Article

Report of an All India Quantitative Study of Consumer Perceptions, Availability, Role, Services Provided, Medicines and Expectations of Pharmacists In India
Part 1- Report of the study on professional and general aspects
D. B. Anantha Narayana*, Kusum Devi1, Asha A. N1, Nimisha Jain1, Uday Bhosale1, T. Naveen Babu1 and co-investigators Roop K. Khar2, Moitreyee Mandal3, Manjiree Gharat4 * Managing Trustee, Delhi Pharmaceutical Trust, New Delhi. 1 Dept. of Pharm.Marketing and Management, Al-Ameen College of Pharmacy, Bangalore. 2 Dept. of Pharmaceutical Sciences, Jamia Hamdard, New Delhi. 3 Dept. of Pharmacy, J.C.Ghosh Polytechnic, Kolkata, 4 K.M.Kundnani Pharmacy Polytechnic, Ulhasnagar-3, Maharashtra. Keywords: pharmacist, retail outlets and availability, first all India survey, quantitative survey

Background & Objectives

During the 1980-1990 lot of activity took place which impacted the way medicines are dispensed and sold through licensed premises commonly called as Drug stores or chemist shops in India. Such premises in India are regulated under Drugs & Cosmetics Act and rules [DCAR]1 as well as Pharmacy Act & Rules2. Under both regulations these premises are required to be manned by a qualified person who has the necessary qualification and experience as prescribed under the Pharmacy Act and also required such a person to be registered as a Pharmacist with the respective State Pharmacy Council. The association of chemists had been demanding that such a registration requirement under rule 65(15) C of Pharmacy Act is not required and this provision should be deleted. However professional associations including Indian Pharmaceutical Association (IPA), the national body of pharmacists of all facets as well as Pharmacy Council of India (PCI) argued that 65(15)C should not be deleted from the provisions and sale of medicines definitely need supervision by a qualified pharmacist. The Ministry of Health after consultation with all stake holders and after careful consideration upheld the demand of professionals and didn't remove the requirements. Several cases in high courts of Allahabad and other states also have upheld putting such reasonable requirements for need of a qualified person in the chemist outlets as completely legal and logical and that the Government of India has exercised their powers under sec 33 of DCAR, in the interest of public, a fact welcomed by everyone. For Correspondence : dptrust@gmail.com

During 1990's most of the professional associations of pharmacy concentrated their activities primarily on various facets of pharmacy other than that dealing with pharmacist /chemist at the end of the professional chain. Delhi Pharmaceutical Trust (DPT)[ www.delhipharmtrust.org ] was constituted in 1998 by a set of professionals as an off shoot of IPA (Delhi branch). DPT initiated a number of activities all of which focused on helping the practicing pharmacist to professionalise and work to improve their knowledge and services leading to efficiency. DPT initiated Continuing Professional Development programs (CPD) for chemists working in Delhi and all their activities centered towards Community Pharmacists. This initiative started a chain of reactions across India with number of other professional associations including chemist associations as well as a number of pharmacy colleges planning and conducting continuing education and training programs for community pharmacists. During the last two decades changes in the chemist bodies have also reflected in more and more number of qualified pharmacists (D.Pharm's, Graduate Pharmacists and in some cases even Post Graduate Pharmacists) taking up jobs or setting up chemist shops as well as getting elected to positions on chemist associations. This has also brought some impact on the mind set changes in those involved in dispensing and sale of medicines. However, there have been many opinions expressed about the role of pharmacists, in various professional circles. Most of these opinions are at best the perceptions of individuals not necessarily involved actively nor form part of the community pharmacy profession in retail, commonly referred to as chemists. One

common perception amongst members of the pharmaceutical industry/ profession other than those involved in community pharmacy is that pharmacists/ chemists work merely like traders and do not provide any professional service and that there is no image of high esteem for them in society as shown to other members of the health care team. Delhi Pharmaceutical Trust conducted a qualitative market research amongst consumers in Bangalore and Delhi and found that the situation is not true. The results of the study brought out many interesting observations about pharmacists and their role including high expectations as well as changing expectations from the consumers3. In another study conducted earlier, by Ramesh Adepu and B G Nagavi, in 2003., titled "Public Perception of Community Pharmacists in the State of Karnataka, India", in which many aspects of pharmacist's role were found wanting and not meeting the requirements, to prove themselves as health care professionals4. Delhi Pharmaceutical Trust [DPT], decided to follow up the qualitative study already published with an all India larger quantitative study. For this, the trust commissioned a research study to be conducted in Greater Bangalore, Greater Mumbai, and National Capital Region of Delhi and in and around of Kolkata (these will be referred as Bangalore, Mumbai, Delhi and Kolkata). The study involved getting written responses to a validated questionnaire consisting of 30 questions, among customers of different profile who have visited chemists' outlets. The study design and methodology was conceived by the first two authors and the active phase of the study was conducted between March 2009 and December 2009. A request to fill up the

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questionnaires and send it to DPT was also made through other publications and some responses were received till July 2010. This report is based on the responses received from 3086 respondents across India, analyzed using a dedicated and validated software developed for the purpose.

performance. The filled questionnaire were serially numbered, stamped with the region, urban or rural area from which they were obtained, Questionnaires that did not answer at least 50 % of questions were rejected. Table 1 shows the Number of Filled questionnaires (FQ's) Table 1: Total number of responses city wise S. No City 1. 2. 3. 4. 5. Bangalore Delhi Mumbai Kolkata Total Number Of Responses 754 764 784 784 3086

which was -accepted and no further revalidation was undertaken. The questionnaire had 30 questions and the responses have been analyzed in three categories: Category 1: To cover availability, accessibility, frequency of visits, identification and gross image. Category 2: To cover professionalism of the pharmacist including drug information provided. Category 3: To cover consumer perceptions on medicines and expectations from the pharmacist.

Methodology
The research study has been conducted using a quantitative method of research. For this a questionnaire was developed with 30 questions, in English, having either predefined set of responses, multiple choices, or open ended spaces for responses, validated for readability and understanding, translated to Kannada, Marathi, Bengali and Hindi. Translations were also validated. Printed questionnaire were made with English and one regional language for each location. Volunteers (students for pharmacy colleges) were trained on the study, their role and work, using a Training Guide. To meet statistical requirements, a minimum of 650 Reponses were obtained from each location, with at least 50 from rural respondents. Questions related to availability, identification, frequency of visits, accessibility, services provided by pharmacists, consumer level of satisfaction currently and expectations for future, consumer understanding of medicines, their categories, Pricing, information on storage and usage which they should know, medicines they perceive to be common medicines that do not need any prescription or consultation with a physician and how they rate a pharmacist etc. For developing the questionnaire a guideline to questionnaire developments5, was adopted. (please visit website of DPT for the questionnaire). Since, a study of this nature and magnitude was being done for the first time in India, it was consciously decided to make it open type and hence a crisp paragraph was drafted about DPT, intention of the study, and a specific request to provide their responses including personal details of the respondents. As a part of ethical aspect it was clearly informed to the respondents that their identity and views would be kept confidential and only the total responses received and analyzed would be published. The respondents were also given an email ID to correspond if they had any queries or doubts of the study. The questionnaire was designed with logo to indicate the profession of pharmacy. The questionnaire at the end asked the respondents to provide some basic information about them, and they were told clearly that this information would be kept confidential. Ethically, only one definite contact detail was insisted upon so that if at any time a need arises for cross checking, and to identify and get demographic information, the region of the country, urban or rural respondent. The number of volunteers who assisted the study in each region varied from 15 - 102 and no monetary benefit was linked to their

Results and Discussion

All results reported below are those obtained by use of the analytical tool. The tool provides data as analyzed linked to specific demographics. Analysis were carried out with linkage to all responses obtained from all India separation region wise, urbanrural, men- women, occupation, education and family income groups. In some cases, analysis across these linkages was also done. The data obtained, have been either reported as percentages of responses/ respondents or given in numbers or graphs. Such resultant data have been interpreted and the interpretations have also been recorded. It may be recognized that the pool of data available is too large and more analysis can be done, however specific analysis that have been done in this first set of analysis to get focused information from the study are reported in this first part of the report of the study. Additional analysis if required for any specific purpose will be undertaken. In this report, results of data and the analysis for category 1 & 2 listed above are reported. The results of analysis for category 1 & 2 responses includes responses to questions at serial no. 1, 2, 3, 4, 5, 12, 18, 19, 20, 21, 22, 23, 24, 26 and 30, along with the responses filled for personal information of the respondent. Demographics: Table 2 provides a summary of the demographics giving the broad As observed, rural population was taken into account more from Kolkata, whilst the urban population constituted from the other cities respectively Bangalore, Delhi and Mumbai. More number of men were seen as respondents as compared to the women.

Software Development
A search on the net revealed a number of open ware software available which are generally used for analyzing results of large survey data whether obtained orally or through filled questionnaire for example, those used for opinion polls. Most of them did not suit for analyzing this study as the questionnaire in this study consisted of more than one type of response structure. Hence, a dedicated analytical tool was got developed by an experienced firm engaged in such activities. Technical inputs on the study design, analysis required, expected outcome in the form of tables, graphs, charts etc were given to the tool developer and number of meetings were held with the tool developer. A written expectation from the tool with built in validation step was given to the tool developer, along with a few FQ's. The resultant tool developed was validated at the developer's end and then installed in the investigator's premise, with built in safety and passwords. Student volunteers keyed in meticulously the responses from each FQ's after undergoing a session on training for the same. In each FQ a mark was placed after it was entered into the tool. After responses of all the 3086 FQ's were keyed in 10 % of the data put into the database were selected by the tool randomly for auditing and validation. The respective FQ numbers that appeared in this 10% was physically taken out from the files and the data fed into the computer was cross checked for accuracy. The degree of accuracy obtained was greater than 99%

Table 2. Demographics of total respondents Bangalore Men Women Rural Urban Total 488 266 160 594 754 Delhi 653 111 106 658 764 Mumbai 511 273 32 752 784 Kolkata 597 187 775 9 784 Total 2249 837 1073 2013 3086

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Figure 1 : Demographic data for total men

Further with regard to how often people visit a chemist/medical shop, among the total population 67% said that they go to chemist shop when required only, 16% of retired said that they visit once a week, 23% of rural population said that they visit once a month. In Bangalore 72% of the population said that they go to medical store when required only and 80% of the rural population has reported the same. In Kolkata only 54% of them said that they visit the medical store when required only, 27% of the housewives said that they visit once in a week. In Delhi 22% of the retired population said that they visit the medical shop once a week and 65% of the population said that they visit when required. In Mumbai 78% of the total population said that they will visit medical shop only when required. Surprisingly, there was only 4% of population who don't visit medical shops. Results are displayed in Figure 3. Figure 3. The perceptions of the respondents with regard to availability of a medical outlet

As observed around 35% of total populationof men is from rural areas, Delhi showed the maximum number of working people and students. Mumbai showed the minimum of rural men. In Kolkata more rural population was taken into account.

Figure 2 : Demographic data for total women

Responses from Bangalore

Responses from Kolkata

As observed more number of women responded from Mumbai and Bangalore as compared to rest two cities. Matriculate qualification and self employment is highest in Kolkata among women. Graduates and Working women are highest in Bangalore, Highest number of students have taken part from Delhi coverage of the respondents. Figures 1 & 2 provide detailed demographic data for men and women separately which are self explanatory.

Responses from Delhi

Responses from Mumbai

Access To Medicine Outlets

To find out whether people have access to medical stores we asked them if they have medical shop/chemist shop near their house or in their locality and if yes what is the number of such shops. An overall analysis on access to an outlet reveals that irrespective of the regional difference, accessibility of a medical shop for consumers is the same. The density of medical shops in urban areas is more than that in rural areas. Only 12% people think they don't have a medical shop in their locality and 88% have at least one shop out of with 39% have more than one.

Recognition
To find out how people recognize a medical shop, we asked them whether they can identify a medical shop by sign board, green cross or Red Cross or by the display of medicines. In Bangalore, students, retired and working people can recognize a medical shop with a Green color Cross sign as compared to housewives who are recognizing by red color sign, which is the sign for Red Cross. Graduates and higher qualified people can recognize a medical shop by sign board and green cross while SSLC and Non-Matriculates people are recognizing by display of medicines. Overall around 31% people can recognize medical shop by a sign board in Bangalore with lesser percentages recognizing by other signs. In Kolkata,

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almost 50% of population identify a medical shop by sign board. Surprisingly housewives in rural area showed maximum identification of medical shop by green cross and signboard. In Delhi most of students are aware and can recognize chemist shop by green cross and sign board. Only 50% population in Delhi can identify correctly by green cross and sign board as compared to 67% in Mumbai. Around 50% of housewives in urban area of Delhi have perception of Red Cross for medical shops. An overall analysis on recognition reveals that 37% of people can recognize medical shop by signboard and 24% by green cross. Qualified people can better identify a medical shop as compared to the other strata's. There is a need to improve the awareness that green cross is associated with pharmacy (medical shop). Hence initiatives should be taken to recognize the profession of pharmacy by green cross.

badges while 34% want only White coat and 23% only ID badges. Around half of Nonmatriculate people want him to wear white coat, which might be because of their lower education status. In Delhi and Kolkata around 50% want both, while 31% in Delhi want only white coat and 32% in Kolkata want only ID badge. In Mumbai around 50% want him to wear only ID badge which can be probably more authentic as compared to a white coat. Majority of the people want the pharmacist to wear both white coat as well as ID badges, which aid them in identifying the pharmacist. On all India basis 50% people want him to wear both, and out of the remaining 50%, half wants only ID badge and the other half wants only White coat. However survey shows that all the respondents are in favor of having a particular dress code for the pharmacist and this probably improves the professional status of the pharmacist.

To further confirm the adequate storage of medicines we asked people whether they have seen the chemist taking out medicines from fridge and giving it to customers. Out of the total population 78% people have seen a chemist taking off medicines out of a fridge. Majority of the High income group (85%) have seen the same while the majority of the low income group and non matriculates have said that they have never seen a chemist take medicines from a fridge. In Bangalore 41% of the non matriculates also are of the same opinion, of not having seen the chemist taking medicines out from a fridge. While the high income group reported to have seen the chemist taking out medicines from a fridge. 26% of the Kolkata population said that they haven't seen the chemist take medicines out of the fridge while dispensing, where majority of the rural population is covered and 20% population of Mumbai and Delhi also say the same. Overall, people have seen a fridge and the chemist taking out medicines from a fridge as well, implying adequate storage of medicines. However around 20% respondents have not seen a fridge, principally in the rural areas and this could be a cause for concern.

Identification
To find out whether the people are able to identify the qualified or the trained pharmacist in the medical shops we asked them whether they are able to identify the trained person or not. We found out that majority of the people cannot identify a trained person across all cities covered in the survey. An overall 56% of urban people can identify trained person in a pharmacy as compared to 43% of rural population. In Bangalore 70% of rural population cannot identify the trained person in the medical shop. A higher percentage of people with higher education are able to identify the qualified person as compared to less educated people, for example 75% of Nonmatriculate people cannot identify a trained person. In Delhi, 71% people are able to identify a trained person and surprisingly 80% of housewives and 75% of Nonmatriculates were also able to identify the qualified person. In Mumbai only 50% of the population, (out of which 96% is from urban areas) are able to identify the trained person. While in Kolkata also only 41% can identify trained people (out of which 96% is from rural areas). The results indicate the need for the Pharmacist to do more to distinguish themselves from other support staff in the outlets

Perception Towards Appearance of Medical Store

To find out about the perception of people about proper maintenance and storage of medicines in the medical shops we asked them whether the medicines were stored neatly and properly in the store and was the pharmacist able to get the correct medicines easily and quickly. Across all four cities people think and agree with the fact that the medicines are arranged neatly and properly (78%). In Mumbai where the majority population considered is urban, around 90% people feel medicines are arranged neatly, and it is the highest among other cities. In Kolkata where survey is mainly concentrated in the rural areas, only 62% people feel medicines are arranged neatly. This may suggests that there should be improvement in arrangement of medicines in medical stores in rural areas. In the national capital Delhi which is also mainly concentrated on urban areas 80% people feel medicines are arranged properly. In Bangalore also 82% population fells that medicines are arranged neatly. Further to get information about the storage of medicines we asked people if they have seen a refrigerator in the medicines store where they buy medicines. Majority of people agree to have had seen a fridge within the pharmacy premises. In Bangalore 89% have seen a fridge, in Mumbai 83% seen a fridge, and in Delhi and Kolkata also good number of people have seen fridge in medical shops. Over all a good visibility of fridge can be seen across the country in medical shops proving that the medicines are being stored as per their requirement.

Information To The Consumer Regarding Shelflife

To find out if the chemist is giving information regarding the shelf-life or expiry date of medicines we asked people if the chemist has ever provided them with such information. Of the total population, 55% of people were not informed about the expiry date of the medications, which is extremely important as a factor to be considered while dispensing medications. 63% of retired population and 58% of mid income group are of the same opinion. In Bangalore 69% of the population, say that chemists do not explain about the expiry date of the medication. 78% of the rural population and low income group, 73% of the retired population have the same opinion. In Kolkata 64 % of the students say that the chemists never explained them about the expiry date of the medications. Surprisingly the nonmatriculate people have said that chemists have explained about the expiry date of the medicine in the city. In Mumbai also, mid income group and non matriculates and SSLC people felt that chemists never explained about the expiry date of the medicine. It has to be noted that, the information about the expiry date of the medications is important information which has to be

Look/Appearance of Pharmacist
To find out what can aid in the better identification of trained or qualified person in medical shops we asked people about what chemist should wear while giving the medicines. They were given options of white coat/ identity badges or both. In Bangalore, 43% people want pharmacist to wear both white coat and ID

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communicated to the medicine buyers and particularly so to the people from low income groups, rural and retired population due to their lack of proper education or dependency on the chemist.

45% of retired population are also of the same opinion. In addition it was also asked the consumers if anytime they were asked to bring a "Cool Pack" or a "flask" before buying any specific medicines. Out of the total population, 89% are of the opinion that either chemist didn't inform the customers to get a cool pack or they don't know what a cool pack is as far as medicines are concerned. It is encouraging to note that nearly 60% of the consumers pan India, opine that chemist is giving them information about the proper storage of medicines and it would be good if all chemists would follow such practices in future.

getting license to run a medical store. In Bangalore, 57% said D. Pharma and 31 % said B.Pharm is the minimum qualification of a chemist. In Mumbai, Kolkata and Delhi, 72%, 63% and 54% of people feel D.Pharm is the minimum qualification of a chemist respectively.

Information Provided on Storage of Medicines

To find about whether the chemist is giving information about the proper storage of medicines after their purchase a query in this regard was posed to the respondents. 58% of the total populations agree to the fact that the chemists explain about the storage conditions of the medications whereas 44% each of rural and retired population opined the contrary. In Bangalore 51% populations haven't been explained by the chemist anytime about how and where to store the medicines. A similar situation was seen with non-matriculate (66%), rural (63%), and low income group people (60%). In Delhi, 43% of the students and 53% of the retired people agreed to the fact that they were not explained about the storage conditions. In Mumbai, 49% of non matriculates, 44% of low income group and

Trustworthiness of a Pharmacist
To determine whether people trust their chemist, we asked them if they think that a chemist is a good source of information on medicines. The respondents were further quizzed about the usefulness of information thus provided. The results are displayed in Figure 4. 77% of total population believes that the chemist is a good person to ask for information regarding the usage and side effects of the medicines, whereas 23% have the belief that he is not a good person. Rural area people believe in chemists more as compared to urban people. Also 67% people said that the given information has helped them and both the rural and people feel the same in this case.

Education Requirement
A query was posed to the respondents to determine their awareness about the minimum qualification required to run a medical store. It is good to find out that around 85% of the people are well aware about B.Pharm/ D.Pharm being the requisite for qualification as pharmacist, in fact around 61% of the total population in all four cities are also aware that D.Pharm is the minimum requisite for

Figure 4. Results of the Trust worthiness of Pharmacists graphs below where, A1Y : respondents who said the chemist is a good person to seek such information. A1N : respondents who said the chemist is not a good person to seek such information. A2Y : respondents who said such information has helped them to get better A2N : respondents who said such information has not helped them to get better

TOTAL RESPONSE

PERCEPTIONS IN BANGALORE

PERCEPTIONS IN KOLKATA

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PERCEPTIONS IN DELHI 85% of Mumbai people believe that chemist is a good person to ask for information and 75% have told that they have been benefited by such information. 81% of Kolkata and 76% Bangalore people believe that chemist is a good & trustworthy. In Delhi only 65% of people believe that chemist as an information giver, and only 62% agrees that this information has helped them. Elderly and retired people (90%) believe the chemist more and 75% of them feel that the information given by the chemist has helped them to use medicines effectively. As majority of the respondents opine that a chemist is the good person to get medicine related information, such professional services rendered by a chemist will go a long way in improving the image of the pharmacist besides ensuring the proper administration (use) of medicines.

PERCEPTIONS IN MUMBAI Chapter IV, Manufacture, sale and distribution of drugs and cosmetics. 2. 3. http://www.pci.nic.in/RulesRegulations/ PharmacyAct1948/Chapter1-5.aspx. D. B. Anantha Narayana, Kusum Devi, Asha A. N. and Nimisha Jain "Perceptions of consumers about Pharmacists Report of the results of a Market research conducted amongst consumers in Bangalore and Delhi", Pharma Times, September 2009, Vol 42, No. 9,15-18. Ramesh Adepu and B G Nagavi, "Public Perception of Community Pharmacists in the State of Karnataka, India", in which many aspects of pharmacist's role were found wanting and not meeting the requirements, to prove themselves as health care professionals". Ind. Jour. Hospital Pharmacy, Jan-Feb 2003, 15-18. Dr. Robert Frary, A brief guide to questionnaire development, Place based education evaluation collaborative available from http:// www.testscoring.vt.edu/fraryquest.html) Readers Digest, March, 2010. Jeffrey M. Jones, Nurses Top Honesty and Ethics List for 11th Year. Gallup, December 3, 2010. http:// www.gallup.com/poll/145043/NursesTop-Honesty-Ethics-List-11-Year.aspx

sound a word of caution that this should not lead to "complacency" but more needs to be done by Pharmacists to take this to even higher levels.

Observations and Authors Notes

The study has for the first time brought out documented quantitative data on the availability of pharmacies/chemist outlets, identification of chemist and outlets, neatness, storage, belief in chemist and trust in their roles and work done. These results point out that the visibility of "pharmacist" in the medical shop needs to be enhanced greatly. Pharmacists need to create a more professional image and ease of identification within the outlet by wearing a specific dress, uniform, badge is highly necessary and sooner the profession adopts it is better. More work needs to be done to almost create a brand image for a pharmacist that they are qualified and trained persons, knowledge on Green and Red Cross signs, neatness of the outlets, information provided to patients. The authors also recognize that the study has covered four major cities and surrounding rural areas, though the proportion of the respondents of urban and rural in each city is not same. Results of responses received for questions related professional services, future expectations and medicines are still under analysis and would be reported separately

4.

Ranking of Pharmacists
Number of studies done in USA and other countries report the ranking of pharmacist in their country for their performance or service or behavior. In this study consumers ranked a pharmacist in their opinion for their ethical behavior, after they have responded to all the questions amongst a doctor, a teacher, a chemist, and a lawyer, by ranking them in the descending order. In such a context the response to this question would mean "the consumers over all opinion about the Pharmacist/chemist". Consumers ranked doctors first on an all India basis and even at regional basis. It was interesting to note that a pharmacist was ranked at number 2 higher than a teacher and a lawyer on an all India basis and also in each of the region surveyed. This is in line with an international finding reported recently in Gallup poll conducted in the United States, where pharmacists came in third position behind nurses and military officers as the most trusted profession6. Also in a survey conducted by Readers Digest where people were asked to rank 40 everyday professionals and the Pharmacist was ranked fairly high in order7. This finding is highly encouraging and should be taken on board by pharmacy professionals who have been thinking otherwise and have been critical of the public image of a chemist. Authors also wish to

5.

6. 7.

Acknowledgements
Sincere appreciations and thanks to all the student volunteers for their contributions to the project and each of them have been given a certificate by DPT. Authors acknowledge the encouragement and support by the Trustees of DPT and Principals of the four colleges of pharmacy for permitting and encouraging their faculty and students to participate in the project. We thank Ms. Ritu Walia, of Consumer Science Department of HUL research, Bangalore for her constant encouragement and inputs.

ATTENTION STUDENT MEMBERS !!

Student members are requested to access their copies of Pharma Times online at w w w.ipapharma.org / PTarchives.aspx. May 2011 onwards, student members will not receive hard copy of Pharma Times.

Bibliography
1. http://cdsco.nic.in/html/ copy%20of%201.%20d&cact121.pdf. The drugs and cosmetics act, 1940,

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