A new model for pharmacies? Insights from a quantitative study regarding the public’s perceptions

RESEARCH ARTICLE Open Access A new model o pha macies? Insigh s om a quan i a i e s udy ega ding he public’s pe cep ions Ve ónica Polica po 1 , Sónia Romano 2* , João H. C. An ónio 3 , Tânia So ia Co eia 3 and Suze e Cos a 4 Abs ac Backg ound: Wo ldwide communi y pha macies a e shi ing hei ole in he heal hca e sys em om simple medica ion dispense s o heal h ca e p o ide s. High le els o sa is ac ion wi h pha macy se ices we e ound in p e ious s udies. This s udy has wo main goals. The p ima y goal is o desc ibe he le els o sa is ac ion and knowledge ega ding pha macy se ices in Po ugal. The seconda y goal is o explo e he pe cep ions and he u ilisa ion o pha macy se ices by he Po uguese. This s a emen includes explo ing he impac o a se o a iables on bo h pe cep ions and uses o pha macies in ega d o se ices ha a e cu en ly o e ed as well as o new se ices ha may be p o ided in he u u e. Me hods: A ace- o- ace su ey o closed-ended ques ions was applied o a na ionwide ep esen a i e sample o he Po uguese popula ion in Sep embe 2015. The sample was weigh ed based on popula ion dis ibu ion ac oss egions, habi a , age and gende . Da a analysis comp ises desc ip i e s a is ics and Mul iple Co espondence Analysis o explo e di e en ypologies o esponden ’s o ien a ion owa d communi y pha macy. Resul s: A o al o 1114 in e iews comp ised he s udy. O he esponden s, 36% used he pha macy as a i s esou ce when seeking o ea a mino ailmen , and 54% epo ed ha hey use he pha macy as a i s esou ce when seeking answe s abou medicines. O hose who isi ed hei pha macy a leas once in he p e ious yea , 94% we e ei he globally sa is ied o e y sa is ied. The le el o acknowledgemen o pha macy se ices’was also high among he Po uguese. O he pa icipan s, 29% conside ed he e could be mo e se ices a ailable in pha macies ha a e cu en ly p o ided by o he heal h ca e acili ies. The cons uc ion o a ypology o o ien a ions owa ds communi y pha macy p ac ice esul ed in h ee ou come g oups: “Mo i a ed”(63%), hose wi h a connec ion o a pha macy; “Se led”(23%), mainly hose who had a pha macy nea by; and “Demobilised”(14%), hose who a e weakly ied o a pha macy. Conclusions: The as majo i y o he Po uguese popula ion has a s ong posi i e a i ude owa ds hei communi y pha macy, as exp essed by he high le els o sa is ac ion wi h, and posi i e e alua ion o , he pha macy’s se ices. Keywo ds: Communi y pha macy, Sa is ac ion, Pha macy se ices, E alua ion o pha macy se ices, Po ugal © The Au ho (s). 2019 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. * Co espondence: sonia. omano@an .p 2 Cen e o Heal h E alua ion & Resea ch (CEFAR), Associação Nacional das Fa mácias (ANF), Rua Ma echal Saldanha 1, 1249-069 Lisbon, Po ugal Full lis o au ho in o ma ion is a ailable a he end o he a icle Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 h ps://doi.o g/10.1186/s12913-019-3987-3 Backg ound Wo ldwide communi y pha macies a e shi ing hei ole in he heal hca e sys em om simple medica ion dis- pense s o heal h ca e p o ide s [1]. Wi h his pa adigm shi , i is ele an o unde s and he ollowing: wha pha - macy use s wan mo e o om hei pha macies; wha a e hei expec a ions ega ding a new se o ad anced se - ices ha pha macies may o e in he nea u u e and; how do such expec a ions ela e o he le el o sa is ac ion ega ding he se ices ha a e cu en ly being p o ided. This pape a emp s o answe hese ques ions, u ilising quan i a i e da a om a s udy conduc ed in Po ugal in 2015, based on a na ionwide s a is ically ep esen a i e sample o he Po uguese popula ion. The opic is app oached om he pe spec i e o he main challenges ha public heal h con on s in he wen y- i s cen u y, including economic c ises, widen- ing inequali ies, he ageing popula ion, inc easing le els o ch onic disease, mig a ion and u banisa ion, en i on- men al damage and clima e change [2]. Add essing heal h ela ed ma e s equi es he join ac ion o heal h and non-heal h sec o s, public and p i a e sec o s and ci izens [3]. Consequen ly, he enhancemen o he ole o communi y pha macies in he heal hca e sys em is a new app oach ha is highligh ed by he poli ical p og amme o he XXI Go e nmen o Po ugal [4]. These issues a e discussed in his pape , in he con ex o Po uguese communi y pha macy p ac ice, which cons i u es an in e es ing case s udy o obse e he ans o ma ion o he ole o communi y pha macies in he heal h ca e sys em, including he means by which pha macy use s e alua e hei se ices and he expec a- ions hey de elop owa ds new ones. The Po uguese heal h sys em is o ganised a ound a Na- ional Heal h Se ice (NHS) ha is p ima ily unded h ough ans e s om he go e nmen budge , meaning ha gene al axa ion is he main sou ce o unding o he NHS. The Po uguese NHS de i es om he Be e idge model and is uni e sal in co e age, gene al in p o ision and enden ially ee o i s use s. The heal h ca e deli e y sys em consis s o a ne wo k o public and p i a e heal h ca e p o ide s; each is connec ed o he Minis y o Heal h and o he pa ien s in i s own way [5]. Po uguese communi y pha macies a e p i a ely owned, and each has a echnical di ec o wi h a deg ee in pha maceu ical sciences [5]. By he end o 2015, he e we e 2936 pha macies dis ibu ed all o e he coun y wi h an a e age o se en ull- ime employees pe pha - macy [6,7]. The u al a eas a e he egions whe e he numbe o pha macies pe capi a is highe [7], p o iding p oximi y suppo o his popula ion wi h lowe di ec access o o he heal h ca e p o ide s. The se ices p o ided by Po uguese communi y pha - macies include, among o he s, hesaleo p esc ip ion-only medicines (POM) and non-p esc ip ion medicines (NPM) and se e al o he heal h- ela ed p oduc s (e.g., cosme ics and i amins). Al hough pha macis s ha e always had in- ol emen in p o iding heal h se ices, his end has in- c eased in ecen yea s [8,9]. In 2007, wi h ecen upda es, a new legisla ion de ined he scope o se ices allowed in pha macies, including: home ca e suppo , i s aid, medi- cines adminis a ion, immunisa ion ( accines no included in he Na ional Vaccina ion Plan), lab es s, diagnos ic and he apeu ic se ices, disease managemen p og ammes, heal h campaigns and collabo a ion in na ional heal h edu- ca ion p og ammes [10,11]. The e o e, as a se ing o pub- lic heal h ac i i ies, communi y pha macies p esen se e al bene i s o i s use s. Wi h ex ended business hou s and no appoin men needed in ad ance, hese pha macies can be mo e accessible han o he heal h ca e p o ide s [12]. Con e sely, a e iew conduc ed in 2008 iden i ied high le els o pa ien sa is ac ion wi h pha macy se ices and highligh ed he need o unde s and expec a ions and p e e ences o pa ien s, explo ing and ma ching hese o he se ices p o ided [13]. Such high le els o sa is ac- ion wi h he communi y pha macy se ices ha e also been epo ed by he Po uguese popula ion in p e ious s udies [14]. Fo many yea s, pha macis s ha e been in he op 5 o he mos us ed p o essions acco ding o consume su eys [15,16]. Dua e e al. [17] showed how pha macy clien s e alua e e y posi i ely he quali y o he se ices p o ided ( a ed as 4 o mo e, in a scale o 1 o 5), as well as he quali y o con ac and in e pe - sonal ela ionship be ween clien s and p o essionals. The highes sco e is us (4.4), ollowed by pe sonalisa ion (4.1) and he an icipa ion o needs (3.6). In hei quali a- i e s udy abou communi y pha macy in Po ugal, Ca aco e al. [18] ound ha he Po uguese appea ed o asc ibe a pa icula social ole o he pha macis , as pa o a suppo i e ne wo k ha con ibu es, among o he issues, o sol e p oblems o access o he heal h sys em. Howe e , his ole appea s o be mo e associa ed o he pe cei ed de iciencies o o he communi y heal h ca e p o ide s (such as doc o s) han o he pe cei ed p o es- sional du ies o pha macis s. Ca aco e al . [18] also ob- se ed ha he in e pe sonal ela ionship o each clien wi h he pha macy s a was a he co e o a gene al posi i e expe ience o he pha macy, namely, a sense o secu i y in ela ion o he adequacy and quali y o dispensed p oduc s. As such, pha macis s a e conside ed o be knowledgeable, eliable, us ul and conside a e, which is a esul ha has also been ound in coun ies such as I an [19], Canada [20], Thailand [21] and Aus alia [22,23]. Mo eo e , he gene al le el o sa is ac ion owa ds pha - macies is highe han owa ds o he heal h ca e p o ide s, such as clinical labs, p i a e medical p ac ices, o p i a e hospi als. Simila esul s we e ound in Canada [20], Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 2 o 11 whe e pha macis s we e iewed posi i ely and conside ed o play a cen al ole in he heal h sys em o hei p o - inces by a la ge majo i y o he popula ion, mainly by women, hose o e 60, and egula isi o s o he pha - macy. A wide majo i y also ag eed ha expanding he ole o pha macis s in heal h ca e deli e y would posi i ely im- pac he pa ien s’quali y o li e, educe o e c owding in eme gency ooms and walk-in clinics and educe o e all heal h ca e cos s [20]. While his s udy a ge s explo ing simila dimensions, such as sa is ac ion, o he ela ionship be ween pha - macy p o ide s and use s, i also a ge s add essing his ela ionship om a di e en angle. Namely, his s udy elucida es how pha macy use s pe cei e he exis en model o communi y pha macy in Po ugal, de ined h ough he se ices o e ed, and hei a i udes owa ds new se ices and he e o e owa ds eme gen new models o communi y pha macy p ac ices. In addi ion, based on hese aspec s, his s udy p oposes a ypology o communi y use s, acco ding o hei a i udes owa ds bo h exis ing and eme gen pha macy models. Main goals and esea ch ques ions This s udy epo s he esul s o a na ionwide su ey whe e he iews o he Po uguese popula ion ega ding he exis ing pha macy model and a p oposed model o be o e ed in he u u e we e explo ed. Ou objec i e is o assess he iabili y o possible eme ging models o communi y pha macy p ac ice in Po ugal. Finally, we in end o do he ollowing: build a ypology o pha macy use s owa ds communi y pha - macy p ac ice; o cha ac e ise each clus e in e ms o hei composi ion (who a e he pe sons ha a e mainly con ibu ing o each clus e ); and o iden i y explana o y ac o s o he clus e i . We in end o answe he ques ion “wha a e he ex- pec a ions o pha macy clien s in ela ion o a se o new se ices ha would expand he ole o pha macies as heal h ca e p o ide s?”In addi ion o his main ques ion, a ew o he s will be add essed: how do clien s a e he impo ance o he se ices ha a e cu en ly p o ided by he pha macies? In addi ion, how sa is ied a e hey wi h hose se ices? To wha ex en a e hese le els o sa is- ac ion ela ed o he equency o isi s o he pha macy and o he expec a ions owa ds enla ging hei ole as heal h ca e p o ide s? The objec i es o his pape a e o explo e possible eme ging models o communi y pha - macy p ac ice in Po ugal and o cha ac e ise he opin- ions o he Po uguese popula ion in ela ion o hese eme gen models. Me hods The s udy u ilised a quan i a i e design, and da a we e collec ed h ough a su ey o closed-ended ques ions (English ansla ed e sion p o ided in Add- i ional ile 1).Thesu eywasdesignedandcon- duc ed by CESOP (Resea ch Cen e o Public Opinion o he Ca holic Uni e si y o Po ugal), wi h he col- labo a ion o CEFAR (Cen e o Heal h E alua ion & Resea ch o he Po uguese Associa ion o Pha ma- cies). The da a we e collec ed by 88 in e iewe s unde he supe ision o 22 ield-wo k coo dina o s. A p e- es was conduc ed o e alua e he ques ion- nai e unde s anding and easibili y. As one o he goals was o measu e he pe cep ions o communi y pha macy se ices in he gene al Po uguese popula- ion and no exclusi ely on pha macies’usual cus- ome s, a ep esen a i e na ional sample was u ilised, in acco dance wi h a s a i ied mul i-s ep me hod. Fi s ly, he locali ies we e chosen andomly om each o he 10 s a a g oups ob ained h ough combining he 5 NUTSII (Nomencla u e o Te i o ial Uni s o S a is ics) egions in Po ugal mainland wi h hei habi a ( u al/u ban). The numbe o locali ies se- lec ed om each s a um was p opo ional o he numbe o adul s li ing in each s a um, based on he elec o al egis e da abase. In Po ugal, e e y ci izen o e 18 is immedia ely included in he elec o al egis- e . Ce ain esiden s wi hou Po uguese na ionally, namely, immig an s om ou side he E.U., whom a e app oxima ely 3% o he o al popula ion, a e no in- cluded in his da abase. Ne e heless, hese indi id- uals could ye be selec ed as esponden as hei dis ibu ion in he coun y is simila o he Po uguese dis ibu ion. Secondly, o each chosen lo- cali y, he household was selec ed h ough a andom ou e pa h. Thi dly, in each household, he espon- den s we e chosen acco ding o he me hod o he las /nex pe son o ha e his/he bi hday o 18 yea s old o mo e. U ilising a doo - o-doo me hodology, he su ey was applied ace- o- ace by skilled in e - iewe s wi h special aining o his p ojec . A o al o 1114 in e iewees comp ised he inal sample (ma - gin o e o o app oxima ely 3% o a 95% con i- dence in e al). The sample was weigh ed based on popula ion dis ibu ion ac oss egions and habi a (u ban/ u al a eas), age and gende , acco ding o he popula ion es ima es p o ided by S a is ics Po ugal [24] ( he o icial s a is ics ins i u ion in Po ugal, www.ine.p ). This pos -sampling weigh ing p ocess al- lows he co ec ion o de ia ions esul ing om he sampling p ocess, making he wo king da abase as nea as possible o he uni e se unde analysis. Desc ip i e s a is ics, bo h uni a ia e and mul i a i- a e, and s a is ical es s comp ised me hods o analysis o measu e possible di e ences be ween g oups and es he esea ch hypo hesis. A e a desc ip i e ana- lysis o he main a iables, c oss abs enabled es ing Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 3 o 11 o di e ences acco ding o he main cha ac e isa ion a iables (gende , age coho , and egion o esi- dence), as well as o he ele an a iables conside ing he objec o s udy (e.g., equency o pha macy use, o ha ing a ch onic disease). Se e al echniques and s eps comp ised mul i a ia e explo a ion o da a. Fi s , Fac o Componen Analysis o he a iables ha mea- su ed he deg ee o impo ance gi en o pha macy se ices ( a imax o a ion; KMO = 0.838; Ba le ’s Sphe ici y Tes p<0.001. N= 754) was conduc ed. Th ee componen s we e ound, and he a iables wi h sco es abo e 0.4 we e e ained o cons uc he new a iables (α> 0.6): suppo wi h he apy and medical p esc ip ion; p e en ion o a heal hy li e; and home and o he p oximi y se ices. Fu he clus e analysis showed ha he mos nume ous g oup was he i s one(56%), ollowedbyhomeando he p oximi yse - ices (34%) and p e en ion (10%). These g oups we e hen used as inpu a iables o a Mul iple Co es- pondence Analysis (MCA), oge he wi h wo o he a iables: heopinion owa d headequacyo he pha macy se ices o he esponden s’needs; and how likely hey we e o isi he pha macy in he u u e, in case i p o ides a pa icula se o new se ices. The analysis p o ided wo main dimensions and sug- ges ed he o ganisa ion o esponses in o h ee g oups, which we e u he alida ed h ough a K-Means Clus e Analysis. The g oups a e p esen ed in he nex sec ion. Resul s A o al o 1114 people pa icipa ed in he s udy. Be o e weighing, 64 % we e women, and pa icipan s’age anged widely, be ween 18 and 95 yea s old (Mean 52.70, SD = 17.19). Pa icipan s’dis ibu ion ac oss he i e main e- gions o Po ugal mainland was he ollowing: No h 40%; Cen e 18%; Lisbon 30%; Alen ejo 6%; and Alga e 6% (Table 1). All analysis was pe o med a e weigh ing he sample on he basis o he popula ion dis ibu ion ac oss egions and habi a (u ban/ u al a eas), age and gende . Use o pha macies o mino ailmen s When he pa icipan s we e asked abou he i s place hey consul when a mino ailmen a ises, mo e han one- hi d o he esponden s (36%) answe ed ‘ he pha - macy’, ollowed by p ima y heal h cen es (27%). The majo i y o he esponden s (54%) s a ed he pha macy was also he i s esou ce hey seek when hey ha e ques ions abou medicines. O he pa icipan s, 17% (n = 185) epo ed “o he ”sou ces, o which 48 indi iduals e e ed o he medicine lea le , while 42 indi iduals e- e ed o he in e ne . The pha macy is a equen op ion o he Po uguese popula ion: he o e whelming majo - i y o esponden s (95%, n= 1057) epo ed o ha e isi ed he pha macy a leas once o e he pas yea . Among hese esponden s, app oxima ely hal (51%, n= 538) isi he pha macy 6 o mo e imes, and 81% (n= 850) isi a leas 3 imes o e he pas 6 mon hs. This e- quency is highe among women (p< 0.001), he elde ly (p < 0.001), he e i ed, pensione s and widowe s (p<0.001). Sa is ac ion wi h pha macy se ice The pa icipan s appea o ha e a high sense o sa is ac- ion wi h hei Pha macy. Among hose who isi ed hei local pha macy a leas once in he pas yea , he o e - whelming majo i y epo ed o be ei he sa is ied o e y sa is ied (94%, n= 995). App oxima ely one in ou e- sponden s (26%, n= 274) s a ed ha he/she is e y sa is- ied. The sa is ac ion le el is also e y high when he a ious dimensions o pha macy se ices we e conside ed sepa a ely (Fig. 1). Mo e han 90% o esponden s decla ed hemsel es sa is ied o e y sa is ied in ela ion o six o he eigh dimensions o which he sa is ac ion le el was measu ed. Examples included he compe ence o p o- ide s, he in o ma ion o e ed, he loca ion, o he amoun and quali y o se ices p o ided by he Pha macy. The dimension wi h he lowes sco e was he one e- la ed o access du ing he nigh and on weekends, ollowed by he cus ome p i acy dimension. Howe e , app oxima ely wo in e e y h ee esponden s decla ed hemsel es ei he sa is ied o e y sa is ied wi h his dimension. Familia i y wi h pha macy se ices Se ices p o ided by pha macies appea o i he exis ing needs o 69% o he esponden s (n= 729). Howe e , 29% (n= 306) o he pa icipan s belie e he e could be mo e se ices a ailable in pha macies ha a e cu en ly p o- ided in o he heal h ca e acili ies. Fu he mo e, he pa - icipan s show a high le el o acknowledgemen o he pha macy’sse ices(Fig.2). The bes -known se ice is he “suppo in he choice o non-p esc ip ion medicines”. App oxima ely 4 in 5 esponden s (79%) epo ed know- ing his se ice. Ne e heless, he e a e ce ain se ices ha emain unknown o he majo i y o he pa icipan s, namely, hose ha a e no a ailable in Po uguese Pha - macies. The leas known se ice is “scheduling a medical appoin men ”wi h he gene al p ac i ione ia pha macy, e e ed o by only one in e e y en indi iduals (11%). Al- hough he e a e se ices ha a e mo e amilia han o he s, he pa icipan s’opinion is nea ly unanimous in hei impo ance; he as majo i y o esponden s a e hem as ei he impo an o e y impo an , e en o se - ices leas known by esponden s (Fig. 3). The mos im- po an se ices a e “poin -o -ca e es s and medical sc eening”(93% a ed his se ice as “impo an ”o “ e y impo an ”), “suppo in keeping ch onic disease pa ien s unde con ol”(92%), “suppo in he choice o Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 4 o 11 non-p esc ibed medica ion”(92%) and “ex ended heal h ca e in pha macies”(91%). When p omp ed o ank he i e mos impo an se ices, despi e hei cu en a ailabili y a he pha macies, he e- sponden s chose: 1) au oma ic enewal o p esc ip- ions o ch onic disease pa ien s (chosen as one o he 5 mos impo an se ices by 50% o he espon- den s and a ed as he mos impo an se ice by 30%); 2) suppo in main aining ch onic disease unde con ol ( op5: 48%; 1s : 20%); 3) home deli - e y o medicines ( op5: 48%; 1s : 12%); 4) ex ended heal h ca e in pha macies (e.g., ea men o small wounds, and i s aid) ( op5: 39%; 1s : 14%); and 5) p o ision o ce ain medicines exclusi ely dispensed a he hospi al pha macy and ollow-up o ea men ( op5: 38%; 1s : 14%). Table 1 Cha ac e is ics o su ey esponden s Cha ac e is ics To al (n=1114) Non-weigh ed ( alid) Weigh ed ( alid) n%n% Region No h 443 39.8 422 37.9 Cen e 197 17.7 270 24.3 Lisbon 336 30.2 295 26.5 Alen ejo 70 6.3 80 7.2 Alga e 68 6.1 46 4.1 Gende Male 394 35.5 536 48.1 Female 715 64.5 578 51.9 Communi y pha macy equency Visi pha macy a leas once in he las yea 1055 94.7 1057 94.9 ≥6 isi s in he las six mon hs 576 54.8 538 51.1 Age g oup (yea s) 18-24 55 4.9 99 8.9 25-34 116 10.4 177 15.9 35-44 228 20.5 208 18.7 45-54 218 19.6 201 18 55-64 171 15.4 172 15.4 ≥65 325 29.2 257 23.1 Ma i al s a us Has a pa ne (ma ied o de ac o) 680 62 645 58.8 Single 205 18.7 281 25.6 Widow / di o ced / sepa a ed 211 19.3 172 15.6 Educa ion No educa ion 33 3 24 2.2 P ima y educa ion (4 h o 6 h yea ) 376 34.7 337 31.1 P ima y educa ion (9 h yea ) 171 15.8 169 15.5 Seconda y educa ion (12 h yea ) 238 21.9 254 23.4 Highe educa ion (uni e si y) 267 24.6 301 27.8 Occupa ion Employed 551 49.7 591 53.3 Unemployed 116 10.5 115 10.3 Pensione 329 29.7 278 25.1 O he 113 10.2 127 11.3 Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 5 o 11 Building a ypology o o ien a ions owa ds communi y pha macy p ac ice Oneo hemaingoalso hiss udywas oexplo e possible eme ging models o communi y pha macy p ac ice in Po ugal and o cha ac e ise he Po u- guese popula ion in ela ion o hose eme gen models. To accomplish his goal, an MCA was con- duc ed, ha ing he ollowing ac i e a iables: he opinion owa ds he adequacy o he pha macy se - ices o gene al needs; how likely esponden s a e o conside isi ing he pha macy in he u u e, in case i p o ides a pa icula se o new se ices; and a new Fig. 2 Le el o knowledge o pha macy se ices Fig. 1 Le el o sa is ac ion wi h pha macy se ices Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 6 o 11 a iable classi ying indi iduals acco ding o how hey a e he impo ance o pha macy se ices (clus e s). MCA allowed he iden i ica ion o wo dimensions, esul ing in h ee ou come g oups (Fig. 4). These g oups a e named acco ding o he main idea ha c oss-cu s he a iables ha a e mos ele an o hei o ma ion. Thus, quali a i ely naming he g oups was a means o be e cap u ing and communica ing he main ai s o each g oup. The “Mo i a ed” People who e eal a connec ion wi h he Pha macy. These people a e egula cus ome s, and we an icipa e hey will seek pha macy se ices mo e o en i hey inc ease and di- e si y. These people wan pha macies o suppo ch onic disease pa ien s h ough ex ended heal h ca e, ollow-up, and au oma ic enewal o p esc ip ions. The “Mo i a ed” cons i u e he la ges g oup in he sample (63%, n=699). Women p ima ily comp ise his g oup, as do he younges and egula pha macy cus ome s. The “Se led” Mainly cha ac e ised by a ou ing se ices “coming o hem”(23%). Pha macy cus ome s occasionally comp ise his g oup; his g oup is unlikely o inc ease i s demand o he Pha macy. These indi iduals belie e pha macy se ices a e adjus ed o hei needs. This g oup high- ligh s he impo ance o se ices such as home deli e y o medicines o p o ision o ce ain medicines exclu- si ely dispensed a he hospi al pha macy. The “Se led” a e p ima ily men, o en olde han younge , e i ed/pen- sione s, and mainly ha e a pha macy nea by. The “Demobilised” This is a mino i y g oup (14% o he sample), weakly ied o he Pha macy. Membe s o his g oup a ely isi he pha macy and do no belie e hey may need o isi mo e o en in he nea u u e. This g oup is p ima ily composed by men, unemployed, hose who a e a e pha macy cus- ome s, and people wi h no easy access o a pha macy. Discussion Resul s sugges ha he as majo i y o he Po uguese popula ion has a s ong posi i e a i ude owa ds he communi y pha macy. These esul s a e in acco dance wi h wha o he s udies ound in di e en coun ies [19–21,23,25–27], emphasising he c oss-coun y ele- ance o communi y pha macies as gene al heal h ca e p o ide s [1,28]. This posi i e a i ude is h ee- old. Fi s , his a i ude is exp essed by he high le els o sa is ac ion wi h he pha macy in gene al and wi h i s pa icula se ices; he compe ence o pha macis s and he quali y o se ices ob ained he highes le els o sa is ac ion, con i ming e- sul s om p e ious s udies de eloped in Aus alia [22], I an [19], Canada [20], I eland [25], o Po ugal [18]. Second, he in e iewees a e as impo an o e y im- po an he majo i y o se ices cu en ly p o ided by communi y pha macies. Finally, he Po uguese also posi i ely e alua e he possibili y o pha macies p o id- ing a new se o se ices in he nea u u e. E alua ing Fig. 3 Le el o impo ance o pha macy se ices Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 7 o 11 pa ien s’sa is ac ion and a ached impo ance wi h di - e en pha macy se ices plays an impo an ole ha can suppo and help o design and de elop inno a i e pha macy se ices o be e se e pa ien s’needs and p e e ences and o maximise he p o essional capaci y o communi y pha macies a local and na ional le els. These esul s encompass an endo semen by he Po - uguese o an enla ged ole o pha macis s and commu- ni y pha macies in he p o ision o ex ended heal h ca e se ices. A simila esul was ound in one s udied con- duc ed in Canada [20], which showed ha 72% o Cana- dians conside ed pha macis s o be heal h ca e p o ide s; mo e han hal a ed hem as cen al playe s in he heal hca e sys em. Simila ly, p e ious esea ch e- ga ding he Po uguese con ex had p e iously highligh ed ha he Po uguese iden i y di e en oles o pha macis s, such as medicines supplie , ad ice p o- ide and communi y heal h p omo e ; hese a e oles ha we e posi i ely ela ed o pa ien s’sa is ac ion and loyal y, explaining 50% o pa ien s’sa is ac ion and 61% o loyal y [29]. The communi y heal h p omo e ole equally ela ed o bo h o hese dimensions. Howe e , in hei quali a i e s udy ega ding he consume s’pe - cep ions o communi y pha macy in Po ugal, Ca aco e al. iden i ied di e gen unde s andings o he pha - macis ’s ole, wi h he main pe cep ions poin ing o a p oduc -supplying ole and associa ed o low le els o knowledge and awa eness o he pha macis s’ esponsi- bili ies [18]. The esea che s hypo hesise ha such poo knowledge and low expec a ions can jus i y a educed desi e o an ex ended ole o he pha macis in he communi y. By con as , ou da a sugges ha he Po uguese popula ion would welcome new se ices, i hey a e o ien ed o enhance be e access o gene al heal h ca e. Howe e , he “cus ome p i acy”dimension needs o be add essed and po en ially imp o ed o u- u e pha macy se ice de elopmen . Ou indings a e mos in acco dance wi h p e ious s udies ha sugges pa ien s’conce ns ega ding p i acy and con iden iali y [12,30]. As pa ien sa is ac ion eme ges as a c i e ion o im- p o e pa ien s’ us [31] and heal h ou comes [32], his a icle a emp s o build a ypology o pha macy’s e ec - i e and po en ial use s, in ega d o hei a i udes o- wa ds a new model o communi y pha macies, composed o bo h old se ices, which a e mo e a ached o POM and NPM counselling and dispensing, and new ones, which a e be e desc ibed as ex ended heal h ca e p o isions (e.g., p o iding POM ha a e cu en ly only a ailable h ough hospi als, o au oma ic enewal o p e- sc ip ions o pa ien s wi h ch onic diseases ha a e unde con ol). The h ee g oups iden i ied sugges wo di e en lines o ac ion. On he one hand, pha macies a e challenged o co espond o he cu en ly high ex- pec a ions and posi i e a achmen o hei egula cus- ome s, mainly women and he younges . The expansion o he pha macies’ ole as a gene al heal h ca e p o ide appea s o i he expec a ions o hese “mo i a ed”indi- iduals, which cu en ly appea o ha e a connec ion o he pha macy; he challenge is o e ain hem in he Fig. 4 A ypology o o ien a ions owa ds communi y pha macy p ac ice Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 8 o 11 changing dynamics o he pha macies. On he o he hand, pha macies a e challenged o add ess he needs o bo h he “se led”(23%) and he “demobilised”(14%); he i s has easy access o a pha macy, which is con a y o he second. Ta ge ing hese g oups wi h new and mo e sophis i- ca ed pha macy se ices ha ul il di e en p e e ences and needs can be an oppo uni y o expand he pa ien -cen ed p o essional ole o communi y pha ma- cis s and o enhance he managemen o ch onic condi- ions in he communi y wi h lowe cos s o he pa ien s and he go e nmen [33]. A ecen s udy es ima ed ha he communi y pha macy se ices p o ided in Po ugal in he las 25 yea s p o ide a gain o 8.3% in he Quali y o Li e (QoL) o pa ien s and an annual economic alue o 879.6 M€, including 342.1 M €in se ices o he han dispensing and 448.1 M€in a oided expenses ela ed o heal h ca e esou ce use. These se ices included: adhe ence in e en ions; ch onic disease in e en ions; and non-p esc ip ion selec ion and counselling. Po en ial u u e communi y pha macy se - ices we e also es ima ed wi h an addi ional inc ease o 6.9% in QoL and an economic alue o 144.8 M€[34]. Al hough his s udy does no explo e he consume s’ willingness o pay (WTP) o pha macy se ices, which may dic a e he easibili y o hei implemen a ion, se - e al s udies epo ha he e a e many consume s will- ing o pay o speci ic communi y pha macy se ices. The willingness o pay appea s o be sensi i e o pe - cei ed u ili y and heal h imp o emen s [35–37]. De eloping and expanding he ole o communi y pha macis s can be a means o enew he ocus on p e- en i e heal h ca e and o ex end he co e age o p i- ma y heal h ca e. Fo example, in Finland, communi y pha macis s a e ac i ely in ol ed in he ea men and p e en ion o majo ch onic diseases. In he Uni ed S a es, communi y pha macies p o ide in luenza immu- nisa ions in communi ies designa ed as medically unde - se ed [38], and in England, he New Medicine Se ice (NMS), a complex medicine managemen in e en ion, suppo s pa ien s’adhe ence o newly p esc ibed medi- cines o long- e m condi ions [39]. B oadening he scope o communi y pha macis s’may be an impo an policy le e ha coun ies could pu sue o p o ide less cos ly and mo e p e en i e heal h ca e and be e man- agemen o long- e m condi ions [40], as pa ien s show s ong a i udes, connec ion and sa is ac ion wi h hese p o essionals and se ices p o ided. Conclusion This s udy explo ed a new app oach in ol ing an unde - s anding o he expec a ions and p e e ences o pa ien s owa ds communi y pha macies, leading o an explo a o y ypology o (po en ial) pha macy cus ome s. One con ibu ion o his a icle is ha i p o ides insigh ega ding he basis o a s a is ically ep esen a i e sam- ple o he Po uguese popula ion. In a ace- o- ace in e - iew conduc ed doo - o-doo , 1114 esponden s answe ed a closed-ques ion su ey ha measu ed hei a i udes in ela ion o he se ices ha communi y pha macies cu en ly p o ide, as well as hose ha could be p o ided in he nea u u e. This ace- o- ace me h- odology, which is known o ha e an ad an age in ob ain- ing quali y da a, also has i s disad an ages, as is he case when in e iewees diligen ly a emp o mee he (imag- ined) expec a ions o he in e iewe s and he e o e ad- he e mo e easily o socially accep able no ms and discou ses. This beha iou may ha e in luenced he e y high le els o sa is ac ion owa ds communi y pha macy se ices and may be one o he limi a ions o he s udy. Ne e heless, his me hodology o ace- o- ace in e - iewees is a ed as one o he bes o ensu ing us among in e iewees and he e o e he eliabili y o he in o ma ion and da a p oduced. The esul s sugges ha he majo i y o he Po uguese ha e a connec ion o a pha macy, in acco dance wi h he esul s om p e ious s udies on communi y pha - macy ac oss he wo ld and in Po ugal. The le els o sa - is ac ion a e high, and he se ices p o ided a e a ed as impo an and e y impo an by he majo i y o he popula ion. On he one hand, he impo ance assigned o se ices is associa ed wi h he knowledge ha cus- ome s cu en ly ha e abou hem ( he mo e knowledge, he mo e impo ance). On he o he hand, esponden s a e open o new se ices ha ha e no ye been imple- men ed, which hey also pe cei ed as impo an . These esul s sugges ha he e is a gene al ag eemen among he popula ion ega ding he ole o pha macies in he heal h sys em and a posi i e a i ude owa d he ex en- sion o hei ole as public heal h p o ide s. Addi ional in es iga ions o de e mine consume s’ willingness o pay o di e en pha macy se ices should be explo ed. This s udy highligh s ce ain u u e di ec ions ha can be pu sued by pa ien s, heal h p o essionals and policy make s o expand he heal h ca e ole o Po uguese communi y pha macies. Addi ional ile Addi ional ile 1: Su ey empla e. English ansla ed e sion o he Po uguese su ey. (PDF 349 kb) Abb e ia ions CEFAR: Cen e o Heal h Resea ch & E alua ion; CESOP: Resea ch Cen e o Public Opinion o he Ca holic Uni e si y o Po ugal; M€: Million eu os; MCA: Mul iple Co espondence Analysis; NHS: Na ional Heal h Se ice; NMD: New Medicine Se ice; NPM: Non-p esc ip ion medicines; Polica po e al. BMC Heal h Se ices Resea ch (2019) 19:186 Page 9 o 11