHIS data to identify groups of people who used herbs appropriately and inappropriately, using a multivariable logistic regression model. RESULTS: Of the 30,617 adults surveyed, 5787 (18.9%) consumed herbs in the past 12 months; of those, 3315 (57.3%) used herbs to treat a specific health condition. Among people who used only 1 herb (except echinacea and ginseng), approximately one third used it consonant with evidence-based indications. Women and people with a college education were more likely to use herbs (with the exception of echinacea) concordant with scientific evidence. Adults younger than 60 years and black adults were significantly less likely to use herbs (with the exception of echinacea) based on evidentiary referents than their counterparts. However, for echinacea users, no significant differences were detected. CONCLUSION: Roughly two thirds of adults using commonly consumed herbs (except echinacea) did not do so in accordance with evidence-based indications. Health care professionals should take a proactive role, and public health policies should disseminate evidence-based information regarding consumption of herbal products.

Factors associated with herb and dietary supplement use by young adults in the United States.

BACKGROUND: Little is known about the association between use of herbs and dietary supplements (HDS) and lifestyle/behavior factors in young adults in the US. METHODS: Analyzing the 2002 National Health Interview Survey (NHIS), we examined the patterns of HDS (excluding vitamins/minerals) use among young adults in the United States using descriptive statistics and logistic regression. RESULTS: In our sample of 18 to 30 year olds (n = 6666), 26% were current smokers, 24% were moderate/heavy drinkers, 43% had high physical activity, and 54% and 76% use prescription and over the counter (OTC) medications respectively. Non-vitamin, non-mineral HDS was used by 17% of the overall sample in the last 12 months. In the multivariable analysis, the lifestyle and behavioral factors associated with HDS use include: current smoking (odds ratio 1.41 95% CI [1.16-1.72]); being a former smoker (1.50 [1.15-1.95]); moderate/heavy alcohol use (2.02 [1.53-2.65]); high physical activity levels (2.45 [1.98-3.03]); and prescription medication use (1.51 [1.26-1.81]). Among HDS users, only 24% discussed their use with a health care professional. CONCLUSION: Nearly one in five young adults report using non-vitamin/non-mineral HDS.

How does the general public view antibiotic use in China? Result from a cross-sectional survey.

Background Resistance to antibiotics is a major threat to global health and general public play a significant role in the fight against antimicrobial resistance. Objective The present study aimed to identify the knowledge, attitudes, and practice of the general public towards antibiotic use in China. Setting Randomly selected parks in three cities of western, central and eastern China: Xi'an, Changsha, and Nanjing. Method A cross-sectional survey was conducted on a sample of 1400 residents, from January to June 2015. Main outcome measures Knowledge, attitudes and practices scores toward self-medication with antibiotics and compliance with antibiotic regimens. Results The response rate was 86.0% (n = 1204). Only 192 (19.5%) respondents gained a score of 3 or above, and the maximum score of 4, reflecting poor knowledge towards antibiotics. Just over half (54.8%) of respondents incorrectly believed antibiotics were effective against viral infections and only one-third (34.3%) knew that antibiotics were not anti-inflammatories. Nearly half of the respondents (49.0%) had changed the dosage when taking antibiotics, 35.6% switched to another class, 33.4% had not finished the full treatment course and over 60.0% kept leftover antibiotics for future use. Almost half of the respondents (45.7%) stated they had used antimicrobials during the last 6 months and 64.4% of them had self-medicated. Conclusion This study identified serious misconceptions regarding antibiotics use in the Chinese general public. Effective interventions should be developed to provide practical and appropriate advice to effect behaviour change within this population.

Antibiotic use practices of pharmacy staff: a cross-sectional study in Saint Petersburg, the Russian Federation.

BACKGROUND: Non-prescription access to antimicrobials is common, and self-prescribing is increasingly popular in Russian society. The aim of this study was to assess the attitudes of community pharmacists regarding antibiotic use and self-medication. METHODS: We conducted a cross-sectional study from September-December 2015 of community pharmacists in the Saint-Petersburg and Leningrad region, Russia. A self-administered questionnaire was used to assess antibiotic use and self-medication practices. The data were analysed using logistic regression and Pearson chi-squared tests. RESULTS: Of the 316 pharmacists (77.07%) who completed the questionnaire, 230 (72.8%) self-medicated with antibiotics. Antibiotics were mostly used to self-treat upper (53.3%) and lower respiratory tract infections (19.3%), relying on their own knowledge (81.5%), previous treatment experience (49%) and patients' prescriptions (17%). The most commonly used antibiotics were macrolides (33.2%). Characteristics such as age, education and experience were related to antibiotic use and self-medication. CONCLUSIONS: The study confirmed that self-prescription of antibiotics is a common practice amongst pharmacists in Saint Petersburg and also identified personal and professional characteristics of pharmacists strongly associated with self-medication.

Management of asthma at private pharmacies in India.

SETTING: Chennai, India. OBJECTIVE: To examine the medications and advice that retail pharmacy attendants recommend to customers presenting with typical symptoms of asthma in an urban area of India. DESIGN: Four simulated clients described symptoms of mild persistent asthma to a quota sample of pharmacies in ten areas of the city. Clients recorded consultations with attendants and purchased a sample of the recommended medications. RESULTS: A total of 52 shops were visited on 56 occasions. Shopkeepers offered 140 medications during the consultations, and clients purchased a sample of 100 medications (71%). Four shops (7%) refused to sell any medications. Attendants recommended oral bronchodilators during 26 (50%) consultations, antibiotics during 23 (44%), methylxanthines during 22 (42%) and oral corticosteroids during 20 (38%). No inhaled medications were ever recommended. The majority of the medications purchased were missing information about dosage (concentration), date of expiry and active ingredients. Thirteen (24%) of 54 attendants advised the clients to seek medical attention. CONCLUSION: The majority of individuals presenting with asthma symptoms did not receive appropriate advice or medications from pharmacy attendants. Efforts to raise the quality of asthma management in developing countries should include interventions to improve pharmacy-guided self-medication.

Explicit criteria for determining potentially inappropriate medication use by the elderly. An update.

This study updates and expands explicit criteria defining potentially inappropriate medication use by the elderly. Additional goals were to address whether adverse outcomes were likely to be clinically severe and to incorporate clinical information on diagnoses when available. These criteria are meant to serve epidemiological studies, drug utilization review systems, health care providers, and educational efforts. Consensus from a panel of 6 nationally recognized experts on the appropriate use of medication in the elderly was sought. The expert panel agreed on the validity of 28 criteria describing the potentially inappropriate use of medication by general populations of the elderly as well as 35 criteria defining potentially inappropriate medication use in older persons known to have any of 15 common medical conditions. Updated, expanded, and more generally applicable criteria are now available to help identify inappropriate use of medications in elderly populations. These criteria define medications that should generally be avoided in the ambulatory elderly, doses or frequencies of administrations that should generally not be exceeded, and medications that should be avoided in older persons known to have any of several common conditions.

Self-medication practices in riverside communities in the Brazilian Amazon Rainforest / Prácticas de automedicación en las comunidades de ribereña en la Amazonía brasileña / Práticas de automedicação em comunidades ribeirinhas na Amazônia brasileira

ABSTRACT Objectives: to analyze the practice of self-medication and the associated factors in the riverside population of the Middle Solimões river region - Amazon rainforest. Methods: a cross-sectional population-based study conducted between April and July 2015, through interviews at home. Results: the prevalence of self-medication among the riverside population was 76.3%. Analgesics and antibacterials were the main therapeutic classes used in self-medication. Self-medication proved to be associated with the male gender, young people, not having sought the health service in the last month, longer commuting from the community to the urban area and the habit of consuming allopathic medicines on their own. Conclusions: self-medication among the riverside population of Coari - Amazon may reflect the need to seek self-care by people, with the use of allopathic medicines without prescription, mainly due to the restricted access to health services.

RESUMEN Objetivos: analizar la práctica de la automedicación y los factores asociados en la población ribereña de la región de Solimões Medio - Amazonas. Métodos: estudio transversal basado en la población realizado entre abril y julio de 2015, a través de entrevistas en el hogar. Resultados: la prevalencia de la automedicación entre los habitantes de la ribera fue del 76,3%. Los analgésicos y los antibacterianos fueron las principales clases terapéuticas utilizadas en la automedicación. Se demostró que la automedicación estaba asociada con el género masculino, los jóvenes, que no habían buscado el servicio de salud en el último mes, el mayor tiempo de viaje al área urbana y el hábito de consumir medicamentos alopáticos por su cuenta. Conclusiones: automedicación entre la población ribereña de Coari - Amazonas puede reflejar la necesidad de buscar el autocuidado de las personas, con el uso de medicamentos alopáticos sin receta, principalmente debido al acceso restringido a los servicios de salud.

RESUMO Objetivos: analisar a prática de automedicação e os fatores associados na população ribeirinha da região do Médio Solimões - Amazonas. Métodos: estudo transversal de base populacional realizado entre abril a julho de 2015, por meio de entrevistas em domicílio. Resultados: a prevalência da automedicação entre os ribeirinhos foi de 76,3%. Analgésicos e antibacterianos foram as principais classes terapêuticas consumidas na prática de automedicação. A automedicação mostrou-se associada ao sexo masculino, jovens, não ter procurado pelo serviço de saúde no último mês, maior tempo de deslocamento da comunidade à zona urbana e o hábito de consumo de medicamentos alopáticos por conta própria. Conclusões: a automedicação entre a população ribeirinha de Coari - Amazonas pode refletir a necessidade de busca do autocuidado pelas pessoas, com o uso de medicamentos alopáticos sem prescrição, sobretudo decorrente do restrito acesso aos serviços de saúde.

Quality supply of nonprescription medicines in Portuguese community pharmacy: An exploratory case study.

BACKGROUND: Inappropriate use of non-prescription medicines (NPM) can increase morbidity, mortality and health care associated costs. Pharmacists have a well-established role in self-medication; however, the literature shows that pharmacies performance in the supply of NPM is often suboptimal. OBJECTIVE: To explore the interaction and dependability of pharmacy staff use of oral language, as well as staff's own assessment of reasons underlying their behavior during consultation regarding NPM. METHODS: In a case-study design, a high street urban community pharmacy was purposively selected as the setting. Covert patient simulation, using trained simulated patients (SPs), was used to ascertain staff's performance in dispensing NPM, via 4 symptom-based scenarios (SbS) and 3 product-based scenarios (PbS). Performance data were converted into 2 composite indexes: the Interpersonal Performance Index (IPI) and Technical Performance Index (TPI). Audiotaped interactions were transcribed verbatim and participants' utterances were identified, time stamped and coded employing the eight higher level categories of a framework inspired by the Roter interaction analysis system (RIAS). The transcripts of the in-depth interviews were analyzed using the Framework Approach. The tripartite model of attitudes was employed to develop the thematic framework. RESULTS: Ten SP visits were considered for analysis. Overall, the mean TPI score was 50% and the mean IPI score was 78%. TPI was higher for SbS (63%) than PbS (31%), whilst there was little difference IPI between SbS (79%) and PbS (76%). The mean number of questions in the evaluation section of technical performance was 4 for SbS and 1 for PbS. There was a clear predominance of closed questions (32%), when compared with open questions (5.5%). Providing advice was more frequent (23.5%) than giving information (12.5%). In line with the SPs data, comparison of information-gathering in SbS and PbS shows that more questions were asked in the former (44% versus 31%), which resulted in more information given by SPs (56% and 49%, respectively). Staff's reaction to their performance showed all the 3 dimensions of attitude: affective, cognitive and behavioral. Divergence between staff's views on what should be done in NPM consultations and performance data surfaced in the interviewees' accounts on direct product requests. While performance data shows that information gathering was scarce, its importance was overtly acknowledged. CONCLUSIONS: The supply of NPM appears to be influenced by both cognitive and emotional issues. This suggests that multimodal improvement interventions are needed, targeting not only technical and interpersonal communication skills but also the organizational context. Managerial tools such as the balanced scorecard, may prove valuable in addressing improvement in the quality supply of NPM.