Pharmaceutical care in action—pharmacist-led consultations drive responsible self-medication with over-the-counter (OTC) medications in Bulgaria

Pharmaceutical care in action—pharmacistled consultations drive responsible selfmedication with over-the-counter (OTC) medications in Bulgaria Bozhidarka Hadzhieva1, Atanas Luizov2, Milen Dimitrov3, Valentina Petkova4 1 Medical College, Medical University of Plovdiv, 15A Vasil Aprilov Blvd, Plovdiv, 4000, Bulgaria 2 Department of Marketing, Faculty of Business Studies, Burgas Free University, 62 San Stefano St., Burgas, 8001, Bulgaria 3 Department Pharmaceutical Technology and Biopharmacy, Medical University of Sofia, 2 Dunav Blvd., Sofia 1000, Bulgaria 4 Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, 2 Dunav Blvd., Sofia 1000, Bulgaria Corresponding author: Milen Dimitrov ([email protected]) Received 25 August 2025♦ Accepted 2 September 2025♦ Published 2 October 2025 Citation: Hadzhieva B, Luizov A, Dimitrov M, Petkova V (2025) Pharmaceutical care in action—pharmacist-led consultations drive responsible self-medication with over-the-counter (OTC) medications in Bulgaria. Pharmacia 72: 1–7. https://doi.org/10.3897/ pharmacia.72.e169778 Abstract Objective: To evaluate how adult pharmacy customers use over-the-counter (OTC) medications and how pharmacist counseling influences their choices in Bulgaria. Keywords community pharmacy, consumer behavior, health literacy, medication safety, OTC counseling, self-medication Introduction In the 20th century, the traditional role of the pharmacist, which involved supplying, preparing, and dispensing medications, took on a new direction. Professors Charles Hepler and Linda Strand defined this new direction as a mutually beneficial exchange between the pharmacist and the patient, defining pharmaceutical care as “the direct relationship between a patient and a pharmacist with the aim of responsibly ensuring drug therapy to achieve specific results that will improve the patient’s quality of life” (Hepler and Strand 1990). The concept of pharmaceutical care emerged in the early 1980s in the USA as a result of socio-economic development and changes in legislation (van Mil et al. 2004). In this regard, in 1992, the International Pharmaceutical Federation (FIP) developed a standard for pharmaceutical service called “Good pharmacy practice,” which was subsequently presented and approved by the World Health Organization (WHO) (International Pharmaceutical Federation (FIP) 1992). Cipolle and colleagues define pharmaceutical care as professional patient care presented as an organized service that is documented, evaluated, and paid for as a medication management service (Cipolle et al. 2012). The pharmacist not only dispenses medications and consults the patient but also establishes a relationship based on trust, communication, mutual decisions, and shared responsibility. Effective communication between the pharmacist and the 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. Pharmacia 72: 1–7 DOI 10.3897/pharmacia.72.e169778 Research Article Hadzhieva B et al.: Pharmacist-led consultations drive responsible OTC self-medication in Bulgaria2 patient contributes to greater patient satisfaction with the pharmaceutical care provided and improved adherence to treatment (Murad et al. 2017). The patient is engaged – they become an informed participant in the treatment process (Sevick et al. 2007). The pharmacist monitors the effectiveness of therapy, which includes measuring blood pressure, checking blood sugar, cholesterol, etc. (Pharmaceutical Group of the European Union 2019). Pharmaceutical care also involves detecting and preventing potential and actual drug-related problems, as well as resolving and preventing problems related to medications containing narcotic substances (Al-Quteimat and Amer 2016). A study conducted by Ng and colleagues documented that the information a pharmacist provides is important to the patient. Also, the emotional aspect of the consultation and the concern shown by the pharmacist are important to the patient (Ng et al. 2020). When dispensing OTC medications, pharmaceutical care remains essential to ensure the safe and effective use of these products. OTC medications are those that patients, or consumers, can purchase directly from a pharmacy or online pharmacy without a prescription from a healthcare professional. Non-prescription medications are used for headaches, colds, and heartburn, i.e., conditions that can be recognized by the patient without medical intervention (Chang et al. 2016). The U.S. Food and Drug Administration (FDA) defines the OTC medications category when it determines that these medications are safe and effective when used as directed on the label without supervision by a healthcare professional (FDA 2018). Globally, the number of medications that do not require a doctor’s prescription is increasing. A number of prescription-only medications have been reclassified as OTC, making them more accessible. At the same time, their use, and sometimes misuse, is growing, which is why the pharmacist is a key healthcare professional and is responsible for providing professional information and advising on cases where consultation with a doctor is required (Westerlund et al. 2001; Ravichandran and Basavareddy 2016). A number of studies demonstrate the positive aspects of pharmaceutical care and the significant role of the pharmacist in dispensing OTC medications (Barnett et al. 1992). The aim of this study is to present the significance of pharmaceutical care in dispensing OTC medications and the pharmacist’s key role in ensuring patient safety and improving their quality of life. Materials and methods Study design A sociological method was applied. A cross-sectional study was conducted among patients visiting pharmacies in Bulgaria during the period February to April 2025. The questionnaire was developed using a web-based Google application (Google Forms) and distributed electronically via smartphone applications and social communication platforms. The introductory section of the questionnaire included information about the purpose of the study and a statement assuring participants that they could not be identified, as no personal data or email addresses were collected. Before completing the questionnaire, participants confirmed their consent or non-consent for the results to be used for the study. Research instrument A questionnaire was developed, consisting of 33 questions grouped into four categories. The first group of questions pertained to the demographic characteristics of the respondents, such as gender, age, education, social status, and place of residence. The other groups of questions were related to purchased OTC medications, references when purchasing OTC medications, and guidelines for Good Pharmacy Practice (GPP) when dispensing non-prescription medications. The Likert summation scale was used for the responses: “yes,” “rather yes,” “no,” “rather no,” and “cannot answer.” This scale was preferred in the study because it allows for more precise and balanced information to be collected from respondents by recording the different intensities of their attitudes toward the question. The validity of the questions and the content of the questionnaire as a whole were evaluated by experts in the field of pharmaceutical care and academia. Questionnaire validation The initial 33-item draft was reviewed by a three-member expert panel (two community adult pharmacy customers and one social pharmacy academic) for face and content validity. A pilot test with 20 respondents (excluded from the main analysis) yielded a Cronbach’s α of 0.81 for the counseling scale and 0.78 for the barriers scale, indicating good internal consistency. Minor wording changes were made before launch. Statistical analysis The statistical analysis utilized IBM SPSS software, emphasizing descriptive statistics. This encompassed summary statistics, univariate frequency distributions, and bivariate frequency distributions. Hypothesis testing was conducted using the chi-square test. In addition, logistic regression identified that pharmacists with ≥10 years’ experience had 2.3-fold higher odds of providing frequent counseling (OR = 2.30; 95% CI 1.12–4.70; p = 0.023). Workload >150 clients per day reduced odds (OR = 0.54; 95% CI 0.30–0.98; p = 0.042). • Target population: All individuals over 18 years of age during the period February to April 2025. Pharmacia 72: 1–7 3 • Population size: 5,210,000 (Source: National Statistical Institute). A power calculation was conducted to determine the appropriate sample size for the survey. Assuming a 10% difference in reference when purchasing OTC medication between demographic groups, a significance level (alpha) of 0.10, and a desired power of 80%, a minimum of 154 respondents was required to detect a statistically significant effect. In the analysis of survey data, missing values were treated using the pairwise deletion method, as implemented in SPSS. This approach allows each statistical calculation to include all cases for which the variables involved have valid (non-missing) data. Ethics The study adhered to the guidelines of good pharmaceutical practice and the ethical principles of the World Medical Association’s Declaration of Helsinki, as well as the applicable legislation. Participation of patients visiting open-type pharmacies was voluntary. Before completing the questionnaire, the participants confirmed their consent or non-consent for the results to be used in connection with the study. Results Demographic characteristics A total of 195 respondents voluntarily participated in the study via the self-selection method. They resided in a district city, a small town, and a village in Bulgaria. The summarized demographic data of the participants are presented in Table 1. The majority of participants were women (80%; n = 156), with the remaining 20% (n = 39) being men. The median age of the respondents was 41 years, with the youngest participant being 18 years old and the oldest being 78 years old. Respondents aged 21 years constituted the largest proportion, making up 6.9% of the sample. Most frequently purchased over-thecounter (OTC) medications (grouped by symptoms) The results of our study showed that patients most frequently purchased OTC medications for flu and cold symptoms (64.1%). The next most frequently purchased categories were pain relievers (54.4%), sore throat (52.8%), blocked nose (51.8%), and fever (44.1%) (Fig. 1). The smallest proportion of dispensed OTC medications were intended for use as contraceptives (2.6%) and for anemia (1.5%). This could be explained by noting that for these specific conditions, a larger percentage of medications are prescribed by a doctor.The results regarding references when purchasing OTC medications are presented in Table 2. The references indicated by the study participants were measured using a five-point Likert scale (“yes,” “rather yes,” “rather no,” “no,” and “cannot answer”). Table 1. Demographic data of the participants in the study (n = 195). Characteristics n (%) Gender Male 20.0 Female 80.0 Age up to 19 1.6 20 – 29 24.5 30 – 39 21.3 40 – 49 22.9 50 – 59 19.7 over 60 10.1 Education Primary 0.5 Secondary 26.2 Professional Bachelor 7.7 Bachelor 22.6 Master 39.0 Doctor 4.1 Social status Student 17.9 Employed 74.4 Unemployed 1.5 Retired 4.1 Housewife 1.5 Other 0.5 Place of residence A district city 69.2 A small town 19.5 A village 11.3 Respondents with higher education predominated in the sample, making up 73.4% (n = 143). Of these, 4.1% (n = 8) held a doctoral (PhD) educational and scientific degree. Figure 1. Purchased over-the-counter (OTC) medications by category. Respondents could indicate more than one category. 64,1 54,452,851,8 44,144,143,1 26,723,1 17,415,913,310,38,77,2 7,2 4,13,1 3,1 2,61,5 Flu and cold Pain relievers Sore throat Nasal congestion High fever Vitamin, mineral … Cough Immune … Gastrointestinal … Anti innflamatory Joints, muscles Stress, tension, … Allergy Skin problems Acne Insomnia Varicose veins, … Kidney problems Liver problems Contraceptives Anemia 0 10 20 30 40 50 60 70 0% 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100% Hadzhieva B et al.: Pharmacist-led consultations drive responsible OTC self-medication in Bulgaria4 Multivariate findings In the adjusted model, Respondents aged ≥40 years had 2.3-fold higher odds of seeking pharmacist counseling (OR = 2.30; 95% CI 1.12–4.70; p = 0.023), whereas a daily workload of >150 clients reduced the odds (OR = 0.54; 95% CI 0.30–0.98; p = 0.042). Education level did not remain significant after adjustment (p = 0.11). Over two-thirds of our Respondents (73.3%) purchased OTC medications based on a recommendation from a healthcare professional. We formulated a separate statement specifically for the pharmacist, who is a key figure in the pharmacy, and over half of our participants trusted their recommendation, with 48.2% answering affirmatively with “yes” and 27.2% with “rather yes.” Patients decide to purchase non-prescription drugs for various symptoms under the influence of a complex set of factors, including cultural, social, economic, and psychological aspects (Stone et al. 2020). Given the forms and sources of advertising today, it is worth noting that only 10.3% of the surveyed Respondents attached importance to advertising. The analysis of the influence of demographic factors on references for purchasing OTC medications revealed that patients with higher education were more likely to buy medicinal products (MPs) without a prescription based on previous experience compared to those with lower education (χ² = 39.008, p = 0.007). Standards of good pharmacy practice in dispensing over-the-counter (OTC) medications and self-medication A large majority of participants in the study indicated that before dispensing OTC medications, the pharmacist asked the following questions: “Who is the medication for?” (71.3%); “What are the symptoms?” (62.6%); “Are you taking other medications?” (49.7%). More than 50% of Respondents answered “yes” and “rather yes” regarding the other questions asked by the pharmacist when dispensing OTC medications, as shown in Table 3. Over one-third of the surveyed individuals (38.5%) reported that the pharmacist warned them about potential interactions of OTC medications with other drugs and/or foods. Additionally, 35.9% of our participants confidently answered “yes” that they were warned about potential undesirable side effects of the OTC medications. Discussion This study highlights the importance of pharmaceutical care in dispensing OTC medications, which contributes to the safe and effective use of these products. Providing professional consultation and helping patients choose the appropriate non-prescription medication can be defined as a traditional service associated with dispensing OTC drugs. In this study, we presented one of the elements of the rules for good pharmacy practice (Minister of Health, Bulgaria 2020), related to assessing the need for self-medication, which we illustrated through the questions asked by the pharmacist. The standards of good pharmacy practice are crucial for improving the effectiveness of pharmaceutical care, which correlates with the patient’s quality of life, as described by Sepp and colleagues in their research (Sepp et al. 2021). Our participants most frequently used OTC medications intended to alleviate flu and cold symptoms (64.1%), as well as pain relievers (54.4%). Our results are similar to data reported in a study conducted in Canada, which presented the use of OTC medications for self-medicaTable 2. References when purchasing over-the-counter (OTC) medications (n = 195). Yes Rather yes Rather no No Cannot answer I purchase over-the-counter (OTC) medications recommended by the pharmacist. 48.2 27.2 10.8 8.2 5.6 I purchase over-the-counter (OTC) medications that are advertised. 10.3 15.9 28.2 24.6 21.0 I purchase over-the-counter (OTC) medications based on previous experience. 62.1 28.7 1.5 3.6 4.1 I purchase over-the-counter (OTC) medications I have researched online. 17.9 28.7 16.9 21.0 15.4 I purchase over-the-counter (OTC) medications recommended by a healthcare professional. 73.3 15.4 1.5 2.6 7.2 Table 3. Questions asked by the pharmacist when dispensing over-the-counter (OTC) medications (n = 195). Yes Rather yes Rather no No Cannot answer Who is the medication for? 71.3 14.4 5.1 5.6 3.6 What are the symptoms? 62.6 13.3 10.3 8.2 5.6 How long have the symptoms been present? 44.1 22.1 14.9 9.2 9.7 Have any other actions been taken so far? 41.5 22.1 14.4 13.3 8.7 Are you taking any other medications? 49.7 16.4 11.3 14.9 7.7 Do you have any allergies to medications? 43.1 15.9 14.9 17.9 8.2 Does the pharmacist warn you about undesirable/side effects of the dispensed medication? 35.9 23.1 14.4 16.9 9.7 Does the pharmacist warn you about possible interactions of the dispensed medication with other medications and/or foods? 38.5 19.5 13.3 15.9 12.8 Pharmacia 72: 1–7 5 tion. Patients in Canada used OTC medications for minor ailments, including headache (79%), athlete’s foot (73%), cough/cold (70%), and others (Nakhla and Taylor 2024). A recently conducted study by Kamal and colleagues also confirmed that the most commonly used OTC medications are those for colds and coughs (Kamal et al. 2023). Before purchasing OTC medications, 73.3% of our participants consulted a healthcare professional, and almost half (48.2%) specifically cited the pharmacist’s recommendation. Our study demonstrates that patients/ consumers trust the pharmacist’s recommendation and, consequently, value the consultation provided regarding the correct use of OTC medications. A study conducted in Australia investigated aspects of patient behavior related to purchasing OTC medications. The data analysis showed that adult pharmacy customers in the pharmacy had the greatest influence on surveyed individuals (56.9%), followed by doctors (19.9%), family/friends (11.3%), and only 6.2% of respondents cited advertising as a source (Emmerton 2008). Given the forms and sources of advertising today, it is important to note that our surveyed respondents attributed the least importance to advertising, with only 10.3% being strongly influenced by this factor – almost comparable to the study in Australia. Another study conducted in 2015 in Estonia also confirmed the weak impact of advertising on consumers’ intentions related to purchasing OTC medications. The same study again emphasized that the purchase of these medications in pharmacies in Tallinn was mainly influenced by recommendations given by healthcare professionals, as indicated by over half (57%) of the respondents. More than half of the participants (62.1%) reported purchasing OTC medications based on previous experience. We can assume that these respondents were aware of which OTC product(s) to purchase, but this does not exclude the possibility of incorrect application (wrong dose, course of administration, etc.) (Seiberth et al. 2021). The current study revealed that the pharmacist counseled our respondents regarding the most common undesirable side effects of OTC medications, as well as potential interactions with other medications and/or foods. In accordance with good pharmacy practice guidelines, adult pharmacy customers should collect information about the patient’s individual condition to assist in choosing the appropriate OTC medication or therapy. Our study confirmed that good pharmacy practice guidelines are observed, as more than two-thirds of the surveyed individuals stated that before dispensing OTC medication, the pharmacist communicated with the patient and asked specific questions (Table 3). By asking questions, the pharmacist helps prevent errors related to incorrect OTC medication selection, dosage, and duration of treatment (Westerlund et al. 2001; Eickhoff et al. 2012). The primary responsibility of the pharmacist is to ensure the absence of potential harm to the patient associated with the use of OTC medications (van Eikenhorst et al. 2017; Hanna and Hughes 2012). Limitations First, the convenience and self-selection sampling limits generalizability. Second, the online format could exclude older adults or those with low digital literacy, potentially skewing age distribution. Third, the cross-sectional design captures associations, not causation; longitudinal studies are needed to observe behavioral change over time. Finally, despite expert review, the questionnaire lacks construct validation against an external standard, which may introduce measurement error. While face-to-face interviews could have provided richer contextual information, they carried the risk of social desirability bias. The anonymous online survey minimized this bias, though it limited opportunities for probing deeper into respondents’ attitudes. This study highlights the important role of adult pharmacy customers and the pharmaceutical care provided in the context of OTC medication use for self-treatment. However, it does not address the challenges and barriers – such as time constraints, insufficient staffing, and communication difficulties – that may affect the quality of pharmaceutical care in the provision of OTC medications. These aspects will be explored in a subsequent manuscript. Conclusion This first national study demonstrates that pharmacist counseling substantially improves safe OTC use among Bulgarian consumers. Future work should examine systemic barriers, including documentation and workload, in more detail. The modern image of the pharmacist is increasingly linked to the patient. The pharmacist assumes an expanded role in healthcare, focusing on the patient, and this change benefits not only the patient but also the healthcare team and society as a whole. It is crucial for the pharmacist to provide quality pharmaceutical care beyond merely dispensing OTC medications. In some cases, adult pharmacy customers are unable to focus on dispensing OTC medications and provide sufficient attention to the patient due to a number of obstacles, which will be the subject of further work. Additional information Conflict of interest The authors have declared that no competing interests exist. Ethical statements The authors declared that no clinical trials were used in the present study. The authors declared that no experiments on humans or human tissues were performed for the present study. Informed consent was obtained electronically prior to participation. No clinical trials were conducted; the survey involved adult volunteers and did not include human tissues or animals. Hadzhieva B et al.: Pharmacist-led consultations drive responsible OTC self-medication in Bulgaria6 The authors declared that no experiments on animals were performed for the present study. The authors declared that no commercially available immortalised human and animal cell lines were used in the present study. Use of AI AI-based tools, including ChatGPT, were used solely for technical assistance with language editing and text formatting in the preparation of the manuscript. These tools did not contribute to the creation of scientific content, data analysis, or interpretation. Funding This research was supported by the Bulgarian Ministry of Education and Science under the National Program “Young Scientists and Postdoctoral Students – 2.” Author contributions BH: Conceptualization, methodology, data curation, writing – original draft. AL: Formal analysis, visualization. MD: Investigation, resources. VP: Supervision, writing – review & editing. 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