Improving pharmacy practice in relation to complementary medicines: a qualitative study evaluating the acceptability and feasibility of a new ethical framework in Australia

"No one went into pharmacy … to sell a lot of Coca-Cola. It's just sort of a necessary evil" - Community pharmacists' perceptions of front-of-store sales and ethical tensions in the retail environment

Background

Community pharmacists are expected to uphold ethical duties to patients and society while maintaining independent businesses or fulfilling expectations of corporate owners. Canadian pharmacy colleges provide only indirect guidance on the retail setting of the profession. Little is known about whether pharmacists identify ethical issues in retail pharmacy or around the sales of non-drug products.

Objective

This study sought to examine pharmacists' perceptions of their roles in health promotion, the factors that influence the selection of front-of-store products, and ethical issues relating to their dual roles as health care providers and retailers.

Methods

In 2020, 25 Canadian pharmacists participated in semi-structured phone interviews. Interviews were audio-recorded, anonymized, transcribed verbatim, and thematically analyzed using qualitative methods.

Results

Almost all participants described their role primarily as a health care provider, though some described themselves as 50-50 health care providers and retailers. Most staff pharmacists reported little control over front-of-store product selection. Where participants reported some control, external factors such as business viability and profitability impacted their choices, though some reported selecting products based on the needs of their patient community or their personal beliefs. The dominant tensions described stemmed from participants' dual roles as health care providers and retailers, though specific issues and situations were varied, ranging corporate targets, to service provision, to the sales of unproven or unhealthy products. Participants suggested solutions to the issues they described, ranging from a complete overhaul of the licensing structure of community pharmacies, down to one-on-one conversations with patients.

Conclusion

Our findings suggest that the retail setting of community pharmacy produces unique ethical tensions: the imposition of retail sales standards and targets are commonplace, and business viability is a primary driving force in front-of-store product selection. Clear guidance from Canadian pharmacy colleges and legislators to address these tensions and issues may be necessary.

Dietary supplement and complementary and alternative medicine use among older adults in Australia and the United States

BACKGROUND

Dietary supplement and complementary and alternative medication (CAM) use can contribute to drug interactions, polypharmacy, nonadherence with prescription medications, and healthcare expenses, whereas evidence supporting benefits of using these products is sparse. There is a lack of current published literature describing the patterns or predictors of their use in community-dwelling older adults.

MATERIALS AND METHODS

We performed a cross-sectional analysis of community-dwelling adults from Australia and the US, aged 70 years and older (65 years for US minorities), enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) study. At study enrollment, eligible participants were required to be without concurrent 5-year life-limiting illness and free of documented evidence of cardiovascular disease, dementia, or significant physical disability. During the final study visit, a questionnaire was administered to collect information about supplement/CAM use. Data from 15,729 participants who completed this questionnaire between January 2017 and January 2018 were analyzed. Descriptive statistics were used to report the prevalence and types of products used. Factors associated with use were determined using multivariate regression.

RESULTS

Mean age of respondents was 79.6 years; 56.4% were female, 88.8% were from Australia, 56.5% reported 12 years of education or less, and 98.7% were living at home. Two-thirds (66.2%) of participants reported use of one or more supplement/CAM in the previous month. Products most commonly used included vitamin D (33.8% of participants), fish oil (22.7%), calcium (20.6%), glucosamine (14.8%), and multivitamin (12.9%). Female sex, US residency, higher education, polypharmacy (prescription medications), and frailty (in women) were significantly associated with higher use of supplements/CAMs.

CONCLUSIONS

Dietary supplement and CAM use is common among community-dwelling older adults in the United States and Australia. Given the high prevalence of use, collaboration between healthcare providers and older adult patients is important to insure safe and optimal use of these products.

Prevalence and Characteristics of Australians Complementary Medicine Product Use, and Concurrent Use with Prescription and Over-the-Counter Medications-A Cross Sectional Study

Data about the characteristics and prevalence of complementary medicine (CM) product use by Australians, including concurrent use with prescription and over-the-counter medications, have not been collected in the last five years. A cross-sectional online survey involving a representative sample of the Australian population was administered in 2021-2022. Of the 2351 survey responses included in this study, 49.4% reported use of a CM product over the previous 12-month period. Of these, 50% reported they always or often used CM products on the same day as a prescription medicine. Participants aged 65 and over were five times more likely to use CMs and other medications on the same day compared to 18-24-year-olds. Lower levels of education and having a chronic illness were also predictors of same-day use. The prevalence and characteristics of CM use by participants was similar to data collected five years ago. The study shows that concurrent use of CM products with prescription medications among older and more vulnerable populations is prevalent and this area requires further research to help ensure appropriate and safe use of CM products.

Development and Validation of a Tool to Improve Community Pharmacists’ Surveillance Role in the Safe Dispensing of Herbal Supplements

Background: There has been an appreciable increase in the use of herbal supplements, including immune boosters, during the current COVID-19 pandemic. However, there are concerns with falsified herbal supplements.

Objectives: Developed a new questionnaire that can potentially help community pharmacists identify the extent of falsified herbal supplements.

Methods: A 9-month cross sectional study was conducted among 500 community pharmacies across United Arab Emirates. A new 5-factor, 24-itmes scale was developed based on current labelling requirements across countries and piloted. This included seven items on identified uses and contraindication, seven items on hazard identification, four items on product identity, three items on packaging and product insert and three items on product handling and storage. The face and content validity of the scale was assessed via the content validity index (CVI). Its construct validity was tested using an exploratory factor analysis (EFA) via principally component analysis (PCA). The model was subsequently confirmed through partial confirmatory factor analysis (PCFA). Its reliability was assessed via test-retest reliability, internal consistency, item internal consistency (IIC), and intraclass correlation coefficients (ICCs).

Results: The CVI of the finalized questionnaire was 0.843. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.891, and Bartlett’s test of sphericity indicated significance (p-value < 0.001). Confirmation of the subsequent 5-domains was achieved through PCFA using maximum likelihood analysis with oblimin rotation. The PCFA obtained values was 0.962 for NFI, 0.977 for CFI, and 0.987 for the Tucker Lewis Index. All values were greater than 0.95, and the RMSEA value was 0.03 (i.e., less than 0.06). Consequently, the model had a good fit. All domains demonstrated Cronbach’s alpha coefficients above 0.70, with 0.940 for the full instrument. Meanwhile, all items met the IIC correlation standard of ≥0.40. The instrument presented good ICC statistics of 0.940 (0.928–0.950) as well as statistical significance (p < 0.001). Community pharmacists with more than 10 experience years were more likely to identify falsified herbal supplements compared to those with 1–10 years experience (p < 0.001).

Conclusion: This study developed and validated a new instrument to identify safe herbal supplements, which should enhance the role of the community pharmacists in the safe and effective treatment of suitable patients with herbal supplements.