Managing Minor Ailments

15 Pages·2016·0.24 MB·English

RESEARCHARTICLE
’
Managing Minor Ailments; The Public s
Preferences for Attributes of Community
Pharmacies. A Discrete Choice Experiment
TerryPorteous1☯,MandyRyan2‡,ChristineBond3‡,MargaretWatson1‡,VerityWatson2☯*
1 HealthServicesResearchUnit,UniversityofAberdeen,InstituteofAppliedHealthSciences,Polwarth
Building,Foresterhill,Aberdeen,AB252ZD,UnitedKingdom,2 HealthEconomicsResearchUnit,University
ofAberdeen,InstituteofAppliedHealthSciences,PolwarthBuilding,Foresterhill,Aberdeen,AB252ZD,
UnitedKingdom,3 AcademicPrimaryCare,UniversityofAberdeen,InstituteofAppliedHealthSciences,
PolwarthBuilding,Foresterhill,Aberdeen,AB252ZD,UnitedKingdom
☯Theseauthorscontributedequallytothiswork.
‡Theseauthorsalsocontributedequallytothiswork.
*[email protected]
Abstract
OPENACCESS
Background
Citation:PorteousT,RyanM,BondC,WatsonM,
WatsonV(2016)ManagingMinorAilments;The Demandforhealthservicescontinuestorise.Greateruseofcommunitypharmacyservices
Public’sPreferencesforAttributesofCommunity insteadofmedicalservicesforminorailmentscouldhelprelievepressureonhealthcare
Pharmacies.ADiscreteChoiceExperiment.PLoS
providersinhigh-costsettings.Communitypharmaciesarerecognisedsourcesoftreat-
ONE11(3):e0152257.doi:10.1371/journal.
pone.0152257 mentandadviceforpeoplewishingtomanagetheseailments.However,increasingthe
public’suseofpharmacyservicesmaydependonattributesofpharmaciesandtheirstaff.
Editor:Yhu-CheringHuang,ChangGungMemorial
Hospital,TAIWAN Thisstudyaimedtodeterminethegeneralpublic’srelativepreferencesforcommunityphar-
macyattributesusingadiscretechoiceexperiment(DCE).
Received:May14,2015
Accepted:March11,2016
Method
Published:March31,2016
AUK-wideDCEsurveyofthegeneralpublicwasconductedusingface-to-facecomputer-
Copyright:©2016Porteousetal.Thisisanopen assistedpersonalinterviews.AttributesandlevelsfortheDCEwereinformedbyaliterature
accessarticledistributedunderthetermsofthe
reviewandacohortstudyofcommunitypharmacycustomers.Thecontextfortheexperi-
CreativeCommonsAttributionLicense,whichpermits
unrestricteduse,distribution,andreproductioninany mentwasaminorailmentscenariodescribingflu-likesymptoms.TheDCEchoicesets
medium,providedtheoriginalauthorandsourceare describedtwohypotheticalcommunitypharmacyservices;respondentswereaskedto
credited.
choosewhich(ifeither)ofthetwopharmaciestheywouldprefertohelpthemmanage
DataAvailabilityStatement:Acopyofthesurvey symptoms.Datafrom1,049interviewswereanalysedusinganerrorcomponentslogit
usedfordatacollectionandtheresultingdataare
model.Willingnesstopay(WTP),amonetarymeasureofbenefit,wasestimatedforthedif-
depositedattheUKDataService:http://discover.
ferentattributelevels.
ukdataservice.ac.uk/catalogue?sn=7886(Permanent
identifier:10.5255/UKDA-SN-7886-1).
Results
Funding:ThisworkwasfundedbyMedical
ResearchCouncilMR/J004812/1toVW(www.mrc. Whenseekinghelportreatmentforflu-likesymptoms,respondentsmostvaluedaphar-
ac.uk),andPharmacyResearchUK1076457toMW
macyservicethatwouldimprovetheirunderstandingandmanagementofsymptoms(WTP
(www.pharmacyresearchuk.org/).Thefundershadno
=£6.28),providedbystaffwhoaretrained(WTP(pharmacist)=£2.63:WTP(trainedassis-
roleinstudydesign,datacollectionandanalysis,
decisiontopublish,orpreparationofthemanuscript. tant)=£3.22),friendlyandapproachable(WTP=£3.38).Waitingtime,pharmacylocation
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ThePublic’sPreferencesforPharmacyAttributes
CompetingInterests:Theauthorshavedeclared andavailabilityofparkingalsocontributedtorespondents’preferences.WTPforaservice
thatnocompetinginterestsexist. comprisingthebestpossiblecombinationofattributesandlevelswascalculatedas£55.43.
Conclusion
Attributesofacommunitypharmacyanditsstaffmayinfluencepeople’sdecisionsabout
whichpharmacytheywouldvisittoaccesstreatmentandadviceforminorailments.Inline
withthepublic’spreferences,offeringcommunitypharmacyservicesthathelppeopleto
betterunderstandandmanagesymptoms,areprovidedpromptlybytrainedstaffwhoare
friendlyandapproachable,andinalocalsettingwitheasyaccesstoparking,hasthepoten-
tialtoincreaseuptakeamongstthoseseekinghelptomanageminorailments.Inthiswayit
maybepossibletoshiftdemandawayfromhigh-costhealthservicesandmakemoreeffi-
cientuseofscarcepublicresources.
Introduction
Communitypharmaciesarewidelyrecognisedaslocationsfromwhichpeopleseekadviceand
treatmentforthemanagementofminorailments.Servicesrangefromtheprovisionofadvice
aboutlifestyle,drugandnon-drugtreatments,throughtoadviceonsymptomsandsalesof
products,sometimesself-selectedbypharmacycustomers,formanagingminorailments.
Communitypharmacystaffhavethecapacitytosupportcustomerswishingtoself-carefor
minorailmentsand,ifnecessary,referthemonwardstoappropriatehealthcareprofessionals
forfurtherinvestigations.Internationally,manycountriespromotethisrole.[1–3]Theaimsof
suchpoliciesincludeencouragingpeopletotakeresponsibilityfortheirownhealth,reducing
demandformoreexpensivehealthcareoptions(suchasappointmentswithprimarycaremedi-
calpractitionersorvisitstohospitalemergencydepartments)andpromotingefficientuseof
scarcepublicresources.
Ourpreviousresearchdemonstratedthatforminorailmentscharacterisedbyflu-likesymp-
tomsoracutediarrhoea,peoplestatedapreferenceforself-carewhenmanagingtheirsymp-
toms.[4,5]Thosepeoplewishingtoseekadvicepreferredtogetthisfromcommunity
pharmaciesorfromtheirgeneralpractitioner(GP).Inreality,however,asubstantialpropor-
tionofemergencydepartment(ED)visitsandappointmentswithGPsintheUnitedKingdom
(UK)areforself-limitingconditionsthatcouldhavebeenmanagedwithoutmedicalinterven-
tion,andasimilarpatternhasbeenobservedinothercountries.[6–11]Arecentstudyinthe
UKestimatedthatatleast5%ofEDvisitsand13%ofGPappointmentsconcernedsuchcondi-
tions,andthatthismightcosttheNationalHealthService(NHS)over£1billioneachyear.[6]
Demandforhigh-costhealthservicesintheUKcontinuestorise[12]despitenationalinitia-
tivesthatencouragethepublictousealternativehealthcareservicessuchastelephonehelp-
lines,websitesprovidinghealthadvice,nurse-ledminorillnessclinics,walk-inclinicsandcom-
munitypharmacyservicessuchasMinorAilmentsSchemes(MAS).[13–16]MASallow
patientswhoareexemptfrompayingNHSprescriptionfeestoregisterwithacommunity
pharmacyandreceiveadviceand/ortreatmentforminorailments,paidforbytheNHS.
Itisunclearwhycommunitypharmacyservicesarenotusedmoreoftenforthemanage-
mentofminorailments.Onepossibilityisthatserviceconfigurationsdonotmeetpotential
users’needsorpreferences.Previousresearchinvestigatingtheuseofcommunitypharmacies
[17]andpreferencesformanagingsymptomsofminorailments[4,5]suggeststhatanumber
offactorsinfluencecommunitypharmacyuse.Someoftheseareusercharacteristics(e.g.age,
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ThePublic’sPreferencesforPharmacyAttributes
gender,natureofsymptoms,previousexperience),whileothersareattributesofpharmacyser-
vices.Whilethesestudiestellussomethingabouttheserviceattributesthatinfluencetheuseof
pharmacyservicesbypeoplewithminorailments,nonehaveestimatedtherelativeimportance
norstrengthofpreferenceforthedifferentattributes.[18]
Thisstudyusedadiscretechoiceexperiment(DCE),[19]astatedpreferencemethod,to
obtaininformationfromthepublicabouttherelativeimportanceofdifferentpharmacyattri-
buteswhentheyconsiderhowtomanageaminorillness.Trade-offsbetweentheseattributes
andthecostofdealingwithsymptomsofminorillnessatapharmacy,wereestimatedas
respondents’willingness-to-pay(WTP).Theseestimatesindicaterespondents’strengthof
preferenceforeachattribute.Policymakersandserviceproviderscouldusesuchinformation
toprovideservicesthatbettersatisfyusers’needsandpreferences.
DCEsareusedineconomicstomeasurepreferencesfordifferentattributesofgoodsand
services,includinghealthcare.[19]Dataarecollectedusingastructuredquestionnaireinwhich
respondentsarepresentedwithhypothetical“choicesets”thatofferalternativegoodsorser-
vices,describedintermsofasetofattributesandthelevelsofthoseattributes.Selectionof
appropriateattributes(andassociatedlevels)fortheDCEiscrucialtothevalidityofthefinal
results;bestpracticeguidelinesrecommendthatattributesareinformedbyliteraturereviews
andqualitativeevidence.[20,21]Withineachchoiceset,respondentsmuststatewhichalterna-
tivetheyprefer;itisassumedthattheselectedalternativemaximisestheirutility(benefit).
Regressionanalysisprovidesinformationonrelativeimportanceofattributesandhowpeople
tradebetweenthemwhenmakingtheirchoices.Ifthecostofaserviceisincludedasanattri-
butethenWTPforeachattributecanbeestimated.Calculationofutilityscoresdemonstrates
howrespondentsvaluespecificcombinationsofattributesandlevels;theseutilityscorescanbe
usedtopredicttheuptakeofdifferentserviceconfigurationsandalsototalWTPforaservice
configuration.DCEshavebeenusedpreviouslytovaluedifferentwaysofmanagingminorail-
mentsincludingminorailmentnursesinGPpractices,[22]nurseprescribingservicesfor
minorailments,[23]andtwostudiesthatcompareddifferentserviceproviders.[4,5]Elsewhere,
DCEshavebeenusedtovalueextendedrolesforpharmacists,[24–26]patient-centredphar-
macyservices,[27]pharmacyservicesformanagingchronicconditions[28]andelectronicpre-
scribing.[29]
Studiesvaluingpatientexperiencesofhealthcarehavemostlyvaluedthe‘process’ofcarein
waysthatarequantifiablee.g.lengthofappointment,professionofhealthcareproviderorloca-
tionofservices.The‘softer’attributesofhealthcaresuchasstaffattitudes,consultationstyles
orpatientenablementhaveseldombeenconsidered.[30]Recentresearchhashighlightedthe
importanceofbroadeningthewaysinwhichpatients’experiencesofhealthcarearevaluedand
recommendsthatfuturestudiesaredesignedwiththisinmind.[31]Whilstidentifyingattri-
butesforthisDCEweremainedalerttoanysuch‘experiential’attributesthatmightbesuitable
forinclusion.
Theaimsofthisstudywere:todevelopandconductaDCEtoestablishthepublic’sprefer-
encesforpharmacyserviceattributeswhenmanagingminorailments;toestablishthetrade-
offspeoplearepreparedtomaketoensureaccesstotheirpreferredpharmacyservice,interms
ofWTP;andtopredictthelikelihoodofuptakeofpharmacyserviceswithspecifiedcombina-
tionsofattributes.
Methods
DiscreteChoiceExperimentdevelopment
Aliteraturereviewwasconductedtoidentifyfactorsthatweresaidtoinfluencethepublic’suse
ofcommunitypharmacies.Thisincludedexistingquantitativeandqualitativeresearchabout
PLOSONE|DOI:10.1371/journal.pone.0152257 March31,2016 3/15
ThePublic’sPreferencesforPharmacyAttributes
preferencesforpharmacyserviceattributes,whenmanagingminorailments.Findingsfrom
thereviewweresupplementedwithdatafromaconcurrentcohortstudyexploringthepublic’s
useofcommunitypharmaciestomanageminorailments.[32]Inthecohortstudy,participants
visitingacommunitypharmacytoseektreatmentoradviceforaminorailmentcompleteda
structuredquestionnaireindicatingwhytheyhadchosentovisitapharmacyonthatoccasion.
Fromtheliteraturereviewandthecohortstudy,morethan30factorsinfluencingthepublic’s
useofcommunitypharmacyservicesforthemanagementofminorailmentswereidentified
(detailsavailableonrequestfromtheauthors).Notalloftheseweresuitableasattributesfor
theDCE;onlyfactorsdeemedpolicy-relevantwereconsideredforinclusionasanattribute,i.e.
factorsthatwereplausible,actionableandcapableofbeingtraded.Tofurtherreducethenum-
berofattributes,wherepossible,potentialattributeswerecollapsedintobroaderthemes
encompassingseveralofthefactorsidentified.Forexample,factorsconcerningstaffattitude
andrapportwerecollapsedintoonethatdescribed‘friendlyandapproachable’staff.Final
selectionoftheattributesandtheirlevelswasdecidedafterdiscussionsbetweentheauthors
andasteeringgroupconvenedspecificallyforthisstudy.Acostattributewasincludedtoper-
mittheestimationofWTPfordifferentattributesofpharmacyservices.Theselectedattributes
andlevelsareshowninTable1.
Table1. Attributesandlevels.
ATTRIBUTES LEVELS
Pharmacylocation (cid:129)Atthelocalshops
(cid:129)Inashoppingcentre
(cid:129)Inasupermarket
(cid:129)Besideadoctor'ssurgery
Carparkingavailability (cid:129)Definitely(yes)
(cid:129)Probably
(cid:129)Unlikely
(cid:129)No
Whoyouareservedby (cid:129)Apharmacist
(cid:129)Atrainedmedicinecounterassistant
(cid:129)Anuntrainedmedicinecounterassistant
Attitudeofstaff (cid:129)Friendlyandapproachable
(cid:129)Notfriendlyandapproachable
Questionsaskedbypharmacystaffabout (cid:129)Yes
symptomsand/orgeneralhealth
(cid:129)No
Understandingofsymptomsandhowtomanage (cid:129)Youunderstandyoursymptomsbetterandfeellike
themafterspeakingtopharmacystaff youknowthebestthingtodotomanagethem
(cid:129)Youdon'tunderstandyoursymptomsbetteranddon't
feellikeyouknowthebestthingtodotomanagethem
Waitingtimeuntilyoucandealwithsymptoms (cid:129)5hours
(cid:129)12hours
(cid:129)1day
(cid:129)2days
Cost(UK£) (cid:129)£2.50
(cid:129)£7.50
(cid:129)£15.00
(cid:129)£25.00
doi:10.1371/journal.pone.0152257.t001
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ThePublic’sPreferencesforPharmacyAttributes
Combiningtheseeightattributes(fourwithfourlevels,onewiththreelevelsandthreewith
twolevels)resultedin3,072differentpossiblepharmacyservices,whichwastoomanytoask
onerespondent.ThesewerereducedusingMacroMktExinSAS(Version9.1)[33]tocreatea
d-efficientdesignwith48choicesets.Tofurtherreducetheburdenonrespondentsandmaxi-
miseresponserates,theseweredividedintosixsub-groups(blocks),eachcomprisingeight
choicesets.Eachrespondent,therefore,waspresentedwitheightchoicesetsfromthefull
design.Participantswererandomlyallocatedtoreceiveaquestionnairefromoneofthesix
blocks;aquotasamplingapproachensuredthatanapproximatelyequalnumberofresponses
werecompletedforeachblock.
ThecontextfortheDCEwasaminorailmentsymptomscenario(Table2).Respondents
wereaskedtoimaginethattheywereexperiencingflu-likesymptoms,thattheycouldnotgeta
GPappointmentfor7days,andthattheydidnothavethemedicinestheymightneedathome.
Theywerethenaskedtochoosebetweentwohypotheticalcommunitypharmaciesthatthey
mightgotowhenmanagingthesymptoms.Alternatively,theycouldchoosea“donothing”
optionifneitherpharmacymettheirpreferences.Thelevelsforthis“donothing”optionwere
definedforrespondents(Table3).Afulldescriptionoftheattributesandlevelsandaworked
exampleofaDCEchoicequestion(Table3)wereprovidedtoassistwiththedecision-making.
Questionnairedevelopment
Aquestionnairewasdevelopedforin-personadministrationusingcomputerassistedpersonal
interviews(CAPI).InadditiontotheDCEchoicequestions,datawerecollectedonrespon-
dents’demographiccharacteristicsincludingage,gender,healthstatusandhouseholdincome.
Theformatofthesequestionswas,asfaraspossible,thesameasthe2011UKCensusorother
nationalsurveys,toallowreliablecomparisonswiththeUKpopulation.Forfullercharacterisa-
tionofrespondents,additionalquestionscollecteddataoncurrentuseofcommunitypharma-
cies.TotestthevalidityofresponsestotheDCEquestionsweincludedaquestionthatasked
respondentsiftheyconsideredallofthepharmacyattributesthatwereincludedwhenthey
weremakingtheirchoicesintheDCE.
Oneofthesixversionsofthequestionnairewaspre-pilotedinpaperformatinAugust2012
usingcognitiveinterviews[34]withvolunteermembersofthepublic(n=8),identifiedoppor-
tunisticallyfromalocalhealthserviceusergroup,andpersonalcontactsoftheresearchteam.
Thisresultedinminorclarificationsbeingmadetotheinstructionsforcompletion.
Participants
ThesamplingframewasbasedonUKCensusOutputAreas(thelowestgeographicallevelat
whichcensusestimatesareprovided).ResearchersfromIpsosMori(www.ipsos-mori.com),a
professionalresearchcompanycontractedtoundertakethesurvey,usedadoor-to-door
approachtorecruitparticipantsforboththepilotandmainsurveys.Thesamplewasstratified
Table2. Symptomscenario.
Pleaseimaginethissituation:
(cid:129)Youhaveaheadacheandafever,yourbonesareaching,youhaveasorethroatandyournosefeels
slightlyblockedup.Youarestillabletodoallthethingsyouusuallydobutaremoretiredthanusual.The
symptomsstartedtoappearfourdaysagoandwereslightlyworsewhenyouwokeupthismorning.
(cid:129)Adoctor’sappointmentisnotavailablefor7daysandyoudon’thaveanyofthemedicinesyoumight
needathome.
doi:10.1371/journal.pone.0152257.t002
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ThePublic’sPreferencesforPharmacyAttributes
Table3. Exampleofachoicequestion. Pleasecomparethepharmaciesandtickwhichpharmacy,ifany,youwouldvisit.
PharmacyA PharmacyB Donothing
Pharmacylocation Inasupermarket BesideDrsurgery Yougo
nowhere
Findacarparkspace Definitely No
nearby
Waitingtimeuntilyoucan 5hours 1day Nowait
dealwithsymptoms
Youareservedby Atrainedmedicinecounterassistant Pharmacist Youdon’t
speakto
anyone
Whois Friendlyandapproachable Notfriendlyandapproachable
Asksquestionsaboutyour Yes No
symptomsandgeneral
health
Afterspeakingwith Youdon’tunderstandyoursymptomsanybetterand Youunderstandyoursymptomsbetterandyou Nodifferent
pharmacystaff youdon’tfeellikeyouknowthebestthingtodoto feellikeyouknowthebestthingtodoto
managethem managethem
Cost £7.50 £15.00 £0
IwouldvisitpharmacyA IwouldvisitpharmacyB Iwoulddo
nothing
Pleasetickonebox
doi:10.1371/journal.pone.0152257.t003
bygeographicalregionand,additionally,subjectedtoquotasamplingforcharacteristicsthat
includedage,genderandworkingstatus.
Surveypilotingandadministration
Thequestionnairewaspilotedbetween21stOctoberand6thNovember2012usingface-to-
faceCAPIconductedbytrainedinterviewersfromIpsosMori;datawerecollectedfrom157
respondentsusingallsixversions(blocks)ofthequestionnaire.Basedonthepilotfindings,
minoralterationsweremadetothewordingandformatofthequestionnaire.Themainsurvey
wasadministeredbyIpsosMoribetween4thand24thMarch2013usingthesameCAPI
methodandwithatargetsamplesizeof1000.[35]DataweredeliveredinanSPSSdatabase
(Version20).Thequestionnaireisavailableonrequestfromtheauthors.
Dataanalysis
AnalysisoftheDCEisbasedonrandomutilitytheory.[36]Inthisstudy,anerrorcomponents
logitmodelwasestimatedusingSTATA(Version12)thusallowingformultipleobservations
fromindividuals.IncommonwithmostDCEs,thesystematicutilityVofpharmacyalternative
jisalinearandadditivefunctionofthepharmacyattributesandlevelswiththecategoricalvar-
iableseffectscoded.
Vj¼aþb ShopCentreþb Supermarketþb Doctorþb LocalShopþb ParkProbably
1 2 3 4 5
þb ParkUnlikelyþb ParkNoþb ParkDefinitelyþb Timeþb TMCAþb UTMCA
6 7 8 9 10 11
þb Attitudeþb Questionsþb Understandþb Cost ð1Þ
12 13 14 15
αrepresentsanalternativespecificconstantindicatingthepreferenceforvisitingapharmacy
(asopposedtodoingnothing).Thesignofthecoefficients(β toβ )indicateswhetherachange
1 15
intheattributelevelhasapositiveoranegativeeffectonutilityofapharmacytorespondents.
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Theunitofmeasurementmustbeconsideredwheninterpretingtheregressionresults;β
9
representstheeffectonpharmacychoiceofaonehourincreaseinwaitingtimeuntilsymptoms
canbedealtwith,andβ theeffectofa£1increaseinthecostofdealingwithsymptoms.The
15
coefficientsforcategoricalvariablesareinterpretedastheeffectofthepresenceoftheattribute
levelontheutilityofthepharmacy,e.g.β representstheeffectonutilityofbeingseenbyan
11
untrainedmedicinescounterassistant.
Utility,WTPandprobabilitiesofuptakewerecalculatedforpharmacyserviceswithspeci-
fiedattributelevels.Utility(V)wascalculatedusingEq1.WTPformarginalchangesinthe
attributeswasestimatedusingEq2,theratioofthecoefficientfortheattributeofinterest(β )
x
tothenegativeofthecostcoefficient(β ):
cost
b
WTP ¼ x ð2Þ
(cid:2)b
cost
ProbabilityofuptakeforahypotheticalpharmacyservicewithutilityVifromasetofactions
includingalternativeavailablepharmacyservicesanddoingnothingwereestimatedusingthe
logitEq3.
eVi
PðVÞ¼P ð3Þ
i J eVj
j¼1
Researchethics
Theresearchteamhadnodirectcontactwithparticipantsinthissurvey,andtheiridentities
wereunknowntotheteam.EthicalapprovalbyanNHSresearchethicscommitteewasnot
required.TheCollegeEthicsReviewBoardattheUniversityofAberdeenadvisedthatitwas
theresponsibilityofIpsosMori,thecompanyconductingtheresearch,toensurethatthesurvey
wasconductedinanethicalmanner.IpsosMoricomplieswithanumberofrelevantindustry
qualitystandardsincludingISO27001:2005,theinternationalstandardforinformationsecu-
ritywhichgovernsthetransfer,storageanddestructionofpersonaldata.
Results
Fromthe3,885approachesmadetoeligibleindividuals,1,049interviewswerecompleted
(27.0%acceptancerate).Themeanageofrespondentswas49years(SD:18.7),50.9%were
female(n=534)andthemajority(71.9%,n=754))self-ratedtheirhealthasgoodorvery
good.Allbut99respondents(9.4%)hadvisitedapharmacyatleastonceintheprevioussix
months,mainlyforprescriptiondispensingservices.Respondents’mainsourcesofnon-pre-
scriptionmedicineswerepharmacies(47.1%,n=494)andsupermarkets(42.1%,n=442).
Table4showsfurtherdetailsofrespondents’characteristicscomparedwithotherUKstatistics.
ResultsoftheregressionanalysisarepresentedinTable5.TheoreticalvalidityoftheDCE
wasdemonstratedbythefactthatthecoefficientsforcostandtimeweresignificantandnega-
tive,i.e.respondentspreferredtopaylessmoneyandwaitlesstimetodealwithsymptoms.
Sixty-onepercentofrespondentsreportedalwaysconsideringallattributeswhenmakingtheir
choices.Allattributeshadlevelsthatwerestatisticallydifferentfromzeroindicatingthatall
attributescontributedtorespondents’preferences.
Forthisflu-likesymptomscenario,respondentsrevealedapreferenceforvisitingaphar-
macytohelpmanagesymptoms,ratherthandoingnothing(asindicatedbythepositiveand
significantconstant),andwerewillingtopayaround£38(95%CI:£33.04-£42.58)todoso.The
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Table4. Respondentcharacteristics(N=1049)comparedtoUKpopulation.
Respondents UK
% n % p-value
Gender1 Male 49.1 515 49.2 p=0.8052
Female 50.9 534 50.8
Ageband1 18–29 18.7 195 20.3 p=0.0733
30–44 25.6 266 25.3 (ofthose
45–59 23.2 242 25.3 responding)
60–74 22.0 229 19.0
75andover 10.5 109 10.1
Missing - (8) -
General Verygood 30.5 320 47.2 p<0.0013
health Good 41.4 434 33.9
Status1 Fair 21.0 220 13.3
Bad 5.8 61 4.4
Verybad 1.3 14 1.3
Annual Upto£5,199peryear 7.6 52 2.0 p<0.0013
Income4 £5,200to£10,399peryear 16.3 111 6.9 (ofthose
£10,400to£15,599peryear 15.8 108 12.9 responding)
£15,600to£20,799peryear 12.0 82 12.9
£20,800to£25,999peryear 15.1 103 10.9
£26,000to£31,199peryear 7.9 54 8.9
£31,200to£36,399peryear 7.9 54 7.9
£36,400to£51,999peryear 10.4 71 15.8
£52,000andaboveperyear 14.6 100 21.8
Prefernottosay - (314) -
UKRegion1 NorthEastEngland 5.0 52 4.1 p=0.1583
NorthWestEngland 11.5 121 11.1
Yorkshire/Humberside 7.1 75 8.3
WestMidlands 7.3 77 8.9
EastMidlands 6.9 72 7.2
EastofEngland 10.3 108 9.3
SouthWestEngland 9.8 103 8.4
SouthEastEngland 11.7 123 13.7
London 13.1 137 13.1
Wales 4.6 48 4.8
Scotland 9.3 98 8.3
NorthernIreland 3.3 35 2.9
Usualsource Pharmacy/chemistshop 47.1 494
ofOTC5 Supermarket 42.1 442
medicines6 Other 8.4 88
NeveruseOTCs 2.4 25
Visitstoa 0 9.4 99
pharmacyin 1–5 48.4 508
past6-months5 6–10 28.7 301
11–15 7.7 81
Morethan15 5.7 60
Mainreasonfor Prescriptiondispensing 75.3 789
pharmacyvisits5 BuyingOTCmedicines 16.2 170
(Continued)
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Table4. (Continued)
Respondents UK
% n % p-value
Other 5.4 58
Nevervisitpharmacies 3.1 32
1.Datafrom2011Census
2.Binomialtest
3Chisquaretest
4DatafromDept.forWork&Pensions“FamilyResourcesSurvey2012to2013”
5OTCstandsforoverthecounter
6Nonationaldataavailableforcomparison
doi:10.1371/journal.pone.0152257.t004
marginalchangeinanattributethatwasmostimportanttorespondents(i.e.hadthecoefficient
ofgreatestmagnitude)waswhetherornotthepharmacyvisitwouldgivethemabetterunder-
standingoftheirsymptomsandhowtomanagethem;WTPforthiswasvaluedat£6.28(95%
CI:£5.66-£6.90).Beingservedbyatrainedstaffmember(pharmacistormedicinecounter
assistant),andfriendliness/approachabilityofpharmacystaffwerealsovaluedrelativelyhighly
byrespondents.Toreducewaitingtimebeforetheycoulddealwithsymptomsbyoneday,
respondentswerewillingtopayaround£5.52(95%CI:£4.56-£6.48).Themostpreferredloca-
tionsforpharmacieswereatthelocalshopsornexttotheGPsurgery;pharmaciesinshopping
centresandsupermarketsreducedWTP.Likelihoodofparkingalsocontributedtopreferences;
locationswithabetterchanceofparkingweremorehighlyvalued.
Basedontheseregressionresults,utilityscores,WTPandprobabilityofuptakewerecalcu-
latedforthe“best”possiblepharmacy(greatestutility),the“worst”pharmacy(leastutility)
andthe“donothing”option(Table6).Inaworldwhereonlythesethreealternativesexist,the
probabilitythatrespondentsexperiencingthesymptomscenario(Table2)wouldusethe
“best”pharmacyservicewas94.7%,the“worst”pharmacyservice,1.3%,and“doingnothing”,
4%.Thissuggeststhatrespondentswouldbemorelikelyto“donothing”aboutsymptomsthan
usethe“worst”pharmacyservice.
Discussion
Thesefindingsindicatethattheattributesofacommunitypharmacyanditsstaffmayinflu-
encepeople’sdecisionsaboutwhichpharmacytheywouldvisittoseektreatmentandadvice
forminorailments.Specifically,pharmacycustomersvaluebeingbetterinformedabouttheir
symptomsandhowtomanagethem,aswellaspharmacystaffthataretrainedandapproach-
able.Consistentwithpreviousresearch,attributesrelatingtoaccessandconvenience(inthis
study:waitingtime,locationandavailabilityofparking)alsoinfluencedpreferences.[32]
ThisisthefirstpublishedDCEexploringthepublic’srelativepreferencesforcommunity
pharmacyattributesinthemanagementofminorailments.Thestudywasconductedinthe
UKwhichhaspubliclyfundedhealthcare(theNHS);theseresultsmay,therefore,havelimited
generalizabilitytootherhealthcaresystems.ThisDCEwasundertakeninthecontextofone
specificminorailment.Understandinghowpeopleprefertomanageflu-likesymptomsis
importantbecauseself-limitingsymptomsofthistypeareamongstthemostcommonthatpeo-
plepresentwithattheirGP.[6]Itispossible,however,thatourfindingsmaynotbegeneraliz-
abletootherminorailments,althoughtwopreviousDCEsfoundthatpreferencesfor
managingflu-likesymptomsandaminorstomachupsetweresimilar.[4,5]Themainriskof
PLOSONE|DOI:10.1371/journal.pone.0152257 March31,2016 9/15
ThePublic’sPreferencesforPharmacyAttributes
Table5. ResultsfromregressionanalysisofDiscreteChoiceExperimentdataandmarginalwillingnesstopay.
Variable Regressioncoefficient(β) Pvalue Willingnesstopay(95%CIa)
Constanttermb
Alternativespecificconstant 2.288 <0.001 £38.31(33.04,43.58)
Pharmacylocation
Localshopsc 0.119 0.001 £2.00(0.81,3.20)
Inashoppingcentre -0.171 <0.001 -£2.86(-3.84,-1.88)
Inasupermarket -0.080 0.009 -£1.34(-2.33,-0.35)
BesideaDr’ssurgery 0.131 <0.001 £2.20(1.183.21)
Carparkingavailability
Definitelyc 0.147 <0.001 £2.47(1.24,3.70)
Probably 0.020 0.527 £0.33(-0.70,1.36)
Unlikely -0.078 0.012 -£1.31(-2.33,-0.29)
No -0.089 0.003 -£1.49(-2.45,-0.53)
Whoyouareservedby
Pharmacistc 0.157 <0.001 £2.63(1.72,3.53)
Atrainedmedicinecounterassistant 0.192 <0.001 £3.22(2.38,4.06)
Anuntrainedmedicinecounterassistant -0.349 <0.001 -£5.84(-6.69,-5.00)
Attitudeofstaff
Notfriendly&approachablec -0.202 <0.001 -£3.38(-3.92,-2.85)
Friendly&approachable 0.202 <0.001 £3.38(2.85,3.92)
Questionsaskedbystaff
Noc -0.090 <0.001 -£1.52(-2.02,-1.02)
Yes 0.090 <0.001 £1.52(1.02,2.02)
Understandingofsymptoms/management
Nobetterunderstandingc -0.375 <0.001 -£6.28(-6.90,-5.66)
Betterunderstanding 0.375 <0.001 £6.28(5.66,6.90)
Waitingtime(timetodealwithsymptomsinhours) -0.014 <0.001 -£0.23perhour(-£0.27,-£0.19)
Cost(costofdealingwithsymptomsin£) -0.081 <0.001
SDofAlternativespecificconstant 3.892 <0.001
Numberofindividuals 1049
Numberofobservations 25176
Log-likelihood -3542.479
AkaikeInformationCriterion 13114.96
a95%confidenceintervalsarecalculatedusingthedeltamethod
bThecoefficientfortheconstantisusedtoestimatethepreferencefordoingsomethingtomanagesymptoms(ratherthandoingnothing)
cThecoefficientsforthebasecasesoftheeffectscodedcategoricalvariablesarecalculatedasthenegativeofthesumofthecoefficientsfortheother
levels.Thestandarderrorsarethemeanoftheotherstandarderrors.Thep-valuesarecalculatedfromthederivedcoefficientsandstandarderrors
doi:10.1371/journal.pone.0152257.t005
biasinthistypeofstudyislikelytobefromsamplingbias,particularlysincetheacceptance
ratewasrelativelylowat27%.Weaimedtominimiseanysuchbiasbyusingastratifiedquota
samplingstrategytoensurethatthesamplewasrepresentativeofthepopulationonkeyindica-
tors(geographicallocation,age,gender,workingstatus).Ourrespondentsweresimilartothe
UKpopulationintermsofage,genderandlocation,however,peopleself-reporting“very
good”healthandthoseinhigherincomebracketsweresomewhatunder-represented.Respon-
dents’useofcommunitypharmacieswasconsistentwithfindingsfrompreviousresearch.
[37,38]Weusedthe“goldstandard”surveymodeforcontingentvaluationstudies(face-to-
faceinterview)[39,40]andthepotentialforinterviewerbiaswasminimisedbytheuseofCAPI
PLOSONE|DOI:10.1371/journal.pone.0152257 March31,2016 10/15