HAL Id: hal-00599847
https://hal.archives-ouvertes.fr/hal-00599847
Submitted on 11 Jun 2011
Ava Lorenc, Nicola Robinson
To cite this version:
Ava Lorenc, Nicola Robinson. Responding to patient demand: community pharmacists and herbal
and nutritional products for children. Phytotherapy Research, Wiley, 2010, �10.1002/ptr.3357�. �hal-
00599847�
For Peer Review
Responding to patient demand: community pharmacists and herbal and nutritional products for children
Journal: Phytotherapy Research Manuscript ID: PTR-10-1085.R1 Wiley - Manuscript type: Full Paper
Date Submitted by the
Author: 11-Oct-2010
Complete List of Authors: Lorenc, Ava; Thames Valley University Robinson, Nicola; Thames Valley University Keyword: herbal, pharmacists, children, nutrition
For Peer Review
Responding to patient demand: community pharmacists and herbal and nutritional products for children
Short title:
Community pharmacists and herbal and nutritional products
Nicola Robinson, Ava Lorenc*
Centre for Complementary Healthcare and Integrated Medicine, Thames Valley University
*Corresponding author: Thames Valley University, Paragon House, Boston Manor Road, Brentford, Middlesex, TW8 9GA; 0044 (0)20 82094414; ava.lorenc@tvu.ac.uk
Deleted: medicines
Deleted: medicines
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Abstract
The attitudes and behaviour of pharmacists working in a multi-ethnic community regarding herbal and nutritional products (HNPs) for children, were explored in depth. Qualitative interviews with four pharmacists were analysed using Framework Analysis. Quantitative diary recording of all HNP-related events for child customers in four pharmacies was carried out over 2 separate week periods between March - June 2008. Of 29 events recorded, most involved parents buying products for their child, especially herbal and nutritional
supplements and topical products, and asking for advice. Pharmacists were generally open to herbal and nutritional products and perceived an increasing demand which they were keen to meet. Although they reported feeling competent to give advice, pharmacists wished to increase their knowledge as information on HNPs was limited, and the need to maintain professionalism at all times was recognised. Pharmacists appear to understand and empathise with customer demand for HNPs and are uniquely positioned within the National Health System to provide product advice and support. However, to maintain
professionalism, pharmacists may require further information on herbal and nutritional products and continuing professional training, especially since herbal and nutritional supplements may interact with prescribed and over-the-counter drugs.
Deleted: products
Deleted: supplements and other complementary and alternative medicine (CAM)
Deleted: CAM
Deleted: CAM
Deleted: CAM Deleted: products
Deleted: CAM Deleted: products
Deleted: CAM product
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Introduction
Complementary and alternative medicine may be defined as healthcare outside of conventional medicine. It is used by 38% of adults and 12% of children, in particular over- the-counter products (homeopathy, herbal, vitamins/minerals and other food supplements) (Nahin et al 2009). Almost all pharmacies in the UK (99%) stock herbal and nutritional products (HNPs) and most (81%) receive CAM queries (Barnes and Abbot 1999). Whether pharmacists should stock HNPs is debatable, given limited evidence of efficacy and safety (Anon 2008). However, such HNP provision may be a natural extension of the pharmacist’s role (Boon 2005), particularly in supporting self-care (DH 2008). Patients and pharmacists believe pharmacists have some responsibility for HNP (Boon 2005) but may lack knowledge, especially for herbal medicine (Cramer et al 2010). The decision to stock these products may be a balance between profit, ethics and patient demand (Naidu 2005). Few studies have explored in-depth the issues of HNP for pharmacy practice, including pharmacists’
attitudes to HNP and the tension between patient demand and evidence-based practice.
Methods
As part of a larger study on complementary and traditional medicines for children (Robinson et al 2009), interviews and diary recording took place in four community pharmacies in a highly multi-ethnic community in Northwest London, between March - June 2008. A diary sheet was completed by pharmacists or assistants for each purchase or enquiry of a HNP for a child for two separate one week periods. Information included child demographics, conventional healthcare, product enquiries, purchases and pharmacist response. Semi- structured interviews of up to one hour were subsequently carried out (by AL) with one pharmacist from each pharmacy. Pharmacists completed consent forms, and
questionnaires about themselves, the pharmacy and HNP stock. Interviews discussed beliefs, knowledge and education on HNPs and their use for children, reason for stocking HNPs, use of HNP information, perception of HNP use in the community and safety issues.
Deleted: (CAM)
Deleted: CAM
Deleted: CAM Deleted: products Deleted: CAM
Deleted: CAM
Deleted: CAM Deleted: products Deleted: CAM
Deleted: CAM
Deleted: product
Deleted: CAM Deleted: CAM Deleted: products Deleted: CAM Deleted: CAM Deleted: products Deleted: CAM Deleted: CAM
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Quantitative diary data is displayed as frequency tables. Framework Analysis, a highly structured and systematic method, was used for qualitative interview data (Ritchie and Spencer 1993) and is described elsewhere (Robinson et al 2009). Harrow Research Ethics Committee approved the study in February 2007, ref 06/Q0405/92.
Results
Table one provides details on the four pharmacies and interviewees. Twenty-nine HNP diary events were recorded. Of these, 86% were product purchases and 79% were advice requests, mainly (45%) for under 4 year olds. Ethnicity of children was varied (24% White, 24% Asian, 14% Black, 38% missing). Many interviewees perceived ethnic variation in HNP use; White populations using more HNPs and Afro-Caribbeans more conventional medicine.
Most children (69%) were currently not taking medication and 83% were not having prescriptions filled. Pharmacists generally perceived HNP were used to avoid conventional medicine (e.g. antidepressants or steroids), and cited that this would also be when they would recommend it. Similarly, from the diaries, HNPs were used predominantly for health maintenance or minor conditions e.g. teething, colds and colic (see table 3). Interviewees also identified that HNPs were used for child development, wellbeing, eczema, dermatitis, asthma and nocturnal enuresis. Pharmacists perceived increasing demand, and reported that they would like to stock more products to meet this demand.
“There is clearly a patient demand for alternative treatments; people are now looking to perhaps try alternative before conventional”
“for children a lot of them prefer using like the, the homeopathic teether, which is a common one, um, I really like the rescue remedy for calming people down”
“Q: Do you think it [HNPs] should be something that you learn about or? P: Yeah definitely, yeah, I think people are going more for alternative medicines, and Ayurvedic”
Deleted: CAM
Deleted: CAM Deleted: CAM Deleted: products
Deleted: CAM Deleted: products
Deleted: CAM Deleted: was
Deleted: CAM Deleted: products
Deleted: CAM
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Nutritional (vitamin/mineral) and herbal dietary supplements and aromatherapy were especially popular (table 2), average cost per event £4.26. Pharmacists cited stocking around 100 HNPs, mainly vitamins, minerals, herbs and homeopathy; with some specific foods, massage oils, and Bach flower remedies. Supplier information and local demand informed stock choice. Location of the pharmacy was important in determining which HNPs were stocked due to variations in customer demand, with less busy pharmacies stocking less.
“if we get more than a couple of requests we usually maybe order a couple in and see how that sells”
Diary forms were completed by pharmacy assistants (15 events) or pharmacists (13 events).
For all recorded events staff felt competent giving advice, although in 31% of events staff reported needing more knowledge. In 41% of events staff used information to give advice.
HNP use was encouraged in 59%, with only 10% recommending another type of HNP and only 3% advising against HNP use, with no concerns over the child’s safety. No interviewees spontaneously mentioned safety issues and none cited direct experience of adverse events.
During the interviews only one pharmacist reported that they would routinely ask customers about HNP, although all felt they ‘should’ ask about and record HNP use, but that it was not
‘natural’ to do so; customer-initiated discussion was seen as much more common.
Recommendations were dependent on knowledge and stocked products.
“they do often ask ‘well you know what I take so is it alright to take it with my medication’, yes, it’s a common request that patients ask before they purchase it”
“I don’t think it’s something we would necessarily suggest straight away”
“we are meant to record people using supplements, particularly if they’re on other medication”
Three pharmacists were open to HNPs; the other was ‘not a big fan’.
Deleted: CAM Deleted: products
Deleted: CAM
Deleted: products
Deleted: CAM Deleted: CAM Deleted: CAM
Deleted: CAM Deleted: CAM Deleted: product
Deleted: CAM
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
One in particular had very positive beliefs, due to seeing HNPs work for others, particularly for avoiding conventional medicine wherever possible. This contrasted with her personal background:
“my Dad’s a pharmacist and we grew up in that …we have two doctors [in the family]
so they’re obviously more geared to [conventional medicine]…. Q: And do you think that affects your attitudes to it [HNPs] now? P: No, because I’m much more open to it, I think I would personally prefer it, and I’m not one to take tablets at all”
Pharmacists appeared to separate their personal and professional beliefs/experience, which created tension. Ethnic background did not appear to affect HNP beliefs or knowledge;
professional experience of conventional medicine harm/overuse appeared more influential.
Only one pharmacist reported professional training on HNPs, none had detailed knowledge.
Pharmacists did feel (P3 particularly) that more knowledge would mean they could stock and recommend more HNPs, improve patient choice and help patients.
Only a few sources of HNP product information were cited; mainly the same as conventional medicine – through suppliers, internet, customers, and occasionally reading. A need for more evidence and information was expressed.
“you read about it…, from time to time, and mainly through conversing with patients you pick up these stories”
“we have a vitamin, a brand, natures aid, and they’re really good, they provide you with a whole file of every single item and what it’s used for, …a reference, which is quite a good idea really”
Discussion
This study identified that parents often approach pharmacies concerning herbal remedies/topical products and nutritional supplements for their children, independent of
Deleted: CAM
Deleted: CAM
Deleted: CAM
Deleted: CAM Deleted: products
Deleted: CAM
Deleted: CAM
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
concurrently filling prescriptions. The previous phases of our study demonstrated that many parents actively choose HNPs to avoid overuse of conventional medicine, which pharmacists recognised (Robinson et al 2009).
This study has shown that pharmacists are uniquely placed as conventional healthcare providers and are influential, responsive and empathetic to patient choice, including HNP.
Expanding the range of services provided by community pharmacies and improving patient choice are part of the new role of pharmacies in the UK (Richardson and Pollock 2010). The new community pharmacy contract in the UK emphasises the role of pharmacist to support self-care, which may include the use of herbal, vitamin and nutritional supplements (NHS 2005):
“To enhance access and choice for people who wish to care for themselves or their families”
In this study pharmacists were, generally, open to HNPs and understood that parents often wish to seek an alternative to conventional medication for their children and themselves, which many empathised with, due to experience of the overuse and harm of medicines.
Belief in overuse/harm of medicines may be related to the Asian ethnic background of all the pharmacists (Horne et al 2004). Although no pharmacists mentioned their ethnic
background influencing their attitudes or behaviour related to HNPs, the influence of the pharmacist’s personal background was debatable. One pharmacist’s strong belief in HNPs despite being brought up with and used to orthodox medicine was of particular interest.
Although staff felt competent, they felt more HNP product knowledge would benefit their business and their customers. Pharmacists want to maintain professionalism and are strongly influenced by professional experience and factors, for example, believing in HNPs despite being brought up with and familiar with orthodox medicine. The emphasis on professional factors, rather than personal background, may be due to a desire to appear
Deleted: CAM
Deleted: CAM
Deleted: CAM Deleted: products
Deleted: CAM
Deleted: CAM
Deleted: CAM
Deleted: CAM
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
‘professional’, highlighting the tension between personal and professional roles (Bourgeault and Hirschkorn 2008)
Cohen (2002) suggests that if pharmacists continue to stock CAM products, they must improve their training. Three pharmacists were trained over 10 years ago, which may account for their lack of HNP education. The literature shows that many pharmacists believe CAM education should be mandatory (Chang et al 2000), part of pharmacy training (Koh et al 2003) or continuing education (Charrois et al 2007). Continuing professional development (CPD) may therefore be needed to ensure unbiased advice is available to help parents make informed choices (Cramer et al 2010).
Due to limited sample size and specific location, findings from this study may not be
generalizable, but does provide in-depth insight into issues which warrant further exploration.
Given the prevalent use of CAM in the UK and that most pharmacies do stock CAM products and receive queries about CAM products (Barnes and Abbot 1999), there may be a need for further research both on the efficacy and safety of HNPs, but also on the relationship between pharmacists, pharmacies and the public.
Conclusions
Pharmacists appear to understand and empathise with customer demand for herbal and nutritional products for children and are in a unique position to provide advice and products.
However, in order to maintain professionalism, which is important to them, pharmacists may need information and CPD.
Acknowledgements and funding
We are very grateful to all the pharmacy staff who took part.
This work was supported by a King’s Fund Partners for Health grant
Deleted: CAM
Deleted: these products
Deleted: CAM such as Deleted: products Deleted: supplements Deleted: CAM
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Reference List
Anon. 2008. An ethical dilemma. Pharmaceutical Journal; 281:58.
Barnes J, Abbot N. 1999. Experiences with complementary remedies: a survey of community pharmacists. Pharmaceutical Journal 263:R37.
Boon H. 2004. CAM and pharmacists: challenge or opportunity? Focus Altern Complement Ther 10:89-91.
Bourgeault, I. L. & Hirschkorn, K. 2008, CAM in inter-professional context: Canada. In Complementary and alternative medicine in nursing and midwifery, Adams J &. Tovey P, (Eds)., Routledge, Abingdon; 11-32.
Chang ZG, Kennedy DT, Holdford DA, Small RE. 2000. Pharmacists' knowledge and attitudes toward herbal medicine. Ann Pharmacother 34:710-5.
Cohen M. 2002. Complementary/Alternative Medicine Use: Responsibilities and implications for pharmacy services. P & T 27:440-4.
Department of Health. Pharmacy in England: Building on strengths - delivering the future. 2008. Stationery Office, London
Horne R, Graupner L, Frost S, Weinman J, Wright SM, Hankins M. 2004. Medicine in a multi-cultural society: the effect of cultural background on beliefs about
medications. Social Science & Medicine 59: 1307-1313
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Koh HL, Teo HH, Ng HL. 2003. Pharmacists' Patterns of Use, Knowledge, and Attitudes Toward Complementary and Alternative Medicine. Journal of Alternative &
Complementary Medicine 9:51-63.
Nahin RL, Barnes PM, Stussman BJ, et al. 2009. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. Natl Health Stat Report 18:1-14.
Naidu S, Wilkinson JM, Simpson MD. 2005. Attitudes of Australian pharmacists toward complementary and alternative medicines. Annals of Pharmacotherapy 2005 39:1456-1461.
NHS. 2005. NHS Community Pharmacy Contractual Framework Essential Service – Support for self-care
http://www.pcc.nhs.uk/uploads/Pharmacy/march_08/support_of_self_care.pdf
Richardson E, Pollock AM. 2010. Community pharmacy: moving from dispensing to diagnosis and treatment. BMJ 340:2298.
Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In:
Bryman A, Burgess R, (Eds). Analysing Qualitative Data. London: Routledge, 1993:
173-194
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Robinson N, Lorenc A, Blair M. 2009 Developing a decision-making model on traditional and complementary medicine use for children. European Journal of Integrative Medicine 1:48-56
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Table One: Pharmacies
Interviewee
Pharmacy No. Pharmacists No. other staff Number of diary events Estimated no. of prescriptions per day CAM Products in stock (estimated by pharmacist) Age Sex Ethnicity Full/part time Time in current position When trained
1 1 5 4 200 100 approx
35 - 44 M Asian British
Full 5yrs 1998 2 1 5 10 280 150 25 - 34 F Asian
British
Full 4yrs, 5months
1997 3 1 3 0 Missi
ng data
missing data
45 - 54 M Asian British
Full 4yrs 5months
1984
4 2 4 15 100 60 -70 25 - 34 F Asian British
Part 3yrs 2001
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Table 2: CAM purchases from diary data
Group of CAM Products Number Details/names of products Vitamins/minerals 3 Zincovit® (vitamin C)
Multivitamins Abidec® multivitamins
Tonics 2 Minadex® tonic
Nutritional supplements (n=7)
Essential fatty acids 2 Seven seas® cod liver oil liquid Omega 3 syrup
Aromatherapy oils 4 Clove oil
Olbas® for children Citronella oil
Menthol and eucalyptus
Creams 2 Arnica cream
Tea tree cream
Oils 2 Olive oil
Herbal/
aromatherapy topical products (n=9)
Balm 1 Happinose® (decongestant)
Teething powder 2 Ashton and Parsons Powder® Herbal oral
products (n=3) Echinacea 1 Echinacea for children Constipation remedy 1 Califig® (syrup of figs) Colic mixtures 2 Colief®
Woodwards gripe mixture® Flower remedies 1 Bach flowers Rescue Remedy® Other (n=6)
Teething granules 2 Nelson® teething granules
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
For Peer Review
Table 3: Conditions treated with CAM from diary data
Health maintenance 6
Teething 4
Respiratory Tract infection (including colds)
4 GI problems (including
colic)
4
Immune stimulation 2
Skin problems 2
Allergy 2
ENT 1
Cuts/injury 1
Stress 1
Toothache 1
