Complementary and alternative medicine (CAM) defined by the National Institute of Health (NIH) as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine or western medicine”. (1) According to NIH definition CAM includes [1]:

1. Natural health products (NHP);

2. Mind-body medicine (including practices such as yoga and acupuncture);

3. Manipulative and body-based systems; and

4. Traditional Chinese medicine.

Traditional Chinese Medicine (TCM) is defined by modalities such as “Chinese herbal medicine, moxibustion, acupuncture or Tuina”. TCM encompasses “herbs, herbal materials, herbal preparations and finished herbal products … [and] may contain non-plant substances” [2]. Approximately 5% of patients in a Vancouver Chinatown survey had used both Chinese and Western medicine concurrently [3]. More than 50% of population in the world use CAM concomitantly with western medicine [4]. CAM is used to treat simple conditions such as back problems, anxiety, and headaches or more complex conditions such as depression, rheumatic diseases, and cancer [5,6].

On January 1, 2004, the Natural Health Product Directorate (NHPD) became the regulatory body for natural health products (NHP) sold in Canada. Based on the survey conducted in 2005, consumers anticipate a growth in the use of NHP in Canada [7]. The majority of Canadians agree that they need additional information on NHPs and that initiative to inform Canadians about NHPs is essential. In 2010, the Ipsos-Reid survey reports that 73% of Canadians have used a CAM product, compared to 71% reported in the 2005 Ipsos-Reid survey [8]. Numerous studies indicate that consumers of CAM generally choose products based on information or recommendations from the Internet®, family, friends, pharmacy assistants, naturopaths, herbalists, physicians, health food store staff, and their pharmacists [5,8,9]. A study showed that 92% of the Australian pharmacy customers agree that pharmacists should be providing customers with information regarding safety and efficacy of CAM products, and 87% believe that pharmacists should be knowledgeable in recommending CAM products that are effective and safe [9]. Major barriers preventing pharmacists from providing holistic patient care is due to non-disclosure from patients regarding CAM use [10]. The main reasons patients do not disclose the use of CAM are 1) they believe that health care providers do not have the need to know about their CAM use, 2) negative responses from the health care provider if the patient disclosed CAM use; and 3) lack of health care provider initiation in assessing CAM use [10].

Studies have identified lack of regulation, lack of scientific evidence and unfamiliarity with CAM practices as key issues that hinder the inclusion of CAM in patient centered care by health care providers [11,12]. More importantly, pharmacy and medical students recommend including CAM in the curriculum [13-16].

Pharmacists are the most easily accessible health care providers in many countries including Canada and are often the providers whom patients commonly refer to seek advice on CAM products. Yet, pharmacists in Canada have identified a lack of knowledge regarding CAM products as a major barrier, especially in a lack of knowledge regarding specific mechanisms of action, adverse effects, drugherbal interactions and doses of certain CAM products [17-22]. The 2010 Ipsos-Reid survey reported 41% of consumers prefer asking pharmacists for information regarding CAM products compared to the 27% in 2005 [8]. Under the Standards for Pharmacist Practice from the Health Professions Act, pharmacists in Alberta “must take reasonable steps to… provide information to a person who… requests assistance in making a choice about a… health care product” [23]. This means that with respect to CAM practices such as the use of natural health products and TCM, pharmacists must be able to provide patients with appropriate information to help patients make informed decisions. Most pharmacists believe that they have a professional responsibility to provide information to patients regarding CAM [5]. With Alberta pharmacists expanding their scope of practice, it is important to evaluate the perceived attitudes and knowledge of pharmacists regarding TCM and CAM practices in Alberta. The purpose of this study is to investigate the perceived attitudes and knowledge competency of pharmacists practicing in Alberta regarding TCM and CAM practices.

Study design

An online survey was created through Google Documents®. Answers to most of the questions were in a 5 point Likert scale. The URL link to the survey along with a letter of information was circulated to all registered pharmacists through Alberta College of Pharmacists electronic newsletter “The Link”.

Data collection

Data were recorded on to a spreadsheet using Google Documents®

Statistical analysis

Data were collected on a spreadsheet using Google Documents. Each survey was assigned a sequential number as data were being collected. Data analyses were primarily limited to descriptive statistics. All variables were reported as proportions or mean and standard deviations, where applicable.

Ethics approval

The Research Ethics Board from the University of Alberta granted approval for this study.

The survey was circulated three times in three months. A total of 219 surveys were completed. Two responses were omitted: one due to incomplete response, and the other due to the unclear status of the responder. Therefore, 217 surveys were included for analysis. A total of 4200 pharmacists registered in Alberta at the time the survey was circulated which resulted in a response rate of only 5%. Over 70% of the pharmacists were female and a majority of responders were less than 50 years of age. Pharmacists practiced in the following settings: 71% (153) in community pharmacies, 24.4% (33) in hospital and 14% (31) in others. Three quarter of pharmacists (163) graduated from University of Alberta, 15% (22) from University of Saskatchewan. Other demographic data are listed in Tables 1-3.

Table 1: Demographics.

Table 2: Education on CAM or TCM by Age Group.

Table 3: Perceived Education on CAM and TCM.

Almost 70% of pharmacists used CAM or TCM. Majority of pharmacists felt they are not prepared to provide patient education or counseling on CAM and TCM upon graduation. Interestingly, the number of pharmacists who felt confident in providing education or counseling on CAM and TCM are similar to those does not feel confident. Most pharmacists expressed interest in obtaining further education in CAM and TCM. Nearly 90% of pharmacists agree or strongly agree that CAM and TCM should be included in the pharmacy curriculum (Table 4).

Table 4: Pharmacists attitudes toward CAM and TCM.

Regarding the patient assessment of CAM and TCM use, 79% either agreed or strongly agreed that it is essential part of standard patient care (Table 5).

Table 5: Use of CAM and TCM in practice.

CAM and TCM practices remain controversial despite the increased use worldwide. It has been shown schools that offer elective CAM education reports increased self-assessed knowledge, and more positive attitudes towards CAM [4,5,24-28]. By incorporating CAM education into pharmacy curriculum over several years leads to an increase in students’ knowledge [4].

Most of the surveyed pharmacists from our study did not feel prepared or confident to provide patient counseling or education on CAM or TCM. The results from our study are consistent with previous studies [9,18,19]. This is not surprising given the lack of formal education about CAM and TCM in pharmacy curricula. It has been shown that pharmacy students scored higher in herbal knowledge scores when these courses are mandatory [17]. A CAM elective course was offered as an elective stand alone course at university of Alberta from 2000 - 2008. Topics included were herbs, functional foods, CAM modalities, vitamins/minerals, homeopathy, and other supplements [17]. Currently the elective course is no longer offered as required or elective stand alone course in the pharmacy curriculum at the University of Alberta. Since then, a new pharmacy curriculum was implemented where the diseases/conditions are being taught as modules. Concepts of CAM and TCM are to be integrated into each module throughout the 4 year pharmacy curriculum. Although, CAM was offered as an elective for 8 years, interestingly, pharmacists in all age groups do not feel prepared to provide patient counseling or education. They all desired further education on CAM/TCM. This is in keeping with the previous study that students retain the information better when the course is mandatory [17].

Community pharmacists are the most visible and accessible health care providers. Patients could go to a pharmacy anytime without an appointment. Over 70% of pharmacists completed the survey worked in community pharmacies in Alberta, yet, 51% of these pharmacists do not feel confident in providing patient counseling or education on CAM and TCM. About 40% of community pharmacists do not feel prepared to provide patient counseling or education on CAM and TCM upon graduation. Overall, 95% pharmacists approved the use of CAM and TCM.

The results from the survey indicated a need to include CAM and TCM to pharmacy curriculum at University of Alberta. A needs assessment should be conducted to identify the best way for current pharmacists to obtain further education on CAM and TCM.

The electronic link to the survey was distributed through Alberta College of Pharmacists electronic monthly newsletter. Unfortunately, not every pharmacist read the electronic newsletter. This may explain the low (5%) response rate for the study. Also, a possible lack of interest in the topic may have resulted in a low response rate.

It appears that pharmacists in Alberta do not feel confident or prepared to provide patient counseling and education on CAM and TCM. Most desired to obtain further education on CAM and TCM.