Tropical Medicine and International Health doi:10.1111/j.1365-3156.2008.02186.

volume 14 no 1 pp 93–100 january 2009

Pharmacy customers’ knowledge of side effects of purchased

medicines in Mexico
Veronika J. Wirtz1, Katja Taxis2 and Anahi Dreser1

1 Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
2 Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands

Summary objectives To analyse pharmacy customers’ knowledge and information sources about side effects of
medicines they purchased and factors associated with this knowledge.
methods Cross-sectional survey and semi-structured interviews with customers of 52 randomly se-
lected community pharmacies in Morelos state, Mexico. Customers were included if they were older
than 18 years, bought at least one drug either with or without medical prescription, and agreed to take
part in the survey. Data were analysed using a multinomial logistic regression model.
results A total of 1445 customers buying 1946 drugs were surveyed (age 42.9 ± 15.7 years, 56.9%
female); 627 (59%) of 1055 customers who purchased prescription-only medicines (POM) did so
without a prescription. Of all customers interviewed, 172 (11.9%) affirmed that the bought medicine(s)
could cause harm. Only half of those (87 or 6%) were able to identify correctly at least one side effect of
the purchased medicines. The majority received the information about side effects from a physician.
Customers in semirural areas knew less about side effects (odds ratio: 0.26; 95% CI: 0.11–0.61;
P = 0.00); whereas customers buying medicines for chronic pain, hypertension or diabetes knew more
(odds ratio 2.63; 95% CI: 1.44–4.80; P = 0.00).
conclusion The overall majority of customers did not know that medicines they bought could be
harmful. This is particularly alarming because they frequently used POM without consulting a physician.

keywords side effects, drugs, knowledge, clients, pharmacy, Mexico

patients who knew about side effects of NSAIDs still

Introduction
Users of medicines want to be informed about side
effects of their medications (Berry et al. 1997; Ziegler
et al. 2001). In the USA, almost 80% of adults visiting
outpatient clinics wished to be informed about all
possible side effects (Ziegler et al. 2001). In contrast to
this, a range of studies from other developed countries
have generally found knowledge about side effects to be
poor; in a small sample of the general public in the UK,
Hughes et al. (2002) reported that only 16% could name
at least one side effect of their over-the-counter (OTC)
medicines. American and British adolescents’ knowledge
about side effects of paracetamol was poor (Gilbertson
et al. 1996). Only 61% of visitors to an emergency
department were able to mention at least one side effect
of non-steroidal anti-inflammatory drugs (NSAIDs)
(Cham et al. 2002). When rheumatoid arthritis and
osteoarthritis patients were asked about side effects, only
37% were well informed (Mahmud et al. 1995). Irish
underestimated the risks associated with these (Cullen
et al. 2006). There is a paucity of studies on this topic
from developing countries. However, these studies seem
particularly relevant in countries such as Mexico where
self-medication is common (Angeles-Chimal et al. 1992;
Vicencio Acevedo et al. 1995) and nearly all prescrip-
tion-only-medicines (POM) can be purchased without a
prescription (Altagracia et al. 2003; Vázquez-Moreno
et al. 2004; Wirtz et al. 2008).
Appropriate information delivered to medicine users
reduces adverse events and harm caused (Raynor et al.
2007). Potential sources of consumer information on
medication side effects are: leaflets delivered with the
drug, promotional information directed to consumers,
and healthcare professionals or untrained personnel
prescribing, recommending or selling medicines. In
contrast to developed countries where most consumers
have access to package inserts and information leaflets,
Mexico does not require that medicines are sold with an

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Tropical Medicine and International Health
V. J. Wirtz et al. Customers’ knowledge of side effects of purchased medicines in Mexico
information leaflet. Furthermore, the General Health
Law and the Official Mexican Norm NOM-072-SSA1-
1993 ‘Labeling of medicines’ (SSA-COFEPRIS 2005)
requires that only OTC medicine labels must include
information on side effects and adverse effects as well as
the dose and a specification on how to take the
medicine. This information is not required for POM;
instead it should be written ‘dose: the one the physician
indicates’ and – apart from a pictogram not to take the
medicine during pregnancy – no information on side
effects or adverse effects has to be included. With respect
to promotional information, product information for
OTC medicines is directly provided by the pharmaceu-
tical industry and is not sufficiently monitored by the
Mexican drug and regulatory authority for accuracy
(Rivas 2001). Trained healthcare professionals are rarely
present in pharmacies, so that people with little or no
relevant training are selling drugs in pharmacies or other
types of outlets (Kroeger et al. 2001).
In Latin America including Mexico, there are few studies
on consumers¢ knowledge about medication side effects.
Our objectives were to analyze pharmacy customers’
knowledge, the factors associated with this knowledge and
the information sources about side effects of medicines
they purchased.
Methods
For the purpose of this work ‘side effects’ were defined as
any secondary effect of a medicine accompanying the
desired effect, but usually adverse effects (as of a drug) (US
National Library of Medicine 2007). This study was part
of a larger research project about consumption of medi-
cines and knowledge of clients and staff of community
pharmacies which had been approved by the local research
and ethic committees (INSP208-6210). A cross-sectional
survey and semi-structured interviews were taken of
customers as they left community pharmacies in the
Mexican state of Morelos. Customers were recruited from
community pharmacies selected from the 2006 official
census of pharmacies of the Mexican state of Morelos,
certified by the State Ministry of Health. Pharmacies were
stratified by location (urban and semi-rural ⁄ rural) and type
of pharmacy (traditional or chain).
Sampling strategy
A representative sample of community pharmacies was
chosen from a mix of semi-rural and urban municipalities
representing 75% of the population and 69% of the
pharmacies at the state level. This ensured that the sample
served a considerable proportion of the state’s population
94
volume 14 no 1 pp 93–100 january 2009
and proportionally represented urban and semi-rural pop-
ulations as these differ mainly in terms of education and
socio-economic status.
Traditional pharmacies were defined as pharmacies
whose owner’s name was listed up to twice on the census
list. Chain pharmacies were defined as establishments
whose owner’s name was listed more than twice on the
census list or which was owned by an association or
cooperative. The distinction between traditional and chain
pharmacies is relevant because of differences in manage-
ment and organization. Traditional pharmacies usually
have less staff than chain pharmacies, and are smaller
stores or store fronts.
Data collection
Data collection took place in October and November 2006.
Four trained field workers visited the study pharmacies one
working day during morning and afternoon business hours.
Pharmacy owners were asked for their consent. Customers
who had purchased at least one medicine were asked on their
way out whether they would participate in the study.
Inclusion criteria were customers 18 years or older, pur-
chasing at least one drug either with or without a medical
prescription, and agreeing to take part in the survey.
Customers who could not understand Spanish or who were
unable to respond to any question were excluded.
A short survey was conducted with all participants. In
addition, a subsample of customers was asked to take part
in a semi-structured interview. The questionnaire for the
short survey comprised 20 questions and had been tested
during a pilot study in five pharmacies with 93 customers.
The pilot data were included in the final sample. The first
question asked about side effects was: ‘Do you know which
kind of harm the medicine(s) you purchased can cause?’
The term ‘harm’ (daño) was found to be the most
appropriate way to express the meaning of ‘side effects’
according to pilot study findings. Customers who reported
one or more potential side effects were asked which of their
purchased medicines could provoke harm. Finally, cus-
tomers were asked who informed them about the potential
harm of the medicines (i.e. doctor, friends, etc.). We also
asked for customers’ age, sex and medical insurance, what
brand and quantity of drug they bought, the type of health
problem they were for and whether the drugs were bought
with or without medical prescription.
In each pharmacy, two randomly chosen customers were
asked whether they would participate in a 10- to 15-min
interview in addition to the short survey (regardless of
whether they knew of side effects or not). These interviews
were designed to obtain more detailed answers about the
information that customers have about medicines and
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Tropical Medicine and International Health volume 14 no 1 pp 93–100 january 2009

V. J. Wirtz et al. Customers’ knowledge of side effects of purchased medicines in Mexico

their side-effects. The interview included the question: ‘Do
you have information about the side effects which the
medicine could cause?’. In the pilot study, we found that it
was not feasible to carry out interviews taking longer than
10 min because the majority of customers refused to
participate. Customers were asked for their agreement to
tape-record the interview.
Data from the semi-structured interviews were tran-
scribed verbatim. Reasons why customers thought that the
medicines would not cause side effects were identified from
the data. A coding frame of common themes was devel-
oped to allow classifying the answers. An EXCEL spread
sheet was used to order and compare data between
interviews.

Data analysis Results

The question ‘Do you know which kind of harm the In 52 community pharmacies, a total of 1445 customers
medicine can cause?’ was analysed as follows: First, buying 1946 drugs were surveyed (age 42.9 ± 15.7 years,
depending on whether the answer was yes or no the 56.9% female); of those, 63 also participated in a semi-
customer was categorized as being aware of side effects or structured interview. Seventy-three per cent of customers
not. Second, if the customer mentioned one or various kind bought POM, however, 59.4% of the customers purchased
of harmful effects of a medicine these were categorized as them without a prescription (Table 1). The most fre-
‘correct’ or ‘incorrect’ for each purchased drug by using quently bought medicines were analgesic drugs, antibiot-
standard pharmacological references (Martindale, The ics, vitamins and antihistaminic drugs (Table 2). About
Complete Drug Reference and the British National For- 18% of analgesic drugs and 33% of antibiotics were
mulary; Sweetman 2006; Mehta 2006). In case the side bought for children and young people less than 18 years
effect mentioned by the interviewee was described in one of old (Table 2).
the two references listed above it was classified as ‘correct’;
in case it was not mentioned or the interviewee’s answer
Customers’ knowledge about side-effects
was vague or unclear it was defined as ‘incorrect’. Vague
answers included ‘I am feeling unwell’ or ‘harm in general’. Only 172 (11.9%) customers were aware that the medicine
Data from the survey were entered into a data base using can cause side effects. Customer knowledge varied
Microsoft EXCEL and transferred into spss (Chicago, IL, according to the top 12 therapeutic groups of medicines
USA), version 14. Data were analysed by using descriptive
statistics of frequencies. In order to probe the association Table 1 Demographics of the study population (N = 1445)
between knowledge that medicines can cause side effects
Number
and independent variables a multinomial logistic regression
Demographics (percentage)
model was used. The dependent variable was coded as: (i)
no awareness of side effects, (ii) awareness that the Age
medicine can cause side effects, but mentioning incorrect Mean (SD) 42.9 (15.7)
side effects, and (iii) awareness of side effects and Sex
Male 509 (35.2)
mentioning correct side effects. Independent variables were
Female 936 (64.8)
customer from a pharmacy in an urban or semi-rural area, Insurance
type of pharmacy, age, sex and health insurance status of Yes 658 (45.5)
the customer, the purchase of medicines for chronic No 769 (53.2)
conditions including chronic pain, hypertension and dia- No response, unknown 18 (1.3)
betes, and the purchase of a POM or OTC medicine with Customers buying medicines with a medical prescription
or without medical prescription. The latter variable was (N = 1445*)
Yes 561 (38.8)
classified into four groups: POM with prescription, POM
POM 428 (29.6)
without prescription, OTC with prescription, OTC with- OTC medicines 103 (7.1)
out prescription, taking ‘POM with prescription’ as the Unknown classification 30 (2.1)
reference category. The medicines for chronic pain, No 884 (61.2)
hypertension and diabetes were chosen to test the hypoth- POM 627 (43.4)
esis that customers who purchased those drugs are better OTC 230 (15.9)
Unknown classification 27 (1.9)
informed about side effects than customers not purchasing
these drugs. Odds ratios (OR) were calculated with 95% POM, prescription-only-medicines; OTC, over-the-counter.
confidence intervals (CI). Statistical significance was *For 57 medicines there was no information whether they are
defined as P-value <0.05. prescription-only-medicines.

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V. J. Wirtz et al. Customers’ knowledge of side effects of purchased medicines in Mexico

Table 2 Customers’ knowledge of side effects according to the top 12 therapeutic groups purchased

Medicines Medicines bought Customer knew

Total number bought for for a child or young that the medicine
of medicines an adult  personà (n = 455) could cause a side effect
Therapeutic group (N = 1889*) (n = 1434) (%§) Yes

Analgesics 412 (21.8) 336 (23.4) 76 (18.4) 46 (11.2)

Antibiotics 296 (15.7) 195 (13.6) 99 (33.4) 34 (11.5)
Vitamins 102 (5.4) 79 (5.5) 23 (22.5) 10 (9.8)
Antihistaminic drugs 71 (3.8) 48 (3.3) 23 (32.4) 7 (9.9)
Antihypertensive drugs 66 (3.5) 66 (4.6) 0 10 (15.2)
Antiulcer drugs 55 (2.9) 53 (3.7) 2 (3.6) 8 (14.5)
Mucolytics 55 (2.9) 22 (1.5) 33 (60) 3 (5.5)
Corticosteriods 53 (2.8) 38 (2.6) 15 (28.3) 6 (11.3)
Antimycotics 51 (2.7) 48 (3.3) 3 (5.9) 5 (9.8)
Antiprotozoal drugs 44 (2.3) 27 (1.9) 17 (38.6) 8 (18.2)
Herbal drugs 38 (2.0) 28 (2.0) 10 (26.3) 1 (2.6)
Anti-diabetic drugs 37 (2.0) 36 (2.5) 1 (2.7) 9 (24.3)

*57 medicines could not be classified.

 18 years or older; à<18 years old; §Percentage out of all medicines of this therapeutic group.

purchased between 2.6% for herbal and 24.3% for
antidiabetic medicines. Of these 172 customers, 87
(50.6%) were able to identify correctly at least one side
effect of the purchased medicines. The top five most
commonly mentioned side effects were stomach irritation,
allergy, vomiting, nausea and renal damage (Table 3). The
medicines most commonly mentioned as causing side
Table 3 Most frequent correctly mentioned side-effects
Frequency SE
mentioned per
medicine
Side-effect (SE) purchased (%)
effects were paracetamol, vitamins, acetylsalicylic acid and
ampicillin.
Factors associated with knowledge about side-effects
Customers in urban areas (P = 0.009) and purchasing
medicines for chronic conditions (chronic pain, hyperten-
sion or diabetes) (P = 0.003) were more likely to be aware
that the medicines purchased could cause harm (Table 4).
Similarly, customers being able to mention at least one
correct side effect were more commonly from urban areas
(P = 0.002) and those purchasing medicines for chronic
diseases (P = 0.02).

Stomach irritation 15 (12.4) Information source about side-effects

Allergy 14 (11.6)
Vomiting 12 (9.9) Forty-nine (56%) of the 172 customers who were aware
Nausea 11 (9.1) that the medicine(s) purchased could cause harm reported
Renal damage 9 (7.4)
that they received the information from a physician,
Sleepiness 9 (7.4)
Dizziness 7 (5.8)
followed by 20 (23%) customers who obtained the
Skin irritation 6 (5.0) information themselves (Table 5). Only four customers
Liver damage 5 (4.1) (5%) received the information about side effects from a
Skin rash or irritation 4 (3.3) pharmacy clerk and only one customer (1%) said that the
Diarrhoea 3 (2.5) information was obtained from the information which
Multiple organ damage 2 (1.7) came with the medicine.
Tachycardia 2 (1.7)
Analysis of the semi-structured interviews revealed five
Haemorrhage 2 (1.7)
Visual damage 2 (1.7) common themes (Table 6). Many mentioned that the
Others 18 (14.9) medicines purchased could not cause harm because they
themselves or others known to them had never experienced
Total 121* (100)
harm. Another common theme was that only if the
*Some customers mentioned more than one side-effects. medicine was used inappropriately (e.g. higher doses or

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V. J. Wirtz et al. Customers’ knowledge of side effects of purchased medicines in Mexico

Table 4 Results of the multinomial logistic regression

Awareness of side-effects, but mentioning

incorrect side effect Knowledge of correct side-effects

95% confidence 95% confidence

Independent variable P-value Odds ratio interval P-value Odds ratio interval

Semi-rural region 0.009 0.345 0.156 0.764 0.002 0.262 0.112 0.612
Medication for chronic diseases 0.003 2.383 1.353 4.197 0.002 2.629 1.441 4.796
POM with a Rx 1 1
POM without a Rx 0.102 1.602 0.911 2.817 0.180 1.425 0.850 2.389
OTC with a Rx 0.968 0.978 0.321 2.976 0.828 0.895 0.330 2.427
OTC without a Rx 0.147 1.660 0.836 3.296 0.236 0.607 0.267 1.384
Type of pharmacy 0.095 0.622 0.356 1.086 0.219 0.701 0.398 1.235
Health insurance 0.206 0.746 0.474 1.174 0.701 0.994 0.962 1.027
Customer age 0.058 1.014 1.000 1.028 0.050 0.985 0.969 1.000
Customer sex 0.397 0.819 0.515 1.301 0.604 1.136 0.702 1.839

POM, prescription-only-medicine; Rx, prescription; OTC, over-the-counter-medicine.

Table 5 Information source of side effects Table 6 Reasons for why medicines do not cause side effects or
harm
Number
Source of information (percentage) Themes Examples of quotations

Medical doctor 49 (56.3) Since the medicine has ‘Since some time ago I use the
Myself ⁄ no one 20 (23) never caused harm in the medicine for my big kids and
Family or friends 9 (10.3) past, it does not have any they never caused harm.’
Pharmacy clerk 4 (4.6) ‘They never have caused harm,
I can not remember 3 (3.4) they do me good.’
Information on the medicine 1 (0.7) The medicine does not ‘No harm because they are
No info 1 (1.1) cause harm because it is prescribed by a doctor.’
Total 87 (100) prescribed by a physician ‘The doctor prescribed it
(the medicine), I don’t think it
will cause harm.’
Since the doctor or drug ‘Well, according to the doctor
promotion did not provide lanzoprazol does not have side
used longer than recommended) would it cause harm.
information about side effects.’
Some explained that the medicine could not cause harm effects or harms, the
because it had been prescribed by a doctor or because the medicine does not provoke
doctor had not mentioned any side effect. Others said that them
the promotion of medicines in the mass media meant that Only if more than ‘Well, they are bad if taken them in
there were no side effects. ‘I don’t believe that it provokes recommended is consumed excess, no? (…) Take only the
does the medicine cause ones that the doctor
damage, they announce it on TV’. Some confused the
harm recommended, but when taken
indication for the medicines or contraindications with side excessively everything is bad.’
effects. For instance, clients said that taking too much of an Since the medicine has the ‘I say that they do not do harm.
antidiabetic medicine would increase the blood sugar level. power to cure it can not Why? Because I will take them
cause harm to get better.’

Discussion
The results of this study show poor knowledge among
consumers about side effects of the medicines purchased in
community pharmacies in Mexico. Only 87 (6%) of 1445
customers could correctly identify at least one side effect
for their purchased medicines. This is even less than in
other studies (Hughes et al. 2002; Gilbertson et al. 1996;
Cham et al. 2002; Mahmud et al. 1995), but because of
differences in study methods and definitions, results are
difficult to compare.
We would argue that knowing about benefits and risks
of medicines is important for two reasons. First, it is the
basis for consumers of medicines to make informed

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Tropical Medicine and International Health
V. J. Wirtz et al. Customers’ knowledge of side effects of purchased medicines in Mexico
decisions on pharmacotherapy (Wirtz et al. 2006). Studies
from developed countries have shown that consumers wish
to be informed about side effects (Berry et al. 1997; Ziegler
et al. 2001). Secondly, consumers need such knowledge to
assess the effects of their medicine taking, in particular
being able to recognize side effects and to respond to those
with appropriate action, including knowing at which point
to seek professional advice. This is relevant for all
consumers of medicines, but particularly relevant for
consumers who self-medicate themselves or their families
using POM (which was 43% in our study). This means that
nearly half of the customers in our study purchased a
pharmaceutical product without a medical prescription
which should be used under supervision of a physician.
Our finding that of 1055 customers who bought POM 627
(59%) purchased them without a prescription is similar to
previous studies from Mexico which found between 43%
and 55% of customers buy POM without a prescription
(Altagracia et al. 2003; Vázquez-Moreno et al. 2004). The
low level of knowledge of side effects is alarming in a
setting where access to POM is unfettered, pharmacy staff
is untrained and medicines bought do not contain any
customer-directed information. In this way, consumers are
unprotected threefold (Leyva-Flores 2002). It remains
unknown if consumers would change their medication
taking behaviour if they had been aware of the potential
risks. Further research needs to address this as well as other
issues including whether consumers recognize side effects
once they actually occur and whether they take appropriate
action.
Of the small number of consumers who knew about side
effects, most reported physicians as the source of infor-
mation about side effects. These data are complemented by
the results from the semi-structured interviews which
revealed that patients expected to be informed by their
physician; otherwise some of them assumed that the
medicines did not have side effects. Only four out of 172
customers had been informed about side effects by phar-
macy clerks, which indicates the minor role they play in
advising customers. This might be due to their poor
knowledge about medicines, as reported by other studies
(Kroeger et al. 2001; Turner et al. 2003; Becker et al.
2004). On the other hand, pharmacy clerks might see
themselves only as drug sellers and not as professionals
with a responsibility to enhance rational use of medicines
by providing information to customers.
Consumers who purchased medicines for chronic dis-
eases including chronic pain, hypertension and diabetes
were more likely to know side effects, a finding which is
supported by another study showing that long-term users
are more aware of side effects and have better knowledge
(Berry et al. 2004). Customers from semi-rural areas were
98
volume 14 no 1 pp 93–100 january 2009
less aware about side effects. A possible explanation is
that educational level was lower in these areas; previous
studies have found that higher education is associated
with better knowledge about side effects (Cham et al.
2002). We did not find any difference in the awareness
and knowledge between customers purchasing an OTC
medicine or a POM with or without a prescription, which
suggests that a physician visit did not make customers
more aware or knowledgeable about the side effects of
their medicines.
There are increasing efforts to make information leaflets
more informative and useful to consumers (Raynor et al.
2007). However, in many developing countries, such as
Mexico, nearly all medicines marketed are not accompa-
nied by an information leaflet. In 2006, the Federal
Commission for the Protection against Sanitary Risks
(COFEPRIS) together with the National Association of
Manufacture of OTC Medicines (AFAMELA) produced
recommendations for manufacturers to include consumer-
directed information on the outer package of OTC
medicines (SSA-COFEPRIS 2005). However, the recom-
mendations are not enforced and so far manufacturers of
POM have refused to provide consumer-directed-informa-
tion, arguing that it would increase requests for POM
without a medical prescription.
One important finding of our study is that although
analgesic drugs and antibiotics were the most frequently
consumed medicines, customers were not more likely to
know their side effects. In our sample, 18% of the
analgesics and 33% of the antibiotics were for children and
young people under 18 years old. Particular children under
12 years of age are vulnerable to overdosing and therefore
mothers could be an important target for the provision of
information, especially of antibiotic side effects.
Few limitations have to be addressed. The data presented
above were obtained in one state of Mexico and can not
necessarily be generalized to other parts of the country and
other developing countries. However, due to the paucity of
data on this subject in developing countries, these findings
are important in giving information on the current level of
knowledge. We did not obtain information about the
educational level of the customers or socio-economic data
(except social insurance status and urban and semi-rural
area which could be used as proxy measure). Future studies
should take these variables into account. Due to the
possibly leading way in which the first question was asked
we even may have overestimated the number of clients
being aware of side-effects. We have classified knowledge
of side effects as incorrect if it was not documented in
standard reference sources. It could be that some customers
experienced so far unknown side effects. However, we
found that these answers rather indicated an absence of
ª 2008 Blackwell Publishing Ltd
Tropical Medicine and International Health
V. J. Wirtz et al. Customers’ knowledge of side effects of purchased medicines in Mexico
knowledge about the concept of side effects. For instance,
one customer mentioned that the anti-diabetic drug
increased the blood glucose level.
The draft of the new pharmaceutical policy in Mexico
promotes responsible self-medication (SSA-COFEPRIS
2005). In the light of our findings, the promoting self-
medication should give priority to providing information
about side effects to support rational use of medicines and
possibly reduce drug-related harm. As physicians are the
main source of information about side effects of medi-
cines, it is important that any consultation is used to
provide information about medicines and their side
effects. We urgently need to explore other sources of
information to effectively inform customers of community
pharmacies in Mexico about medicines and their side
effects.
Acknowledgements
We would like to thank the Center of Research for
Population Health of the National Institute of Public
Health, Mexico and the Simon Fraser University in
Vancouver, Canada for funding the study. Also thank
you to our colleagues from the Institute of Public Health
who supported the conduct of the study, in particular
Angelica Angeles and Guadalupe Ruelas for supervision of
the field work, Gabriela Torres who commented on a
previous draft and Sujeiry Navarro who contributed to
the classification of side effects. Thanks to Petros
Pechlivanoglov from University of Groningen who kindly
helped with the statistical analysis and Ann Payson for
support in editing the manuscript. Finally, we would like to
thank all the community pharmacies and customers who
participated in this study.
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Corresponding Author Veronika J. Wirtz, National Institute of Public Health, Center for Health Systems Research, Av. Universidad
655, Cuernavaca, Morelos 62508, Mexico. Tel.: +52 777 329 3040; Fax: +52 777 311 1156; E-mail: vwirtz@correo.insp.mx

100 ª 2008 Blackwell Publishing Ltd