How will (or should) this increase come about? Achieving an increase will necessitate that either pharmacists make more offers or, consumers ask more frequently for assistance. At present consumers generally ask for NPM-related advice. [4-6] Consumer-initiated interaction may continue to be the sensible approach in that it would be practical for pharmacists to offer help to every consumer considering a product. It is also unlikely that consumers want or need advice during every purchase. If this is to be the model, then consumers who desire information and wish to discuss their concerns with a pharmacist must feel at ease to do so.

This unfortunately may not be the case. [7] While reports indicate that many consumers want more information than they currently receive, some also hesitate to ask for it. Several factors are likely important in determining whether consumers will seek out pharmacists for advice. [8-9] Alternatively, the barriers that inhibit this process have also been discussed.[10-12] One such barrier is the prescription counter, a fixture considered a hindrance to the counseling process. The extent to which it is a hindrance has never been described, especially for consumers considering the purchase of a NPM.

Several authors have considered putting a pharmacist in front of the prescription counter. [6,13- 15] This in some respects removes the prescription counter from the interactive process. Any change in the rate of interaction as a result of such a step may be a measure of the degree to which interaction is normally impeded. The pharmacists of Kennebocasis Drugs in New Brunswick (Canada), for example, found that 67 percent of the people given advice by a front-shop pharmacist would have self-selected had that pharmacist not been in the aisle at the time of their purchase.

Based on the anecdotal interest shown for the idea of a front-shop pharmacist and questions over whether consumers may hesitate to ask for advice, the following study was carried out.

Methods
Consumers in a single pharmacy were observed as they considered the purchase of select NPMs. Observations were carried out from 4:00 to 6:59 pm, seven days a week, for four straight weeks (October 31 to November 27, 1993). Staff pharmacists were told that a study to determine how many consumers ask for advice on NPMs was in progress.

During the first week, a pharmacy student discreetly observed the rate of interaction normally occurring between consumers and pharmacists. This observer was dressed in street clothes and appeared to be another shopper, except that he carried a clipboard. As consumers considered the purchase of a product, interaction with any pharmacy personnel was noted using methods previously described. [5] When the selection process ended, consumers were categorized as those who did not receive advice (self-selectors) and those who did (advice-receivers). For the latter group, the source of the advice was recorded as was the initiator of the encounter. Information provided on product location, price, or availability was not considered "advice".

During the second week, an additional pharmacist (front-shop pharmacist, FSP) was stationed directly in front of the prescription counter in close proximity to the products under study. This pharmacist wore a white coat, a nametag, carried a clipboard, and had never worked at the study site. Regular pharmacist shifts in the dispensary did not change during this period. As consumers entered the NPM area, the FSP would browse past the person under the guise of facing products or ordering stock, yet trying not to appear too busy. Attempts were made to establish eye contact with as many consumers as possible. However, the pharmacist would only say "Hello" if eye contact was established; no offer of assistance was made. If called upon to answer a question pertaining to one of the NPMs in the study area, it was answered. Dispensary pharmacists were free to offer assistance to consumers or respond to questions, if that was usual behavior. The FSP recorded data for this part of the study, not the student observer.

During week three, the student observer again determined the baseline interactive rate, under the same conditions as week one.

For the final week, the FSP was again stationed in front of the prescription counter. The same methodology as week two was followed, with one change - an offer of assistance was issued to consumers (as often as possible) as they considered the selection of a product. This occurred as "Hello, I am a pharmacist. Can I help you?" The offer was not directed to people casually walking by, but to those who stopped in front of the NPMs under study and appeared to consider a product.

The pharmacy selected for this study was located in a strip mall on one of the city's busiest streets. It carried health and beauty aids, post office services, and food products. Between 100 and 150 prescriptions were filled per day. Excluding storage space, the building covered approximately 850 m². Pharmacists were on duty from 8:00 am to midnight - one on the early shift and one on the evening shift. Except on weekends, a pharmacy technician was on duty when observations were being made.

Products shelved directly in front of the prescription counter and down one aisle were considered within the scope of the study; cough and cold products, products for allergic rhinitis, oral analgesics, muscle relaxants, vitamins and minerals, hemorrhoidal preps, diet aids, enteral nutrition products, external analgesics, sleep aids and stimulants.²

Results
Over the 28 days of operation, 577 consumers were observed (43 percent male; 57 percent female). The number of people observed for the consecutive weekly periods were 118, 166, 139 and 154. These consumers purchased (or considered) 701 study-related products. Each episode with a product was called a transaction.

Table 1 depicts the number of transactions that occurred during each week, as well as the percentage involving advice. the percentages are based on the total number of transactions (n=701) observed rather than the total number of consumers (n=577).

Table 1. Rate of consumer-pharmacist interaction

		Transactions with advice
Week	Total number of transactions	Dispensary pharmacist	Technicians and clerks	Front-shop pharmacist	Total	Events with advice (%)
1 2 3 4	148 202 169 182	18 05 15 02	03 00 02 00	N/A 33 N/A 57	21 38 17 59		14.2% 18.8% 10.1% 32.4%

Although the presence of the FSP led to an increase in the rate of interaction, the change (4.6 percent) from week one (14.2 percent) to week two (18.8 percent) was not significant. The rate of interaction for week four (32.4 percent), however, was significantly greater than thart of weeks one and three. the extent consumers received advice during week two was also significantly greater than that of week three.

Over the entire four-week period, 21.6 prercent (n=87) of transactions involving women occured wirth advice while 16.1 percent (n=48) of male-associated transactions involved advice.

During weeks two and four, the FSP handled the majority of study-related questions and in addition, 69 product-and-service-related questions considered outside the scope of the study. While clerks and technicians only gave advice in five situations, they also assisted in finding products for several consumers (considered self-selection).

During week four, an effort was made to offer assistance to all consumers considering study-related product selections. Over this time, 154 consumers were observed, with 67 offers of assistance made by the FSP. Thirty-four people approached the FSP before assistance could be offered. No interaction took place with 53 of the 154 consumers; these consumers selected a product and quickly left.

Not everyone offered help accepted it. Subsequent to the 67 offers, the following took place: 26 rejected the offer of assistance; 7 rejected the offer initially but later asked for advice; 9 accepted assistance for product location only; 8 accepted assistance for product location and later asked for advice; and 17 accepted the offer and received advice.

Table 2 describes the type of products selected (or considered) by the consumers. This study took place during the early part of winter, therefore, it was not surprising that the main type of product purchased were those for colds.

Table 2. Number of products per category (n=701)

275 cough/cold3 165 analgesics 126 vitamins 55 no product 26 single-entry antihistamines 14 muscle relaxants

13 external analgesics 12 sleep aids/stimulants 7 diet aids/enterals 6 hemorrhoidal products 2 miscellaneous

Many consumers (n=55) did not purchase a product while in the pharmacy and could conceivably been excluded from the study. However, it was felt that a purchase was not a prerequisite for inclusion. These consumers appeared to consider a product in the same manner as those who eventually made a purchase. Their actions were therefore included in the results. People who appeared to be "browsing" while waiting for prescriptions were excluded.

Discussion and Limitations

Placing an extra pharmacist into the non-prescription product area of this pharmacy led to 4.6 to 8.7 percentage points(depending on baseline chosen) more consumer-pharmacist interaction. As this measure corresponded in some respects to the "removal" of the prescription counter from the interactive process, the range of increase seen may be indicative of the extent it acts as a barrier. It appears that for a small number of consumers, the path (from a physical point of view) to the regular dispensary pharmacists was not ideal. Logically, pharmacists may be more accessible to NPM consumers when not behind the counter.

While mentioned in a number of references on patient counseling, the extent a prescription counter might act as a hindrance to interaction between pharmacist and patient has never been documented. Morris et al did find patients that felt this fixture was not a problem, but also a group that said it would.[16] A British report found less public tendency for seeking information when pharmacists were restricted to the dispensary, regardless of whether the pharmacist was simply screened or actually closed off from public view.[17]

The prescription counter may be considered an impediment to interaction, but the presence of the FSP alone did not raise the rate of interaction by a tremendous amount. Another factor appears to be more important in increasing the rate of interaction. As a result of offering assistance, an increase of 18.2 to 22.3 percent occurred over baseline.

Since most consumers receive advice on NPMs through asking, those who do desire information and wish to discuss their concerns with a pharmacist must feel at ease to do so. Based on the over two-fold increase in interaction observed during week four, a degree of hesitation appears evident with the consumers of this study. Had the baseline rates equaled the rate for week four, it might be plausible to suggest that all those who want advice, do indeed ask for it. The act of offering may have signaled to the consumers that the pharmacist was indicating readiness to help with their concern(s).

While the prescription counter and consumer hesitation have been singled out for discussion, other possible explanations for the increase in interaction should be considered: 1) the FSP looked friendlier than the regular pharmacists; 2) there was more anonymity with an unknown pharmacist; 3) consumers felt it would be faster to ask the FSP for assistance than the regular pharmacists; 4) consumers were more apt to consider a pharmacist as a reference source on seeing/hearing them talk to other NPM consumers; and 5) consumers accepted offers of advice to be polite.

Pharmacy selection for this study was critical. If one was chosen where very little NPM counseling took place, but with high traffic volume, the effect of the FSP could have been tremendous. Conversely, one where pharmacists were constantly assisting people may have yielded little effect. We carefully considered the selection of sites available, and chose one we felt was fairly common to the city. The limitations of such a decision must be considered when examining the results.

The presence of the student observer and FSP may have altered the behavior of pharmacy personnel and consumers visiting the pharmacy. The student observer minimized the effect on consumers by discreetly observing people from a distance. Regarding pharmacists, a concern existed at the start of the study that they might offer more assistance to improve the numbers. The behavior of the regular dispensary pharmacists did not appear to change, validated by the limited number of offers they initiated. It is felt that the FSP had little effect on regular pharmacists, except that they handled less NPM-related questions. Clerk involvement in helping consumers find products may have been significantly curtailed, however.

Recording of data during weeks two and four by the FSP is an important limitation. The potential existed to be busy with one consumer and lose eye contact with others also under observation. Limiting observation to only three hours per day was also a limitation.

A factor that may have affected the results was the season in which the study was completed. Consumers were observed in early winter, a peak period for cough and cold activity. People may behave differently with respect to seeking advice during other months of the year. Also, it has been shown that people ask for advice on different products at different rates [18-22] and therefore the product mix can influence the rate of interaction observed.