Table 3 Outcomes and Findings of Eligible Studies

Community pharmacists’ professional practices for complementary medicines: a qualitative study in New Zealand

Barnes and Butler. 2020 [30]

1. Participants found it difficult to clearly describe products they considered complementary medicines.

2. Perspectives towards CMs ranged from strongly supportive to somewhat sceptical

3. Consumer demand and profits were the most stated motivations for selling CMs.

4. Pharmacists limited knowledge/training and lack of evidence of efficacy were the most common ethical issues surrounding CMs that pharmacists acknowledged.

5. Very few pharmacists explicitly referred to the CMs-related statements in the Pharmacy Council of New Zealand’s Code of Ethics to guide their practice.

1. Lack of knowledge/training on CMs

2. Lack of specific regulatory framework for CMs

3. Lack of evidence-based studies

1. Non-representative, purposive/convenience sample: pharmacists supportive of CMs may be over-represented

2. Possibility of social desirability bias

Pharmacists justify selling CMs despite their lack of knowledge in these products. Pharmacists are mindful of professional and ethical issues regarding CMs, but their practice is not guided by the Pharmacy Council of New Zealand’s Code of Ethics. There lacks a specific regulatory framework for CMs in New Zealand.

Integrating traditional Chinese medicines into professional community pharmacy practice in China-Key stakeholder perspectives

Yao et al. 2020 [31]

1. Participants agreed that pharmacists should play a role in drug safety associated with concurrent use of TCM and western medicine.

2. Barriers exist within the government, education, pharmacy, pharmacist, and research sectors.

3. Prominent themes were a lack of clarity in defining the pharmacists’ role surrounding HMs and a disconnect between current regulatory standards and education system.

4. The most important enablers identified were the development of policies that support pharmacy practice and practice guidelines, the review of competency standards, and registration criteria.

1. Lack of the competence to provide professional service

2. Lack of knowledge about Chinese medicines or conventional medicines

3. Lack of professional image

4. Lack of motivation or interests in direct patient care

5. Lack of information source

6. Lack of practice guidelines

1. Small sample size only representative of a small number of key stakeholders and certain regions of the country

2. The exclusion of other ethnic minority medicine

3. The perspectives of patients and consumers were not included

Key stakeholders report that there are gaps in pharmacists’ knowledge in HMs and therefore are unable to provide comprehensive pharmaceutical care. Guiding principles that outline standards for such use would serve as a baseline for professional expectations and as a framework to model pharmacy education.

Advancing the pharmacist’s role in promoting the appropriate and safe use of dietary supplements

Harnett et al. 2019 [32]

1. Pharmacists proposed they could develop and promote themselves in DS.

2. Four key areas surrounding DS identified by participants as needing improvement were (1) Education and training; (2) Strategies for ensuring high standards related to DS safety and quality assurance (3) Workplace resources (4) DS Research.

1. Lack of education and training

2. Lack of regulations

3. Lack of workplace resources

4. Lack of DS research

1. Small sample size limits extrapolation of the results.

Pharmacists and key stakeholders hold reasonable ideas on how to overcome the challenges facing pharmacy related DS use. Pharmacists believe that quality education and training on DS, as well as improvement of DS regulation on a governmental and industry level are appropriate next steps.

Barriers to pharmacists adopting professional responsibilities that support the appropriate and safe use of dietary supplements in the United States: Perspectives of key stakeholders

Ung et al. 2019 [33]

1. Pharmacists acknowledge their ethical and professional responsibilities regarding dietary supplements.

2. Due to multiple barriers, most pharmacists are not expecting to assume responsibilities regarding dietary supplements soon.

1. Perceived lack of an evidence base and support to access information

2. Concerns about the regulation of DS 3. Services for DS were not considered by pharmacists to be within their scope of practice 4. Barriers in being able to include DS in electronic records

5. Many pharmacists did not believe they should accept responsibility to report suspected adverse events

6. Ambiguity in expectations; lack of clarity

1. The qualitative approach found rich information not likely to be gleaned from a quantitative survey, precluding generalizability to a larger group

2. Limited number of interviewee participants precludes extrapolation of the results

3. The interviewees comprised 2 separate groups; however, the design precludes direct comparisons as well as any sort of consensus building

Pharmacists lack in their understanding of their professional roles and responsibilities surrounding dietary supplement awareness and use. Key stakeholders need to be involved to improve the situation.

Informing the homeopathic practice for Turkish pharmacists: reviewing the example of Portuguese community pharmacies

Cavaco et al. 2017 [34]

1. Pharmacists’ attitudes regarding homeopathy is greatly influenced by their education and relationship with homeopathic physicians.

2. Specialized homeopathic education was considered an important factor for success.

1. Lack in knowledge of homeopathy and the regulatory framework that surrounds it

2. Lack of reliable information resources

Not reported

Pharmacists believe that job satisfaction and appropriate legal frameworks are important features of homeopathic practice. Specialized homeopathic education and improved patient counselling were also considered by pharmacists to be important factors for success. Further investigation is required to examine how the present qualitative findings can be generalized to a larger sample of pharmacists.

Development of a strategic model for integrating complementary medicines into professional pharmacy practice

Ung et al. 2017 [35]

1. Pharmacists identified 7 key CMs related dilemmas that they face during their day-to-day practice.

2. Four developments were proposed that require a collaborative effort: education and training; building the evidence base; developing reliable and accessible information resources; and workplace support for best practice

1. Dilemmas surrounding TM/CM

2. Lack of education

3. Lack of access to reliable information resources

1. An over-representation of pharmacists working in the independent pharmacies and under-representation of community pharmacists from urban areas.

2. Snowballing and self-selection of participants

This study proposed a strategic model to integrate TM/CM products into pharmacy practice. Pharmacists suggest the need for improvement in education and the regulatory policies related to CMs.

Key stakeholder perspectives on the barriers and solutions to pharmacy practice towards complementary medicines: an Australian experience

Ung et al. 2017 [36]

1. The main barriers identified by many pharmacists were a lack of CMs knowledge, doubts about the evidence-base, a lack of research skills and access to reliable information

2. Participants proposed the integration of CMs curricula into under-graduate and professional pharmacy education and defining a clearer role for pharmacists’ standard of practice.

3. Participants had apposing opinions about the role of naturopaths in pharmacies.

1. Insufficient knowledge about CMs

2. Pharmacists’ attitude towards CMs

3. Lack of research skills

4. Lack of evidence for efficacy and safety of CM

5. Lack of access to trustworthy information and support

6. Lack of time

7. Consumers’ attitudes

8. Lack of a defined role for pharmacists

9. Poor inter-professional communication with doctors

1. The findings are only representative of Australia

2. Small sample size

Many barriers exist preventing pharmacists from properly fulfilling their responsibilities surrounding CMs. Collaboration between stakeholders is required to plan the implementation of this extended role for pharmacists.

Assessing the Awareness and Knowledge on the Use of Probiotics by Healthcare Professionals in Nigeria

Amarauche 2016 [36]

1.Healthcare professionals in Nigeria possess limited knowledge and awareness of probiotic products.

2. Amongst physicians, pharmacists, dentists and nurses, pharmacists were the most knowledgeable on probiotics.

1. Lack of knowledge

2. Limited access to information on probiotics

Not reported

Healthcare professionals in Nigeria have limited awareness and knowledge of the use of probiotics. Seminars and workshops should be hosted to target this issue.

Perceptions of traditional, complementary and alternative medicine among conventional healthcare practitioners in Accra, Ghana: Implications for integrative healthcare

Kretchy et al. 2016 [38]

1. Participants were worried about the possible negative effects of TM-CAM.

2. Participants’ knowledge of TM-CAM was low.

3. Participants recognized alternative medicine to be as important as conventional medicine.

1. Pharmacists’ lack of confidence in the use of TM-CAM products

1. Results are generalizable since a qualitative approach was adopted

2. Participants were based in more affluent areas, where demand for TM-CAM may generally be different from more deprived areas

Conventional healthcare professionals welcome the idea of integrative medicine. Practitioners’ knowledge on the safety and regulation of TM-CAM must be improved.

Pharmacists’ knowledge and attitudes about natural health products: a mixed-methods study

Kheir et al. 2014 [39]

1. Most pharmacists had average to poor knowledge about NHPs.

2. Poor access to evidence-based information limited pharmacists’ abilities to counsel patients.

3. Pharmacists criticized undergraduate pharmacy education for inadequate preparation to deal with NHPs.

4. Pharmacists deem natural health products to be safe.

1. Lack of education on NHPs 2. Ethical dilemmas - Large profit margin and financial bonus associated with the sale of NHPs presents a sense of pressure on pharmacists to sell NHPs

1. Only Qatar-based pharmacists with contact addresses with the College of Pharmacy were contacted, limiting the generalizability of the results

2. Poor response rate

Pharmacists are disadvantaged in providing adequate services surrounding CAM due to a lack of knowledge and limited access to information resources. A continuing pharmacy education program would help pharmacists improve their NHP related knowledge.

Community pharmacists’ attitudes relating to patients’ use of health products in Japan

Asahina et al. 2012 [40]

1. Pharmacists were not comfortable inquiring about patients’ use of health products due to the lack of scientific evidence on safety and efficacy and feared they could not advise patients properly or answer their questions.

2. Pharmacists expressed their concern regarding the ambiguity surrounding their professional role as a pharmacist.

3. Pharmacists who facilitated discussions with patients regarding natural health products were motivated by their duties as a pharmacist to keep patients healthy and safe.

1. Communication between healthcare professionals on CAM

2. Lack of scientific evidence

3. The ambiguity surrounding pharmacists’ role in relation to health products

1. Focus group interviews cause a lack of generalizability of the results

2. Deficiencies in heterogeneity within the focus groups, especially with respect to sex distribution

3. The number of participants and the number of FGIs were limited due to the small number of available participants

4. The differences between users and nonusers of i-PHISS were not explored in detail

Ambiguity regarding pharmacists’ professional role surrounding health products may cause a lack of communication with patients. Pharmacists must realize the objectives of counselling patients interested in natural health products. Further research is needed to clarify the roles of pharmacists and to ensure the implementation of appropriate educational objectives in pharmacy curriculums.

Understanding pharmacists’ experiences with advice-giving in the community pharmacy setting: a focus group study

Simmons-Yon et al. 2012 [41]

1. Patients try to delay physician visits by seeking pharmacist advice.

2. Most pharmacists felt uncomfortable recommending CAM because of the lack of evidence and regulation.

3. To prepare pharmacy graduates for employment in community settings, participants suggested that pharmacy curricula expand training on symptom triage, pharmacist–patient communication, and CAM.

1. Lack of education

2. Lack of evidence

3. Lack of regulations

1. The perspectives of the focus group participants may not be representative of pharmacists and students in other regions

2. Most of the focus group participants were pharmacy students

3. The results are based on self-reported data from the participants

4. Most of the participants worked in chain pharmacies

A lack of education, evidence and regulations on CAM reduces pharmacists’ comfort levels in recommending CAM to patients. Pharmacy education should be enhanced to include training on CAM use. Pharmacies should provide easily accessible educational materials for pharmacists on CAM products to better enable them to answer patient inquiries.

Assessment of herbal weight loss supplement counseling provided to patients by pharmacists and nonpharmacists in community settings

Jordan et al. 2011 [42]

1. Pharmacist and nonpharmacist responses to questions regarding product safety differed significantly.

2. Most pharmacists and nonpharmacists advised against the use of herbal products during pregnancy and breast-feeding.

3. When unsure about safety, nonpharmacists did not usually refer the investigators to a health care provider.

4. Pharmacists usually referred the investigator to a health care provider when unsure about safety.

5. Patients may not be given complete or correct information about herb–drug and herb–disease interactions.

1. Lack of knowledge 2. Lack of time

3. Lack of reliable information

4. Lack of training

1. Exclusion of participants outside of Phoenix, AZ

2. The interview process did not allow for interviewers to obtain a detailed history of each participant’s training in herbal products

Counselling on herbal supplements provided by personnel at health food stores, retail stores, grocery stores, and pharmacies was highly variable. The herbal and medical communities should work together to create mechanisms by which patients can be properly informed about herbal products.

Reporting natural health product related adverse drug reactions: is it the pharmacist’s responsibility?

Walji et al. 2011 [43]

1. Pharmacists generally did not submit reports of adverse events associated with NHPs to the national ADR reporting system due to several barriers.

2. Pharmacists who reported adverse events did so because they saw themselves as ‘knowledge generators’

3. There is a need for more formal education and training on NHPs.

1. Lack of time

2. Complexity of reporting process

3. Lack of knowledge

4. Varying opinions in pharmacists’ responsibilities and roles in ADR reporting

1. Small sample size not representative of all of Ontario or Canadian pharmacists

Pharmacists’ perceptions of their professional roles may explain their reporting behaviour for suspected adverse drug reactions associated with NHPs. Information regarding safety and ADRs is lacking in herbal medicines. The improvement of pharmacy education and clearly defining the professional role of a pharmacist are important next steps.

Over-the-counter advice seeking about complementary and alternative medicines (CAM) in community pharmacies and health shops: an ethnographic study

Cramer et al. 2010 [44]

1. Most customers purchasing CAM products need extensive help selecting an appropriate remedy

2. Pharmacists (and counter staff) lack training on CAM products, preventing them from providing appropriate and detailed advice.

3. Health shops may lack knowledge regarding potential interactions between pharmaceutical products and CAM.

1. Lack of proper training and education

Not reported

Customers require help selecting CAM products since there are a wide variety of products offered in pharmacies and health stores. Pharmacists and health product retailers are lacking in the support needed surrounding CAM. Staff in health food stores and pharmacists would benefit from further training and education.

Responding to patient demand: community pharmacists and herbal and nutritional products for children

Robinson et al. 2010 [45]

1. Pharmacists were generally open to herbal and nutritional products and were keen to meet the increasing demand.

2. Pharmacists reported feeling competent to give advice on HNPs.

3. Pharmacists wished to increase their knowledge on HNPs to maintain professionalism, but information on HNPs was limited.

4. Pharmacists understand and empathize with customer demand for HNPs.

1. Lack of knowledge

1. Small sample size and specific location; findings from this study may not be generalizable

Pharmacists acknowledge and empathize with customer demand for herbal and nutritional products, but they may require continued professional training.

An evaluation of pharmacist and health food store retailer’s knowledge regarding potential drug interactions associated with St. John’s wort

Sim et al. 2010 [46]

1. Most pharmacists and NHP retailers recognized that St. John’s wort could be useful for improving mood.

2. Overall low knowledge on potential herb-drug interactions.

1. Insufficient education and training on NHPs 2. Lack of quick access to necessary information about herbal medications

1. Small sample size included only community-based pharmacists

2. Incorrect interpretations of responses may have occurred due to the complexity in answers provided by respondents

Pharmacists and natural health product retailers must become more educated about potential herb-drug interactions and have access to resources to evaluate potential threats.

Exploratory study of factors influencing practice of pharmacists in Australia and Thailand with respect to dietary supplements and complementary medicines

Kanjanarach et al. 2006 [47]

1. Australian pharmacists evaluated the safety of DS/CM in the same way as for conventional medicines.

2. Thai pharmacists quickly assessed customers’ health before selling them DS/CM products.

3. Both Thai and Australian pharmacists provided inadequate information about DS/CM products and their efficacy.

4. Australian pharmacists recommended products that they were knowledgeable about.

5. Thai pharmacists would suggest brands that yielded a higher profit margin.

6. Neither Australian nor Thai pharmacists were proactive in providing services to support the use of DS/CM.

Not reported

1. The interviewer was a pharmacist, which could have influenced the way in which respondents answered questions

2. The possible impact of transcription and translation on the meaning of messages

Thai nor Australian pharmacists took initiative to provide appropriate services to ensure DS/CM products were being used correctly. Australian and Thai pharmacists had different motives to sell or recommend DS/CM products to customers. Pharmacists’ professional role in relation to DS/CM products should be clarified.

An investigation of pharmacists’ and health food store employees’ knowledge about and attitudes toward kava

Webb et al. 2004 [48]

1. Both pharmacists and health food store employees agreed on similar conditions that could be treated with kava.

2. Most pharmacists were cautious about the safety of Kava.

3. Health food employees were likely to deny the possibility of adverse effects associated with kava use.

4. There was inconsistency in the level of caution advised by both groups regarding safety and efficacy of kava.

5. Pharmacists and retailers were greatly misinformed about kava.

Not reported

Not reported

Pharmacists and health food store employees have different views on the safety of Kava. There is a significant level of misinformation provided by health food store employees about Kava compared to pharmacists. Misinformation could lead to negative health consequences and a waste of customers’ money.