THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 9, Number 1, 2003, pp. 51–63© Mary Ann Liebert, Inc.

Pharmacists’ Patterns of Use, Knowledge, and AttitudesToward Complementary and Alternative Medicine

HWEE-LING KOH, Ph.D., HSIAO-HUEI TEO, B.Sc. (Pharm), and HUI-LING NG, B.Sc. (Pharm)

ABSTRACT

Objectives: To determine the patterns of use, knowledge, and attitudes toward complemen-tary and alternative medicine (CAM) among pharmacists.

Design: Anonymous self-administered survey.Settings: 61st International Congress of International Pharmaceutical Federation (FIP), Singa-

pore Traditional Chinese Medicine (TCM) Research Symposium, and retail and hospital phar-macies in Singapore.

Subjects: Pharmacists attending the FIP Congress, TCM Symposium, and pharmacists work-ing in retail and hospital pharmacies.

Outcome measures: Frequency of use of different types of CAM by demographic attributes,knowledge scores, and attitudinal scores.

Results:Of the 430 surveys received, 420 fit the criteria for inclusion. Of the pharmacists, 84.3%reported use of some form of CAM in their lifetime. CAM was used for chronic and acute con-ditions. There was no difference in use of CAM based on gender and income. The mean scoreon the knowledge test was 7.23 of 10. Of the pharmacists, 72.6% were moderately satisfied withCAM and 79.4% indicated they would recommend CAM to family and friends. They receivedinformation on CAM from books/magazines (64%), friends/family (35.7%), and the Internet(31.4%). Eighty-one percent (81%) of pharmacists felt they had inadequate skills and knowledgeto counsel patients on herbal medicine and 90.5% felt the professional curricula should havemore components on CAM.

Conclusions: The use of CAM among pharmacists is widespread and prevalent. The increaseduse of CAM necessitates the need for more education. Pharmacists acknowledge that CAM mayhave a place in health care and accept their role as information providers. There is also a needfor reliable sources of information on CAM.

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INTRODUCTION

Complementary and alternative medicine(CAM) is defined as “interventions not

widely taught in medical schools or availableat hospitals” (Eisenberg et al, 1993). This in-cludes a wide variety of modalities, such as

acupuncture, chiropractic, herbs, aromather-apy, relaxation techniques, and energy healing.CAM is also termed “unconventional,” “un-orthodox,” “naturopathic,” and “integrative”medicine.

CAM has enjoyed a worldwide increase inpopularity over the last decade. The use of

Department of Pharmacy, Faculty of Science, National University of Singapore, Republic of Singapore.

CAM by the public in the United States in-creased from 33.8% in 1990 to 42.1% in 1997(Eisenberg et al, 1998). Alternative therapieswere used most frequently for chronic condi-tions such as back problems, anxiety, depres-sion, and headaches. According to Eisenberg etal., 83% of those who used unconventionaltherapy for serious medical conditions also sawa medical doctor for the same condition (Eisen-berg et al, 1993). However, 72% of the patientsdid not inform their medical doctor of their use of CAM. This suggests a flaw in the pa-tient–physician relationship and could be po-tentially damaging. Failure to report concomi-tant use of herbal medicinals could lead todangerous herb–drug interactions, especiallythose with narrow therapeutic margins (Bauer,2000; Miller, 1998). A substantial percentage ofAmericans surveyed reported that they do notdiscuss their regular use of dietary supple-ments with their physicians because they be-lieve that the physicians know little about theseproducts and may be biased against them(Blendon et al, 2001).

CAM instruction, including herbal products,was not available in 13 of 60 (Miller and Mur-ray, 1997) and in 14 of 50 (Rowell and Kroll,1998) U.S. pharmacy schools. A study carriedout on pharmacy students demonstrated theneed for herbal instruction in core curricula ofpharmacy schools if students are expected toprovide comprehensive pharmaceutical care forpatients in the future (Mackowaik et al, 2001).

The widespread acceptance of CAM is par-alleled by both public and health care profes-sionals. Studies in Australia, the United States,Canada, and New Zealand have indicated thatphysicians acknowledge that CAM may havesome usefulness but know little about it (Cas-sileth, 2000; Easthope et al, 2000; Goldszmidt etal., 1995; Hadley, 1988; Lee et al., 2000; Priottaet al., 2000; Sikand, 1998).

This increased use of complementary thera-pies, particularly herbal remedies and dietarysupplements makes it necessary for pharma-cists to keep themselves updated with currentdevelopments in CAM (Chang et al., 2000;Chavis, 2001; Messerer et al., 2000; Miller et al.,2000). With little emphasis on CAM in phar-macy schools, pharmacists need to make agreater effort to educate themselves (Chang et

al., 2000; Portyansky, 1998). A survey of 800pharmacists asked them to rate their knowl-edge of nutraceuticals, herbals, and homeo-pathic products on a scale of 1 (least knowl-edgeable) to 5 (extremely knowledgeable). Therespondents gave themselves a dismal 2 on av-erage (167 pharmacists gave themselves a 2)(Portyansky, 1998). In another study, Chang re-ported an average score of 6.3 of 15 on a herbalknowledge test given to pharmacists (Chang et al., 2000).

In Singapore, although the health care systemis mainly based on Western medicine, a studyperformed in 1994 by the Ministry of Healthshowed that 45% of the population used Tradi-tional Chinese Medicine (TCM; Traditional Chinese Medicine, 1995). However, this studyfocused only on TCM. Information about preva-lence, patterns of use, attitudes, and knowledgeof pharmacists toward CAM in Singapore islacking. This study was designed to determinethe patterns of use, knowledge, and attitudes to-ward CAM among pharmacists.

MATERIALS AND METHODS

Design

A survey was designed to collect informationon pharmacists’ patterns of use, attitude to-ward, and knowledge of CAM. It consisted ofthree parts. The first section consisted of de-mographic and other background data. Thesecond section included questions on personaluse of CAM, reasons for use, and degree of sat-isfaction with CAM. The third section asked re-spondents about their attitudes toward CAM,desire for more training in CAM, and perceivedknowledge of CAM. Their actual knowledgewas evaluated with a 10-item knowledge teston uses and adverse effects of CAM. Re-spondents were given three options: “True,”“False,” and “I don’t know” to eliminate guess-ing and knowledge scores were calculated asthe percentage of correct answers. The attitudessection contained a 5-point scale ranging from1 (strongly disagree) to 5 (strongly agree). A pi-lot study was carried out on 10 students (phar-macy and nonpharmacy) before it was distrib-uted to the pharmacists.

KOH ET AL.52

Data collection

Data were collected at two internationalmeetings and from retail and hospital phar-macies. The survey forms were distributed dur-ing the 61st International Congress of the In-ternational Pharmaceutical Federation (FIP)held from September 1–6, 2001 in Singaporeand the Singapore Traditional Chinese Medi-cine (TCM) Research Symposium 2001 (No-vember 12–14, 2001). There was no time limitas long as the delegates returned the completedsurvey forms during the Congress/Sympo-sium to the collection boxes. The survey formswere also given to retail and hospital pharma-cists through individual visits to the pharma-cies. They were either completed immediately,collected at a later date, or mailed back to theuniversity.

Selection criteria

Inclusion criteria. Surveys were included ifthe respondent indicated his or her occupationas “pharmacist”, with satisfactory completionof survey forms (both overseas and local).

Exclusion criteria. Surveys were excluded ifmore than three questions in the attitudes sec-tion or knowledge test were not answered.

Statistical analysis. Statistical analysis wasperformed using the Statistical Package for Social Sciences (SPSS) version 10 (SPSS Inc.,Chicago, IL). Statistical differences in the use ofCAM by demographic attributes were identi-fied using the x2 test at the 5% level of signifi-cance. A one-way analysis of variance (ANOVA)was used to test for differences in knowledgebased on area of work and demographic at-tributes.

RESULTS

A total of 430 surveys were collected. Ten(10) were rejected because they were incom-plete and did not meet the inclusion criteria.The respondents consisted of 283 (67.4%)women and 137 (32.6%) men; 42.9% were Sin-gaporeans, 12.1% were Malaysians, and 45%were overseas pharmacists from Australia,

Canada, Croatia, China, Denmark, Egypt, Fin-land, Hong Kong, Ireland, India, Israel, In-donesia, The Netherlands, Portugal, the UnitedKingdom, the United States, Japan, France,Germany, Slovenia, Nigeria, and South Africa.The pharmacists were of varied ages, with mostof them between 25 and 34 years. The majorityof the pharmacists worked in retail (35.5%) andhospital pharmacies (34%); 10.5% were in acad-emia; 4% in sales; 1% in manufacturing; 5.7%in research and development; 4.5% worked inregulatory or government agencies; and 4.3%in other settings. Half of those surveyed weremarried, 192 (45.7%) were single, and 7 (1.7%)were divorced. Of the respondents, 55.7% werepracticing or residing in Singapore in the last 6months. Other demographic data are presentedin Table 1.

Usage

Three hundred and fifty-four (84.3%) of thepharmacists reported using some form of CAMin their lifetime, and 278 (66.2%) reported us-ing CAM in the past 12 months. The top fivetypes of CAM ever used in the respondent’slifetime were herbal medicine, TCM, massage,aromatherapy and homeopathy, in decreasingorder of frequency. These were almost similarto the top five CAM used by the respondentsin the last 12 months, except that reflexologywas more popular than homeopathy, as shownin Figure 1.

There was no statistically significant differ-ence in the use of CAM based on gender andincome. Race, nationality, age, country of prac-tice or residence, and marital status were foundto have a statistically significant effect (p ,0.05) on the lifetime use of CAM.

Reasons for use

The main reason for using CAM was cited as“maintenance of general health” (50.6%) asseen in Table 2A. Of the 354 users of CAM,47.7% were recommended by friends or fam-ily, 47.7% used it to treat health problems, and31.1% used CAM to relieve stress. Only 9.3%used CAM because they felt it was natural andtherefore safer. Respondents were allowed tochoose more than one option if applicable. Themain reason for not using CAM was cited as

PHARMACISTS’ CAM USE 53

KOH ET AL.54

TABLE 1. DEMOGRAPHIC INFORMATION (n 5 420)

Characteristics Frequency Percentage % Use of CAMa x2 p

Gender 0.118Male 137 32.6 86.2Female 283 67.4 80.3

Nationality 0.000Singaporean 180 42.9 89.4Malaysian 51 12.1 98.9Others 189 45.0 75.7

Country of residence in last 6 months/ 0.000Country of practiceSingapore 234 55.7 91.0Malaysia 4 1.0 100.9Others 182 43.3 75.3

Race 0.000Chinese 233 55.5 91.0Malay 7 1.7 57.1Indian 13 3.1 92.3Eurasian 24 5.7 66.7Others 143 34.0 76.9

Age 0.02620–24 48 11.4 85.425–29 109 26.0 92.730–34 55 13.1 90.935–39 40 9.5 85.040–44 49 11.7 77.645–49 35 8.3 71.450–54 37 8.8 75.755–59 24 5.7 75.0. 60 23 5.5 82.6

Language proficiency 0.045English only 206 49.0 80.1Chinese only 7 1.7 85.7Others only 35 8.3 80.0English and Chinese 121 28.8 92.6English and 1 other 34 8.1 79.4English and 2 others 17 4.0 94.1

Monthly gross personal income 0.757, $499 5 1.2 80.9$500–$999 8 1.9 62.5$1000–$1999 35 8.3 80.0$2000–$2999 104 24.8 87.5$3000–$3999 79 18.8 86.1$4000–$4999 31 7.4 87.1$5000–$5999 31 7.4 87.1$6000–$6999 27 6.4 77.8$7000–$7999 21 5.0 76.2$8000–$8999 7 1.7 71.4$9000–$9999 11 2.6 90.9. $10000 42 10.0 83.3NA 19 4.5

Marital status 0.039bSingle 192 45.7 88.5Married 214 51.0 79.9Divorced 7 1.7 100.9Others 7 1.7 85.7

aThis refers to percentage use of CAM within each subclass.bThis was calculated by combining those under “divorced” and “Others” as one category.CAM, complementary and alternative medicine, NA, not applicable.

PHARMACISTS’ CAM USE 55

FIG. 1. Types of complementary and alternative medicine (CAM) used.

TABLE 2B. REASONS FOR NOT USING CAM (n 5 66)

Reasons Frequency Percentage

Lack of evidence of effectiveness 31 47.0Satisfied with conventional medicines 41 62.1More expensive than conventional medicine 5 7.6Longer time to see effect 5 7.6Others 3 4.6

CAM, complementary and alternative medicine.

TABLE 2A. REASONS FOR USING CAM (n 5 354)

Reasons Frequency Percentage

Recommended by friends or family 169 47.7Recommended by medical practitioner or pharmacist 36 10.2Dissatisfaction with conventional medicine 53 15.0To treat health problems 169 47.7For maintenance of general health 179 50.6Holistic orientation toward health 59 16.7To relieve stress 110 31.1Natural, and therefore safer 33 9.3Greater control over health care decisions 34 9.6Not applicable 17 4.8

CAM, complementary and alternative medicine.

KOH ET AL.56

P

FIG. 2. Medical conditions treated with complementary and alternative medicine (n 5 354). Others include coughs,colds, flu, gastrointestinal problems, menstrual problems, skin problems, infections, general fatigue, bone problems,neck tension, pregnancy, and weight problems. NA, not applicable.

“satisfaction with conventional medicines”(62.1%). Other reasons are presented in Table 2B.

Medical conditions treated with CAM

The most frequently cited medical conditionstreated with CAM were back problems, sprainsor strains, headache, allergies, and insomnia.CAM was also used for cough and cold, flu, di-arrhea, skin problems, bone problems, urinarytract infections, menstrual problems and inpregnancy. The data is summarized in Figure 2.

Reporting use of CAM

Of the 193 pharmacists who used CAM at thesame time as conventional medicine, 136(70.5%) did not inform or consult a doctorabout it. The main reason (82%) was that thepharmacists felt that they did not need the ad-vice. The survey form allowed respondents tochoose more than one reason if applicable.Other reasons are listed in Table 3. Of the 193 pharmacists, 23.3% (45) consulted anotherpharmacist while 76.7% (148) did not.

Satisfaction

More than two thirds (72.6%) of the 354 phar-macists who used CAM were moderately sat-isfied with CAM, 13.8% (49) were extremelysatisfied, and 5.6% (20) were not satisfied. Twohundred and eighty-one (79.4%) of these phar-macists also indicated that they would recom-mend CAM to their family and friends.

Amount spent and willing to spend on CAM

Most pharmacists (37.6%) were likely tospend less than $5.60 per month on CAM (Fig.3). Only 3.9% spent more than $55.60 permonth on CAM and most (26.5%) were onlywilling to spend between $5.60 and $16.10 permonth. A small minority (4.2%) indicated thatthey were willing to pay more than $55.60 permonth on CAM.

Interest in and need for training

Eighty-one percent (81%; 340) of the phar-macists surveyed felt their training did not

PHARMACISTS’ CAM USE 57

equip them with the necessary skills andknowledge to counsel patients about herbalremedies; only 19% (80) felt otherwise. A largemajority (90.5%) also felt that the professionalcurriculum should have more components onherbal medicine. Sixty-nine (69; 16.4%) of thepharmacists felt that while their training pro-vided them with sufficient skills and knowl-edge, there should also be more componentson CAM in the professional curricula.

Pharmacists were most interested in attend-ing talks and seminars on herbal medicine(78.3%), TCM (58.3%), acupuncture (34.5%),and homeopathy (27.4%) as seen in Figure 4.

Perceived and actual knowledge

When asked to rate their own knowledge ofherbal medicine, 49% (206) of the pharmacistsfelt they did not know much about it, 39.8%(167) felt they had moderate knowledge, and6.7% (28) declared they knew nothing at all.Only 4.5% (19) felt that they knew a great deal.

On the 10-item knowledge test, the phar-macists obtained a mean score of 7.23 6 1.96(maximum score is 10) and 91% of respon-dents answered half or more of the questionscorrect. Table 4 shows the results of the knowl-edge test.

TABLE 3. REASONS FOR NOT REPORTING CAM USAGE (n 5 161)

Reason Frequency Percentage

Health professionals do not know much about it 28 17.4Health professionals do not encourage the use of CAM 25 15.5Anticipate disparaging comments from health professionals 17 10.6Do not need their advice 132 82.0

CAM, complementary and alternative medicine.

FIG. 3. Amounts patients spent and were willing to spend on complementary and alternative therapy per month(n 5 420). NA, not applicable. (Note: 1 U.S. dollar is equivalent to 1.8 Singapore dollars S$)

There was no statistically significant differ-ence in knowledge based on area of work.

Attitudes

More than half of the pharmacists believedit is important to have a basic understandingof CAM before using it and that patients maydisregard or even avoid doctors and healthcare

professionals who do not understand theirhealth beliefs (Table 5). The majority also agree(scores 4 and 5) that it is important to consulta health professional before using CAM.Twenty-six percent (26%) were neutral regard-ing consulting; this may mean they felt thatCAM could be used with or without advice.Seventy-one percent (71%) disagree (scores 1

KOH ET AL.58

FIG. 4. Talks/seminars on complementary and alternative medicine that respondents were interested in attending(n 5 420). Others include bioenergy, nutritional therapy, naturopathy, qigong, t’ai chi, yoga, and osteopathy.

TABLE 4. PHARMACISTS’ KNOWLEDGE ON COMPLEMENTARY AND ALTERNATIVE MEDICINE (n 5 420)

Percentage

Statement (correct answer) Correct Incorrect I don’t know

Herbal medicine is natural and therefore is safe and 94.0 3.4 2.6without side effects (false)

St. John’s wort is commonly used for the treatment of 75.0 2.6 22.4mild-to-moderate depression (true)

St. John’s wort has been proven to cause some 74.3 1.4 24.3drug-herb interactions (true)

Echinacea is commonly used for cold and flu 80.0 2.4 17.6symptoms (true)

Long-term use of echinacea is not recommended (true) 49.0 9.5 41.4Garlic can lower blood lipid level (true) 67.9 11.9 20.2Ginseng can be used safely in people with high 52.1 12.3 35.6

blood pressure (false)Ginkgo biloba is commonly used in people with 66.7 11.6 21.7

Alzheimer’s disease (true)Acupunture can be used to decrease withdrawal 90.7 0.2 9.2

symptoms and relieve pain (true)Chiropractic specializes in spinal manipulation and is 68.3 4.2 27.5

used to treat low-back pain (true)

and 2) that herbal medicine is unsafe and inef-fective; 81.4% of the pharmacists agree that self-care and interest in our own health is one rea-son why people use CAM. Compared to the76.4% of pharmacists who felt that they have aprofessional responsibility to provide informa-tion on herbal medicine, 47.4% of the pharma-cists agree (scores 4 and 5) that providing infor-mation on herbal medicine is part of a doctor’sprofessional responsibility. While 54% of the re-spondents agree that education on CAM shouldtake place in schools, approximately one thirdwere neutral, and 13.1% disagree.

Sources of information

Most pharmacists learned about herbal med-icine from books and magazines (64%), friendsor family (35.7%), the Internet (31.4%), phar-macists (17.9%), sales promoters (13.8%), tele-vision (10%), doctors (3.8%), or some othermeans (20%) such as journals, seminars, andthrough their university education (Fig. 5).

CAM in Singapore

One hundred and sixty-one (161; 89.4%) ofthe 180 Singaporean pharmacists in this surveyhave used CAM in their lifetime and 114(63.7%) used CAM in the last 12 months. The

top three types of CAM most frequently usedin a lifetime were the same as those used in thelast 12 months, namely, herbal medicine, TCM,and massage. The main reasons for using CAMwere cited as “for maintenance of generalhealth” (53.1%), “to treat health problems”(49%), “recommended by friends and family”(46.2%), and “to relieve stress” (29%). CAMwas used to treat back problems, sprains orstrains, allergies headache and insomnia, aswell as acute conditions such as cold and in-fections. The majority (59.3%) of these Singa-porean pharmacists spent between less than$5.60 and $16.10 per month on CAM and mostwere willing to spend below $16.10 a month onCAM. They indicated the greatest interest in at-tending talks and seminars on herbal medicine(77.1%), TCM (55.9%), acupuncture (33.5%),and aromatherapy (29.1%). One hundred andforty-nine (149; 83.2%) of the pharmacists feltthat their training did not equip them with theskills and knowledge to counsel patients onherbal medicine and 92.2% also believed thereshould be more component on herbal medicinein the professional curricula. The mean scoreon the knowledge test was 7.66 6 1.78. Theylearned about herbal medicine from books andmagazines (66.5%), friends and family (33.5%),the Internet (30.7%), and sales promoters (15.6%).

PHARMACISTS’ CAM USE 59

TABLE 5. PHARMACISTS’ ATTITUDES TOWARD COMPLEMENTARY AND ALTERNATIVE MEDICINE (n 5 420)

Frequency

Scores 1 2 3 4 5

It is important to have a basic understanding of 4 8 34 167 207CAM before using them.

Education on CAM therapies should take place 13 42 138 150 77in schools.

Patients may disregard or even avoid doctors and 24 53 104 170 69health care professionals who do not understandtheir health beliefs.

Herbal medicine is unsafe and ineffective. 182 116 102 12 8Self-care and interest in our own health is one reason 4 18 56 249 93

that people are drawn to CAM.Providing information about herbal medicine is part of 6 24 69 210 111

a pharmacist’s professional responsibility.Providing information about herbal medicine is part of 9 48 164 154 45

a doctor’s professional responsibility.It is important to consult a health professional before 7 34 109 181 89

using CAM.

1 5 strongly disagree; 2 5 disagree; 3 5 neutral; 4 5 agree; 5 5 strongly agree.CAM, complementary and alternative medicine.

Comments from respondents

The respondents gave a variety of commentsat the end of the survey. Generally, pharma-cists recognized that CAM may be beneficial tohealth and that the increased use by patientsnecessitates the need for education on CAM.Others feel they cannot abandon their allo-pathic training or understand the different sys-tems of belief and philosophies on which CAMis based.

DISCUSSION

Overall, the pharmacists’ scores from theknowledge test were fair, with an average of7.23 6 1.96. This is higher than a previous sur-vey on herbal medicine knowledge (Chang etal., 2000) where pharmacists scored 6 of 15.There is no statistically significant difference inknowledge based on area of work (p 5 0.077).

Pharmacists were more likely to answer cor-rectly the statements regarding uses of herbalmedicines and were not so sure of statementsinvolving precautions. This finding is consis-tent with the results of a previous survey(Chang et al., 2000). This is significant because

potential side-effects and drug–herb interac-tions have been documented and pharmacistsshould be informed and knowledgeable aboutsuch risks. Promoting patient safety is a cor-nerstone of pharmacy and pharmacists have aresponsibility to safeguard public health andimprove the well-being of patients.

CAM usage among pharmacists is high, with84.3% of pharmacists having used CAM before.The types of CAM used vary regionally. Al-though alternative treatments of cancer appearto be widely used in many parts of the world,this is not so in Singapore (Cassileth and Chap-man, 1996; Cassileth et al., 2001; Ernst and Cas-sileth, 1998). Herbal medicine, TCM and mas-sage were the most popular CAM therapiesused by pharmacists in general.

CAM was most often used for chronic ail-ments such as backache, allergies, and headache.This is similar to findings from previous stud-ies (Eisenberg et al., 1998; Wootton and Spar-ber, 2001). However, CAM was also used totreat acute conditions such as cough, cold, flu,diarrhea, and infections.

The results from this study agree with a pre-vious report, which suggested that disenchant-ment with conventional medicine was not nec-essarily the reason that people turn to CAM

KOH ET AL.60

FIG. 5. Sources of information (n 5 420). Others include journals, courses, seminars, university education, patients,products, and postgraduate degrees in complementary and alternative medicine.

(Astin, 1998). In this study, the main reason thatpharmacists used CAM was to maintain gen-eral health and promote well-being. This sup-ports the idea of CAM as a preventive as wellas curative measure to treat health problemsand may explain the large percentage (81.3%)of pharmacists who feel that self-care and in-terest in our own health is one of the reasonsthat draw people to CAM. Robinson et al. alsosuggested that users of herbs or supplementsappear to be a more health conscious group(Robinson et al., 2002). On the other hand, con-trary to a study by Furnham and Forey, only8.8% of the pharmacists in our study used CAMbecause of its perceived safety (Furnham andForey, 1994). This is possibly because pharma-cists are aware that herbal medicine is not with-out its risks. Herbal medicine is one of the mostcommonly used CAM around the world and isan area many pharmacists are interested in(Jonas, 2001). While they recognized its bene-fits, they also acknowledge that it is not safe forall.

Overall, pharmacists expressed satisfactionwith CAM and indicated they would recom-mend it to family and friends. This is similar tofindings from a survey of South Carolina adults(Oldendick et al., 2000).

Although 29% more pharmacists felt thatthey had a greater responsibility to provide in-formation on herbal medicine compared todoctors, almost half of them indicated they didnot know much about herbal medicine. It is ofinterest to note that 81% of the pharmacists feltthat there was inadequate training to equipthem with the skills and knowledge to counselpatients. The need for more training in CAM isevident in the face of increasing interest inCAM, to equip pharmacists to provide com-prehensive patient counseling and informationto other health care providers. With the in-creasing popularity of CAM, it is vital for phar-macists to become knowledgeable about CAMand to be prepared to discuss them with pa-tients or customers. In order to do this, phar-macists must enhance their knowledge ofCAM, especially medicinal botanicals (e.g., inaromatherapy, homeopathy, naturopathy, TCM,and herbs). Results from our study are similarto a survey by Baugniet and Boon, wherebypharmacy students were more likely to think

that CAM should be taught as a separate coursein their curriculum as compared to studentsfrom other health care professions (Baugnietand Boon, 2000).

Vague labeling, lack of standardization, andquality assurance mean that consumers are in-creasingly faced with an array of products thatmay claim to do wonders (Blendon et al., 2001;Chavis, 2001; Miller et al., 2000). Pharmacistsare frequently asked by patients and otherhealth care professionals about the use of theseCAM. Pharmacists are expected to maintain ac-curate information about herbal products andto use this expertise when advising consumers.They are in an excellent position to do this asdrug experts, and counseling patients on CAM(or herbal products) is simply an extension ofpharmaceutical care, to ensure patients get theoptimal benefit from therapy (Chavis, 2001;Miller et al., 2000). However, the inadequacy ofreliable sources of information poses a prob-lem. More than a third of the pharmacists ob-tain information about CAM through friendsand family, and recommendations by friendsand family is also one of the main reasons thatpharmacists use CAM. Results from this sur-vey clearly demonstrate that friends and fam-ily have an important influence on the use ofCAM by pharmacists. In addition to that, an-other 31.4% of pharmacists receive informationregarding CAM from the Internet. While the In-ternet may contain a wealth of medical infor-mation to help pharmacists keep up to date, itis also important to recognise that some of theinformation may be inaccurate or biased(Felkey and Fox, 2001; Pankaskie and Sullivan,1998). There is therefore a need for reliablesources of information and reference materialson CAM to aid health care professionals in theirwork.

In terms of cost, 37.6% of respondents spendless than $5.60 on CAM a month and only 4.2%are willing to spend more than $55.60 a monthon CAM. Most are only willing to spend be-tween $5.60 and $16.10 a month. Pharmacistsdo not and are also unwilling to spend a lot ofmoney on CAM. This may mean that they areunlikely to turn to CAM because it is cheaper.This is unlike previous findings, where usersof CAM paid out of pocket for treatments thatwere not covered under their health insurance

PHARMACISTS’ CAM USE 61

(Eisenberg et al., 1998). As health care profes-sionals, pharmacists may be more selective inthe kind of CAM they believe in and are there-fore less likely to spend large sums of moneyon less established treatments.

Several limitations to this study exist. A non-validated instrument was used in this study,because it was not known what valid survey-ing instrument could be used for validation.However, few survey tools have been validatedand this is a limitation most survey instrumentssuffer from. The results may not be generalizedto pharmacists worldwide as the sample con-sisted of a large proportion of pharmacists fromSingapore. Recall bias may have affected the re-sults as retrospective accounts of one’s healthpractices may be subject to inaccuracy. It wasalso assumed that all respondents interpretedthe questions in the intended manner, thus thepossibility of incorrect interpretation of ques-tions must be considered. These shortcomingsare commonly encountered and inherent insurveys, and every effort has been made tominimize them.

CONCLUSION

The use of CAM among pharmacists is wide-spread and prevalent in many cultures andcountries. Pharmacists acknowledge that CAMtherapies may be beneficial and have a place inhealth care. CAM was used by pharmacists inaddition to conventional medicine (comple-mentary) and also as an alternative, to promotehealth and treat illness. Pharmacists feel that itis their professional responsibility to counselpatients on herbal medicine, and accept theirrole as educators and information providers.This is an excellent opportunity for pharma-cists to gain recognition for pharmaceuticalcare and cognitive services. However, many ofthem do not think they know much aboutCAM. There is therefore a need for more edu-cation on CAM as its use increases, to ensurethat pharmacists are well equipped with thenecessary skills and knowledge. Pharmacistsneed to know the uses, claims, and adverse ef-fects of frequently used products and under-stand the basic principles behind them. Thereshould also be reliable sources of information

to aid health care professionals in the area ofCAM.

ACKNOWLEDGMENTS

The authors wish to thank the pharmacymanagers of the Changi General Hospital, EastShore Hospital, Mount Alvernia Hospital, Na-tional University Hospital, Raffles Hospital,Singapore General Hospital, Tan Tock SengHospital, Thomson Medical Centre, Wood-bridge Hospital and Institute of Mental Health,Guardian Pharmacy, National Trades UnionCongress (NTUC) Healthcare Pharmacy, aswell as all pharmacists who participated in thisstudy, for their time and kind support.

Free samples of Brands Essence of chickenand other samples (sponsored by Cerebos Pa-cific, Singapore) were given to respondents whocompleted the survey. The company was not involved in the survey in any other way. Wewould like to thank the company.

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Address reprint requests to:Hwee-Ling Koh, Ph.D.

Department of PharmacyNational University of Singapore

18 Science Drive 4Singapore 117543

Republic of Singapore

E-mail: phakohhl@nus.edu.sg

PHARMACISTS’ CAM USE 63

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