Previous research investigating the integration of CMs into pharmacy practice has not examined in detail the factors that impact the decision of a pharmacist to recommend a CM product to a customer. This study has identified a range of influential factors, including pharmacy protocols relating to companion selling of CMs; the desire to provide health benefits to a customer; the pharmacist’s knowledge about CMs, which is linked to confidence in recommending based on efficacy and safety; awareness of evidence in support of CMs; the presence of a naturopath in the store (an increasingly common phenomenon in Australian pharmacies ); customer demand and positive feedback from customers; and the quality of products available and profile of the company providing them (Table 2).
Previous studies have reported the primary reason for patients choosing or being recommended a CM product is for particular health benefits – the maintenance of general health, prevention of disease and the treatment of minor conditions [7, 8, 13]. This correlates with the findings of this study, that patient benefit from CMs was a major motivating factor for pharmacists in all groups.
The concept of providing a health benefit differed somewhat between Group 2 and 3 respondents. Those in Group 2 were more likely to accept that a CM could offer health benefits if they were satisfied with the evidence provided, whether by a company or by independent sources, or if they had witnessed the benefit themselves. This concurs with previous studies that have found that knowledge of a particular CM and a proven mechanism of action are influential factors [6, 7]. In contrast, Group 3 respondents (those who recommended CMs most frequently) were passionate about a ‘holistic approach’ and commonly linked health benefits with a ‘healthcare solution’ comprising not only a specific treatment, but also the provision of supportive measures to prevent recurrence and thereby improve patient care. This in turn was seen to be linked to business benefits. All Group 3 respondents were owners or managers of their stores, which may have influenced their emphasis on business-related benefits. Previous research has reported that profit is not an important motive for pharmacists [6, 7, 15], although there is an understanding that CM products are an important contributor to the business of pharmacy .
The provision of a ‘healthcare solution’ or adopting a ‘holistic approach’ was mentioned by the majority of Group 2 and 3 respondents. For most, this involved the practice of recommending a CM as a companion product for a pharmaceutical medicine, or recommending several products with a view to providing the best patient care. This professional behaviour of pharmacists has only recently been described. A 2010 Australian survey investigating the integration of CMs into pharmacy practice found that nearly half of the respondents described their practice as providing ‘integrative care’, which was defined as ‘recommending CMs together with conventional medicines as part of standard practice’ .
In banner pharmacies, the implementation of protocols for companion recommendation appeared to be a major driver of the recommendation of CMs. The four Group 2 respondents who worked in banner pharmacies all mentioned corporate companion selling protocols as a major driver. Group 3 respondents had all been instrumental in implementing such protocols in their stores; they embraced this approach in order to provide good customer service, and said it provided them with a feeling of job satisfaction. The role of companion selling protocols as a driver of recommendation of CMs by pharmacists has not previously been described. The existence of such protocols may cause pharmacists to feel compelled to learn more about CMs and in turn result in increased recommendation of CMs. It also raises the question to what extent the professional judgment of the pharmacist may be influenced by a protocol when deciding whether or not to recommended CMs to a customer.
Questions of whether the relationship with other healthcare professionals affected the recommendation of CMs provided some interesting insights. All but one respondent articulated either a neutral (n=4) or strained (n=4) relationship with doctors. The main contentious issue, identified by four respondents, was doctors dissuading patients from taking a CM that the pharmacist had recommended. The pharmacists were unhappy with this situation and claimed it was a difficult situation to deal with, as the communication between the two professions was poor.
The relationship with naturopaths was described as far more harmonious. Naturopaths were seen as being able to provide good quality information and were considered to be a valuable resource in the pharmacy. Five respondents worked alongside a naturopath, and one of these stated that because a naturopath was present, they would refer customers to the naturopath for a CM recommendation, rather than make it themselves. Three Group 3 respondents, who were store managers and had employed naturopaths, felt that the presence of a naturopath had not changed their recommendation behaviour, although they would often refer to the naturopath for more information about a CM. A previous Australian survey found that pharmacists who work alongside naturopaths find the service provided by naturopaths valuable, while the presence of a naturopath made pharmacists less likely to recommend CMs themselves .
Barriers to the recommendation of CMs were relatively clear-cut, with safety concerns (drug interactions and adverse effects) being the most important, identified by all respondents. Other identified barriers varied between groups. Group 1 felt inadequately trained. Group 2 reported a lack of evidence as a significant factor and felt the need to be confident in the patient benefit before recommending a CM. Group 3 respondents were the only to mention a lack of time as a reason for not recommending CMs. This may be because they also wanted to offer a more comprehensive ‘healthcare solution’, which no doubt takes some time to provide. Previous studies have identified a lack of knowledge or lack of evidence as the main barriers to recommending CM products [4, 6, 11, 16–20, 27]. As many pharmacists by their own admission do not have adequate training in CM, it is unclear whether in some cases they have truly assessed the evidence for a CM before reaching the conclusion that there is a lack of it.
All groups expressed discomfort with ‘fad’ products, and respondents claimed they would not recommend them if asked their opinion, while maintaining that customers have a right to choose such products, and thus they should be available from the pharmacy. Conversely, respondents considered some CM companies to be trustworthy and providing good quality and properly researched CM products. The trusted companies were considered to be the larger, more established ones with larger products ranges. Previous research has also found that poor product quality is a disincentive to recommend CMs .
There was an impetus to learn more about CMs, especially in Groups 2 and 3, which is encouraging, as the majority of Australian pharmacy customers expect the pharmacist to be able to provide accurate CM information . Respondents consistently reported that customers are becoming more educated, are interested in preventative approaches and want to take more control of their healthcare, a picture also reported from Canada in the context of CM customers in pharmacies . Therefore, significant motivating factors for Group 2 respondents to increase knowledge about CMs were likely the encouragement to follow pharmacy protocols for companion selling, customer demand and positive customer feedback.
The respondents seemed moderately satisfied with the CM educational materials available but did find room for improvement, both in terms of quality and presentation of the information. They preferred brief but professionally produced information that reflects similar resources for pharmaceuticals, including easily accessible online databases, which is consistent with the suggestion that evidence-based CM information should be included in professional handbooks and guidelines for pharmacists . Interestingly, respondents in this study were also happy to get information from CM companies, as long as it is professionally presented with a clear description of levels of evidence to support efficacy.
A Canadian study has highlighted the professional and ethical dilemma faced by pharmacists who sell CMs without possessing sufficient knowledge about these products , and most respondents in the present study saw a clear need to incorporate more CM education into formal pharmacy training. Whilst there are some moves to do so [30, 31], there seems to be ample evidence from this and other studies that the majority of pharmacists would like more CM training [4, 6, 8, 16, 27, 32, 33].
As with all studies relying on volunteer subjects, some degree of selection bias is likely, and our small sample is therefore unlikely to be truly representative of the population of community pharmacists in Australia. In particular, it may have been the case that pharmacists with a greater interest in CM would have been more likely to agree to take part in the study.
Another source of potential bias is that the primary investigator (SEC), who conducted the interviews, is an employee of a CM company, a fact the respondents were aware of. This dual role of the investigator could potentially have biased responses in favour of CM, but the desire of study subjects to please the investigators is always a potential source of bias, and we do not believe that this would have influenced responses in a significant way.
Although the small sample size and the above caveats clearly limit the generalisability of the findings, it is noteworthy that data saturation was reached, with no new themes emerging in the final interviews. This, combined with the in-depth nature of the interviews, allows for this study to make a valuable contribution to the understanding of the evolving interface between complementary medicine and pharmacy, in particular in Australia. It should also provide a sound basis for a larger qualitative study in the area.