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1.  The Ethics of Dietary Supplements and Natural Health Products in Pharmacy Practice: A Systematic Documentary Analysis 
Aims and Objectives
Many natural health products (NHPs) and dietary supplements (DS) are purchased in pharmacies and it has been argued that pharmacists are in the best position to provide patients with evidence-based information about them. This study was designed to identify how the pharmacist’s role with respect to NHPs/DS is portrayed in the literature.
Method
A systematic search was conducted in a variety of health databases to identify all literature that pertained to both pharmacy and NHPs/DS. Of the 786 articles identified, 665 were broad-coded and 259 were subjected to in-depth qualitative content analysis for emergent themes.
Key Findings
Overwhelmingly, support for the sale of NHPs/DS in pharmacies is strong. Additionally, a role for pharmacists in NHP/DS counselling is underscored. But another recurrent theme is that pharmacists are ill-equipped to counsel patients about these products that are available on their shelves. This situation has led some to question the ethics of pharmacists selling NHPs/DS and to highlight the existence of an ethical conflict stemming from the profit-motive associated with NHP/DS sales.
Conclusion
This analysis raises concerns about the ethics of NHPs/DS being sold in pharmacies, and about pharmacists being expected to counsel about products of which they have little knowledge.
PMCID: PMC2918535  PMID: 20218027 CAMSID: cams1317
2.  Exploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural health products: a study of focus groups 
Background
Natural health products (NHPs) such as herbs, vitamins and homeopathic medicines, are currently available for sale in most Canadian pharmacies. However, most pharmacists report that they have limited knowledge about these products which have been regulated in Canada as a specific sub-category of drugs. In this paper, consumers' and practicing pharmacists' perceptions of pharmacists' professional responsibilities with respect to NHPs are examined.
Methods
A total of 16 focus groups were conducted with consumers (n = 50) and pharmacists (n = 47) from four different cities across Canada (Vancouver, Edmonton, Toronto, and Halifax).
Results
In this paper, we illustrate the ways in which pharmacists' professional responsibilities are impacted by changing consumer needs. Many consumers in the study utilized a wide range of information resources that may or may not have included pharmacists. Nevertheless, the majority of consumers and pharmacists agreed that pharmacists should be knowledgeable about NHPs and felt that pharmacists should be able to manage drug-NHPs interactions as well as identify and evaluate the variety of information available to help consumers make informed decisions.
Conclusion
This paper demonstrates that consumers' expectations and behaviour significantly impact pharmacists' perceptions of their professional responsibilities with respect to NHPs.
doi:10.1186/1472-6882-8-40
PMCID: PMC2483265  PMID: 18625059
3.  Public awareness, patterns of use and attitudes toward natural health products in Kuwait: a cross-sectional survey 
Background
There has been a global rise in the use of natural health products (NHPs). Proper regulation of NHPs is pivotal to ensure good quality control standards, enhance consumers' safety and facilitate their integration into modern healthcare systems. There is scarcity of published data on the prevalence of NHPs usage among the general Kuwaiti population. Hence, this study was designed to determine awareness, patterns of use, general attitude and information requirements about NHPs among the public in Kuwait.
Methods
A descriptive cross-sectional survey was performed using a pretested self-administered questionnaire on a sample of 1300 Kuwaiti individuals, selected from six governorates in Kuwait using a multistage stratified clustered sampling. Descriptive and multivariate logistic regression analysis were used in data analysis.
Results
The response rate was 90.2%. NHPs were thought to be herbal remedies by most of participants (63.5%), followed by vitamins/minerals (40.5%), traditional medicines (21.1%), probiotics (14.9%), amino acids and essential fatty acids (7.2%), and homeopathic medicines (5.6%). NHPs usage was reported by 71.4% (95% CI: 68.8-74.0%) of respondents, and mostly associated with females (OR: 1.90; 95% CI: 1.44-2.51). Herbal remedies were the most commonly used (41.3%; 95% CI: 38.5-44.2%). The most common reasons for using NHPs were to promote and maintain health and to prevent illness and build immune system. Family members and/or friends and mass media were the main sources for providing information about NHPs. About 18% of consumers have experienced a side effect due to using a NHP. Attitudes toward NHPs were generally positive; with more than 75% of participants believing that the Ministry of Health in Kuwait should regulate the claims made by the manufacturers of NHPs and it is important to talk to a medical doctor or a pharmacist prior to using NHPs. Most of the respondents showed increased interest to acquire knowledge about different types of information related to NHPs.
Conclusions
The prevalence of use of NHPs among Kuwaiti population is high. The present findings have major public health policy implications for Kuwait. Therefore, there is an apparent need to establish effective health education programs and implement better and more regulated NHPs use policies in Kuwait.
doi:10.1186/1472-6882-14-105
PMCID: PMC3999934  PMID: 24646341
Natural health products; Herbal remedies; Patterns of use; Kuwait
4.  Core Competencies in Natural Health Products for Canadian Pharmacy Students 
Objective
To reach consensus on core competency statements for natural health products (NHPs) for Canadian pharmacy students.
Methods
Four rounds of a modified Delphi method were used to achieve consensus on core competency statements for NHPs. Pharmacy educators from Canada and the United States, and representatives from Canadian pharmacy organizations ranked their agreement using a 5-point Likert scale.
Results
Consensus was achieved on 3 NHP-related core competency statements: (1) to incorporate NHP knowledge when providing pharmaceutical care; (2) to access and critically appraise NHP-related information sources; and (3) to provide appropriate education to patients and other health care providers on the effectiveness, potential adverse effects, and drug interactions of NHPs.
Conclusions
Consensus was reached among leaders in NHP education on 3 NHP-related core competency statements. Implementation of these competencies would ensure that graduating Canadian pharmacists would be able to fulfill their professional responsibilities related to NHPs.
PMCID: PMC2865411  PMID: 20498738
natural health products (NHPs); competencies; Delphi method; complementary and alternative medicine; herbal medicine
5.  Study of Natural Health Product Adverse Reactions (SONAR): Active Surveillance of Adverse Events Following Concurrent Natural Health Product and Prescription Drug Use in Community Pharmacies 
PLoS ONE  2012;7(9):e45196.
Background
Many consumers use natural health products (NHPs) concurrently with prescription medications. As NHP-related harms are under-reported through passive surveillance, the safety of concurrent NHP-drug use remains unknown. To conduct active surveillance in participating community pharmacies to identify adverse events related to concurrent NHP-prescription drug use.
Methodology/Principal Findings
Participating pharmacists asked individuals collecting prescription medications about (i) concurrent NHP/drug use in the previous three months and (ii) experiences of adverse events. If an adverse event was identified and if the patient provided written consent, a research pharmacist conducted a guided telephone interview to gather additional information after obtaining additional verbal consent and documenting so within the interview form. Over a total of 112 pharmacy weeks, 2615 patients were screened, of which 1037 (39.7%; 95% CI: 37.8% to 41.5%) reported concurrent NHP and prescription medication use. A total of 77 patients reported a possible AE (2.94%; 95% CI: 2.4% to 3.7%), which represents 7.4% of those using NHPs and prescription medications concurrently (95%CI: 6.0% to 9.2%). Of 15 patients available for an interview, 4 (26.7%: 95% CI: 4.3% to 49.0%) reported an AE that was determined to be “probably” due to NHP use.
Conclusions/Significance
Active surveillance markedly improves identification and reporting of adverse events associated with concurrent NHP-drug use. Although not without challenges, active surveillance is feasible and can generate adverse event data of sufficient quality to allow for meaningful adjudication to assess potential harms.
doi:10.1371/journal.pone.0045196
PMCID: PMC3461007  PMID: 23028841
6.  Pharmacists’ knowledge and attitudes about natural health products: a mixed-methods study 
Objectives
To explore knowledge and attitude of pharmacists in Qatar towards natural health products (NHPs).
Methods
The quantitative component of this study consisted of an anonymous, online, self-administered questionnaire to assess knowledge about NHPs among pharmacists in Qatar. Descriptive statistics and inferential analysis were conducted using Statistical Package of Social Sciences (SPSS®). Means and standard deviation were used to analyze descriptive data, and statistical significance was expressed as P-value, where P≤0.05 was considered statistically significant. Associations between variables were measured using Pearson correlation. The qualitative component utilized focus group (FG) meetings with a purposive sample of community pharmacists. Meetings were conducted until a point of saturation was reached. FG discussions were audio-taped and transcribed verbatim. Data were analyzed using a framework approach to sort the data according to emerging themes.
Results
The majority of participants had average to poor knowledge about NHPs while only around 7% had good knowledge. In the FG meetings, participants considered the media, medical representatives, and old systems of natural health as major source of their knowledge. They criticized undergraduate pharmacy courses (for inadequately preparing pharmacists to deal with NHPs) and the pharmacy regulations (for being irrelevant). A perception of NHPs as being “safe” still exists among pharmacists.
Conclusions
Pharmacists’ ability to provide effective services associated with NHPs is limited by poor access to evidence-based information and poor knowledge. A perception of NHPs and CAM as ‘safe’ still exists among pharmacists, and regulations related to NHPs require addressing to follow best practice and ensure patient safety.
doi:10.2147/DHPS.S57756
PMCID: PMC3912048  PMID: 24501547
Qatar; focus group; complimentary alternative medicine
7.  Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study 
BMJ Open  2012;2(3):e000939.
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
doi:10.1136/bmjopen-2012-000939
PMCID: PMC3358628  PMID: 22586286
8.  The Prevalence of Natural Health Product Use in Patients with Acute Cardiovascular Disease 
PLoS ONE  2011;6(5):e19623.
Background
Natural health products (NHP) use may have implications with respect to adverse effects, drug interactions and adherence yet the prevalence of NHP use by patients with acute cardiovascular disease and the best method to ascertain this information is unknown.
Objective
To identify the best method to ascertain information on NHP, and the prevalence of use in a population with acute cardiovascular disease.
Methods
Structured interviews were conducted with a convenience sample of consecutive patients admitted with acute cardiovascular disease to the University of Alberta Hospital during January 2009. NHP use was explored using structured and open-ended questions based on Health Canada's definition of NHP. The medical record was reviewed, and documentation of NHP use by physicians, nurses, and pharmacists, compared against the gold-standard structured interview.
Results
88 patients were interviewed (mean age 62 years, standard deviation [SD 14]; 80% male; 41% admitted for acute coronary syndromes). Common co-morbidities included hypertension (59%), diabetes (26%) and renal impairment (19%). NHP use was common (78% of patients) and 75% of NHP users reported daily use. The category of NHP most commonly used was vitamins and minerals (73%) followed by herbal products (20%), traditional medicines including Chinese medicines (9%), homeopathic preparations (1%) and other products including amino acids, essential fatty acids and probiotics (35%). In a multivariable model, only older age was associated with increased NHP use (OR 1.5 per age decile [95%CI 1.03 to 2.2]). When compared to the interview, the highest rate of NHP documentation was the pharmacist history (41%). NHP were documented in 22% of patients by the physician and 19% by the nurse.
Conclusions
NHP use is common in patients admitted with acute cardiovascular disease. However, health professionals do not commonly identify NHP as part of the medication profile despite its potential importance. Structured interview appears to be the best method to accurately identify patient use of NHP.
doi:10.1371/journal.pone.0019623
PMCID: PMC3090400  PMID: 21573067
9.  Patient self-management and pharmacist-led patient self-management in Hong Kong: A focus group study from different healthcare professionals' perspectives 
Background
Patient self-management is a key approach to manage non-communicable diseases. A pharmacist-led approach in patient self-management means collaborative care between pharmacists and patients. However, the development of both patient self-management and role of pharmacists is limited in Hong Kong. The objectives of this study are to understand the perspectives of physicians, pharmacists, traditional Chinese medicine (TCM) practitioners, and dispensers on self-management of patients with chronic conditions, in addition to exploring the possibilities of developing pharmacist-led patient self-management in Hong Kong.
Methods
Participants were invited through the University as well as professional networks. Fifty-one participants comprised of physicians, pharmacists, TCM practitioners and dispensers participated in homogenous focus group discussions. Perspectives in patient self-management and pharmacist-led patient self-management were discussed. The discussions were audio recorded, transcribed and analysed accordingly.
Results
The majority of the participants were in support of patients with stable chronic diseases engaging in self-management. Medication compliance, monitoring of disease parameters and complications, lifestyle modification and identifying situations to seek help from health professionals were generally agreed to be covered in patient self-management. All pharmacists believed that they had extended roles in addition to drug management but the other three professionals believed that pharmacists were drug experts only and could only play an assisting role. Physicians, TCM practitioners, and dispensers were concerned that pharmacist-led patient self-management could be hindered, due to unfamiliarity with the pharmacy profession, the perception of insufficient training in disease management, and lack of trust of patients.
Conclusions
An effective chronic disease management model should involve patients in stable condition to participate in self-management in order to prevent health deterioration and to save healthcare costs. The role of pharmacists should not be limited to drugs and should be extended in the primary healthcare system. Pharmacist-led patient self-management could be developed gradually with the support of government by enhancing pharmacists' responsibilities in health services and developing public-private partnership with community pharmacists. Developing facilitating measures to enhance the implementation of the pharmacist-led approach should also be considered, such as allowing pharmacists to access electronic health records, as well as deregulation of more prescription-only medicines to pharmacy-only medicines.
doi:10.1186/1472-6963-11-121
PMCID: PMC3127980  PMID: 21609422
patient self-management; pharmacist-led patient self-management; chronic disease; health policy; Hong Kong
10.  Public’s attitudes towards community pharmacy in Qatar: a pilot study 
Objectives
To assess the public’s attitudes towards the community pharmacist’s role in Qatar, to investigate the public’s use of community pharmacy, and to determine the public’s views of and satisfaction with community pharmacy services currently provided in Qatar.
Materials and methods
Three community pharmacies in Qatar were randomly selected as study sites. Patients 16 years of age and over who were able to communicate in English or Arabic were randomly approached and anonymously interviewed using a multipart pretested survey.
Results
Over 5 weeks, 58 patients were interviewed (60% response rate). A total of 45% of respondents perceived community pharmacists as having a good balance between health and business matters. The physician was considered the first person to contact to answer drug- related questions by 50% of respondents. Most patients agreed that the community pharmacist should provide them with the medication directions of use (93%) and advise them about the treatment of minor ailments (79%); however, more than 70% didn’t expect the community pharmacist to monitor their health progress or to perform any health screening. Half of the participants (52%) reported visiting the pharmacy at least monthly. The top factor that affected a patient’s choice of any pharmacy was pharmacy location (90%). When asked about their views about community pharmacy services in Qatar, only 37% agreed that the pharmacist gave them sufficient time to discuss their problem and was knowledgeable enough to answer their questions.
Conclusion
This pilot study suggested that the public has a poor understanding of the community pharmacist’s role in monitoring drug therapy, performing health screening, and providing drug information. Several issues of concern were raised including insufficient pharmacist– patient contact time and unsatisfactory pharmacist knowledge. To advance pharmacy practice in Qatar, efforts may be warranted to address identified issues and to promote the community pharmacist’s role in drug therapy monitoring, drug information provision, and health screening.
doi:10.2147/PPA.S22117
PMCID: PMC3176180  PMID: 21949604
pharmacist; public; attitudes; Qatar
11.  Tobacco sales in pharmacies: a survey of attitudes, knowledge and beliefs of pharmacists employed in student experiential and other worksites in Western New York 
BMC Research Notes  2012;5:413.
Background
Pharmacies are venues in which patients seek out products and professional advice in order to improve overall health. However, many pharmacies in the United States continue to sell tobacco products, which are widely known to cause detrimental health effects. This conflict presents a challenge to pharmacists, who are becoming increasingly more involved in patient health promotion activities. This study sought to assess Western New York (WNY) area pharmacists’ opinions about the sale of tobacco products in pharmacies, and pharmacists’ opinions on their role in patient smoking cessation.
Methods
Participants responded to two parallel surveys; a web-based survey was completed by 148 university-affiliated pharmacist preceptors via a list based sample, and a mail-based survey was completed by the supervising pharmacist in 120 area pharmacies via a list-based sample. The combined response rate for both surveys was 31%. Univariate and bivariate analyses were performed to determine any significant differences between the preceptor and supervising pharmacist survey groups.
Results
Over 75% of respondents support legislation banning the sale of tobacco products in pharmacies. Over 86% of respondents would prefer to work in a pharmacy that does not sell tobacco products. Differences between preceptor and supervising pharmacist groups were observed. Action regarding counseling patients was uncommon among both groups.
Conclusions
Pharmacists support initiatives that increase their role in cessation counseling and initiatives that restrict the sale of tobacco products in pharmacies. These data could have important implications for communities and pharmacy practice.
doi:10.1186/1756-0500-5-413
PMCID: PMC3492148  PMID: 22867129
Tobacco sales; Pharmacists; Preceptors; Public health policy; Survey research; Pharmacies
12.  Pharmacists’ Perceptions of Their Professional Role: Insights into Hospital Pharmacy Culture 
Background:
Numerous studies have demonstrated the positive impacts of pharmacists on patient outcomes. To capitalize on these positive impacts, hospital pharmacy organizations around the world are now calling on pharmacists to shift their focus from distribution of medications to patient outcomes. This new emphasis is consistent with the vision statement for the profession of pharmacy in Canada, as set out in the Blueprint for Pharmacy: “Optimal drug therapy outcomes for Canadians through patient-centred care”. Given the ambitious nature of this statement and these goals, it is essential to understand what pharmacists currently think of their practice.
Objective:
To conduct a qualitative and semiquantitative analysis of hospital pharmacists’ perceptions of their role in patient care.
Methods:
A researcher posing as a University of Alberta student who was studying how health professionals use language to describe what they do contacted the pharmacy departments of all hospitals in Alberta. The “top-of-mind” approach was used in asking hospital pharmacists 2 questions: (1) How many years have you been practising pharmacy? (2) In 3 or 4 words (or phrases), from your perspective could you please tell me, “What does a pharmacist do”? These techniques were used to minimize the impact of social desirability bias. Content analysis was used to categorize hospital pharmacists’ responses into 4 broad categories: patient-centred, drug-focused, drug distribution, and ambiguous.
Results:
A total of 103 phone calls were made to hospital pharmacies, and 85 pharmacists contacted in this way were willing to participate in the survey. Hospital pharmacists provided 333 individual responses to the question about their activities. Of these, 79 (23.7%) were patient-centred, 98 (29.4%) were drug-focused, and 82 (24.6%) were in the drug-distribution category. Ambiguous responses accounted for the remaining 74 (22.2%).
Conclusion:
Aspects of care categorized as other than patient-centred should not be construed as unimportant. However, the fact that they were reported in this survey more frequently than patient-centred aspects suggests that hospital pharmacists in Alberta may have not fully embraced the concept of patient-centred care as outlined in the Blueprint for Pharmacy.
PMCID: PMC3053190  PMID: 22479026
patient-centred; drug-focused; drug distribution; top-of-mind approach; hospital pharmacist; pharmacy culture; pratique axée sur le patient; pratique axée sur les médicaments; distribution des médicaments; analyse des réponses spontanées; pharmacien d’hôpital; culture de la pharmacie
13.  A qualitative study exploring the impact and consequence of the medicines use review service on pharmacy support-staff 
Pharmacy Practice  2013;11(2):118-124.
Background
Pharmacy support-staff (pharmacy technicians, dispensers and Medicines Counter Assistants) support the delivery of pharmaceutical and retail functions of the pharmacy. Workflow is supervised and at times dependent upon the pharmacist’s presence. Policy makers and pharmacy’s representative bodies are seeking to extend the community pharmacist's role including requiring the pharmacist to undertake private consultations away from the dispensary and shop floor areas. However, support-staff voices are seldom heard and little is known about the impact such policies have on them.
Objective
The objective of this study is to explore the impact and consequences of the English Medicine Use Review (MUR) service on pharmacy support-staff.
Methods
Ten weeks of ethnographic-oriented observations in two English community pharmacies and interviews with 5 pharmacists and 12 support-staff. A thematic approach was used to analyse the data.
Results
Despite viewing MURs as a worthwhile activity, interviews with support-staff revealed that some felt frustrated when they were left to explain to patients why the pharmacist was not available when carrying out an MUR. Dependency on the pharmacist to complete professional and accuracy checks on prescriptions grieved dispensing staff because dispensing workflow was disrupted and they could not get their work done. Medicines Counter Assistants were observed to have less dependency when selling medicines but some still reported concerns over of customers and patients waiting for the pharmacist. A range of tacit and ad hoc strategies were consequently found to be deployed to handle situations when the pharmacist was absent performing an MUR.
Conclusions
Consideration should be given to support-staff and pharmacists’ existing work obligations when developing new pharmacy extended roles that require private consultations with patients. Understanding organisational culture and providing adequate resourcing for new services are needed to avoid improvisations or enactments by pharmacy support-staff and to allow successful innovation and policy implementation.
PMCID: PMC3798177  PMID: 24155859
Pharmacists' Aides; Pharmacists; Workflow; Community Pharmacy Services; Drug Utilization Review; Professional Practice; United Kingdom
14.  Pharmacy practice and its challenges in Yemen 
Background
Pharmacy practice in Yemen was established in 1875 in Aden.
Objectives
To describe pharmacy practice as it currently exists in Yemen, the challenges the profession faces, and to recommend changes that will improve pharmaceutical care services.
Methods
This study has two parts. Part 1 comprised a literature search performed between May and July 2011 to identify published studies on pharmacy practice in Yemen. Full text papers, abstracts, and reports in Arabic or English between 1970 and 2011 were reviewed. Part 2 consisted of a qualitative study with face-to-face interviews with a representative sample of pharmacists, staff from the Ministry of Public Health and Population (MoPHP), and patients.
Results
The analysis revealed several issues that plague pharmacy practice in Yemen:
Fewer than 10 per cent of pharmacists working in pharmacies and drug stores are graduates of governmentrecognised colleges.
Most Yemeni pharmacists are dissatisfied with their work conditions and opportunities.
Medicines are expensive and hard to access in Yemen, and counterfeit medicines are a serious problem.
Few regulations and standards exist for pharmacists and pharmaceutical care.
Pharmaceutical marketing plays an important role in marketing and selling products in Yemen.
A dearth of standards, regulations, and laws are hurting pharmacy practice in the country and potentially endangering peoples’ lives.
Conclusion
In order to improve pharmacy practice in Yemen, many changes are needed, including updating the pharmacy curriculum taught, implementing industry standards for pharmacy practice, implementing and reinforcing laws, and integrating pharmacists more fully in the healthcare industry. Additionally, the quality of the pharmacy workforce needs to be improved, and there needs to be increased awareness by the public, physicians, other healthcare professionals, and policy makers about the value of pharmacists.
doi:10.4066/AMJ.2014.1890
PMCID: PMC3920470  PMID: 24567762
Pharmacy practice; workforce; satisfaction; challenges; recommendations and Yemen
15.  Consumers of natural health products: natural-born pharmacovigilantes? 
Background
Natural health products (NHPs), such as herbal medicines and vitamins, are widely available over-the-counter and are often purchased by consumers without advice from a healthcare provider. This study examined how consumers respond when they believe they have experienced NHP-related adverse drug reactions (ADRs) in order to determine how to improve current safety monitoring strategies.
Methods
Qualitative semi-structured interviews were conducted with twelve consumers who had experienced a self-identified NHP-related ADR. Key emergent themes were identified and coded using content analysis techniques.
Results
Consumers were generally not comfortable enough with their conventional health care providers to discuss their NHP-related ADRs. Consumers reported being more comfortable discussing NHP-related ADRs with personnel from health food stores, friends or family with whom they had developed trusted relationships. No one reported their suspected ADR to Health Canada and most did not know this was possible.
Conclusion
Consumers generally did not report their suspected NHP-related ADRs to healthcare providers or to Health Canada. Passive reporting systems for collecting information on NHP-related ADRs cannot be effective if consumers who experience NHP-related ADRs do not report their experiences. Healthcare providers, health food store personnel, manufacturers and other stakeholders also need to take responsibility for reporting ADRs in order to improve current pharmacovigilance of NHPs.
doi:10.1186/1472-6882-10-8
PMCID: PMC2847952  PMID: 20184759
16.  e-Health, m-Health and healthier social media reform: the big scale view 
Introduction
In the upcoming decade, digital platforms will be the backbone of a strategic revolution in the way medical services are provided, affecting both healthcare providers and patients. Digital-based patient-centered healthcare services allow patients to actively participate in managing their own care, in times of health as well as illness, using personally tailored interactive tools. Such empowerment is expected to increase patients’ willingness to adopt actions and lifestyles that promote health as well as improve follow-up and compliance with treatment in cases of chronic illness. Clalit Health Services (CHS) is the largest HMO in Israel and second largest world-wide. Through its 14 hospitals, 1300 primary and specialized clinics, and 650 pharmacies, CHS provides comprehensive medical care to the majority of Israel’s population (above 4 million members). CHS e-Health wing focuses on deepening patient involvement in managing health, through personalized digital interactive tools. Currently, CHS e-Health wing provides e-health services for 1.56 million unique patients monthly with 2.4 million interactions every month (August 2011). Successful implementation of e-Health solutions is not a sum of technology, innovation and health; rather it’s the expertise of tailoring knowledge and leadership capabilities in multidisciplinary areas: clinical, ethical, psychological, legal, comprehension of patient and medical team engagement etc. The Google Health case excellently demonstrates this point. On the other hand, our success with CHS is a demonstration that e-Health can be enrolled effectively and fast with huge benefits for both patients and medical teams, and with a robust business model.
CHS e-Health core components
They include:
1. The personal health record layer (what the patient can see) presents patients with their own medical history as well as the medical history of their preadult children, including diagnoses, allergies, vaccinations, laboratory results with interpretations in layman’s terms, medications with clear, straightforward explanations regarding dosing instructions, important side effects, contraindications, such as lactation etc., and other important medical information. All personal e-Health services require identification and authorization.
2. The personal knowledge layer (what the patient should know) presents patients with personally tailored recommendations for preventative medicine and health promotion. For example, diabetic patients are push notified regarding their yearly eye exam. The various health recommendations include: occult blood testing, mammography, lipid profile etc. Each recommendation contains textual, visual and interactive content components in order to promote engagement and motivate the patient to actually change his health behaviour.
3. The personal health services layer (what the patient can do) enables patients to schedule clinic visits, order chronic prescriptions, e-consult their physician via secured e-mail, set SMS medication reminders, e-consult a pharmacist regarding personal medications. Consultants’ answers are sent securely to the patients’ personal mobile device.
On December 2009 CHS launched secured, web based, synchronous medical consultation via video conference. Currently 11,780 e-visits are performed monthly (May 2011). The medical encounter includes e-prescription and referral capabilities which are biometrically signed by the physician. On December 2010 CHS launched a unique mobile health platform, which is one of the most comprehensive personal m-Health applications world-wide. An essential advantage of mobile devices is their potential to bridge the digital divide. Currently, CHS m-Health platform is used by more than 45,000 unique users, with 75,000 laboratory results views/month, 1100 m-consultations/month and 9000 physician visit scheduling/month.
4. The Bio-Sensing layer (what physiological data the patient can populate) includes diagnostic means that allow remote physical examination, bio-sensors that broadcast various physiological measurements, and smart homecare devices, such as e-Pill boxes that gives seniors, patients and their caregivers the ability to stay at home and live life to its fullest. Monitored data is automatically transmitted to the patient’s Personal Health Record and to relevant medical personnel.
The monitoring layer is embedded in the chronic disease management platform, and in the interactive health promotion and wellness platform. It includes tailoring of consumer-oriented medical devices and service provided by various professional personnel—physicians, nurses, pharmacists, dieticians and more.
5. The Social layer (what the patient can share). Social media networks triggered an essential change at the humanity ‘genome’ level, yet to be further defined in the upcoming years. Social media has huge potential in promoting health as it combines fun, simple yet extraordinary user experience, and bio-social-feedback. There are two major challenges in leveraging health care through social networks:
a. Our personal health information is the cornerstone for personalizing healthier lifestyle, disease management and preventative medicine. We naturally see our personal health data as a super-private territory. So, how do we bring the power of our private health information, currently locked within our Personal Health Record, into social media networks without offending basic privacy issues?
b. Disease management and preventive medicine are currently neither considered ‘cool’ nor ‘fun’ or ‘potentially highly viral’ activities; yet, health is a major issue of everybody’s life. It seems like we are missing a crucial element with a huge potential in health behavioural change—the Fun Theory. Social media platforms comprehends user experience tools that potentially could break current misconception, and engage people in the daily task of taking better care of themselves.
CHS e-Health innovation team characterized several break-through applications in this unexplored territory within social media networks, fusing personal health and social media platforms without offending privacy. One of the most crucial issues regarding adoption of e-health and m-health platforms is change management. Being a ‘hot’ innovative ‘gadget’ is far from sufficient for changing health behaviours at the individual and population levels.
CHS health behaviour change management methodology includes 4 core elements:
1. Engaging two completely different populations: patients, and medical teams. e-Health applications must present true added value for both medical teams and patients, engaging them through understanding and assimilating “what’s really in it for me”. Medical teams are further subdivided into physicians, nurses, pharmacists and administrative personnel—each with their own driving incentive. Resistance to change is an obstacle in many fields but it is particularly true in the conservative health industry. To successfully manage a large scale persuasive process, we treat intra-organizational human resources as “Change Agents”. Harnessing the persuasive power of ~40,000 employees requires engaging them as the primary target group. Successful recruitment has the potential of converting each patient-medical team interaction into an exposure opportunity to the new era of participatory medicine via e-health and m-health channels.
2. Implementation waves: every group of digital health products that are released at the same time are seen as one project. Each implementation wave leverages the focus of the organization and target populations to a defined time span. There are three major and three minor implementation waves a year.
3. Change-Support Arrow: a structured infrastructure for every implementation wave. The sub-stages in this strategy include:
Cross organizational mapping and identification of early adopters and stakeholders relevant to the implementation wave
Mapping positive or negative perceptions and designing specific marketing approaches for the distinct target groups
Intra and extra organizational marketing
Conducting intensive training and presentation sessions for groups of implementers
Running conflict-prevention activities, such as advanced tackling of potential union resistance
Training change-agents with resistance-management behavioural techniques, focused intervention for specific incidents and for key opinion leaders
Extensive presence in the clinics during the launch period, etc.
The entire process is monitored and managed continuously by a review team.
4. Closing Phase: each wave is analyzed and a “lessons-learned” session concludes the changes required in the modus operandi of the e-health project team.
PMCID: PMC3571141
e-Health; mobile health; personal health record; online visit; patient empowerment; knowledge prescription
17.  U.S. and Canadian pharmacists' attitudes, knowledge, and professional practice behaviors toward dietary supplements: a systematic review 
Background
Although dietary supplements (DS) are widely sold in pharmacies, the legal, ethical, and practice responsibilities of pharmacists with respect to these products have not been well defined. This systematic review of pharmacists' attitudes, knowledge, and professional practice behaviours toward DS is intended to inform pharmacy regulators' and educators' decision making around this topic.
Methods
Eligible studies were identified through a systematic database search for all available years through to March 2006. Articles were analyzed for this review if they included survey data on U.S. or Canadian pharmacists' attitudes, knowledge, or professional practice behaviors toward DS published in 1990 or later.
Results
Due to the heterogeneity of the data, it was not possible to draw a conclusion with respect to pharmacists' general attitudes toward DS. Approximately equal numbers of pharmacists report positive as well as negative attitudes about the safety and efficacy of DS. There is strong agreement among pharmacists for the need to have additional training on DS, increased regulation of DS, and quality information on DS. In addition, survey data indicate that pharmacists do not perceive their knowledge of DS to be adequate and that pharmacists do not routinely document, monitor, or inquire about patients' use of DS. Despite this, a large proportion of pharmacists reported receiving questions about DS from patients and other health care practitioners.
Conclusion
Further research is needed to explore the factors that influence pharmacists' beliefs and attitudes about DS, to accurately evaluate pharmacists' knowledge of DS, and to uncover the reasons why pharmacists do not routinely document, monitor, or inquire about patients' use of DS.
doi:10.1186/1472-6882-6-31
PMCID: PMC1586212  PMID: 16984649
18.  Exploring successful community pharmacist-physician collaborative working relationships using mixed methods 
Background
Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.
Objective
To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.
Methods
A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.
Results
On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.
Conclusions
The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.
doi:10.1016/j.sapharm.2009.11.008
PMCID: PMC3004536  PMID: 21111388
Pharmacists; Physicians; Collaborative working relationships; Pharmacist-physician collaborative index; Community
19.  Patients’ perception, views and satisfaction with pharmacists’ role as health care provider in community pharmacy setting at Riyadh, Saudi Arabia 
Objectives
This study will provide guiding information about the population perception, views and satisfaction with pharmacist’s performance as health care provider in the community pharmacy setting in Riyadh, Saudi Arabia.
Method
The study was conducted in Riyadh, Saudi Arabia, from July through December 2010. A total of 125 community pharmacies in Riyadh city were randomly selected according to their geographical distribution (north, south, east, and west). They represent about 10–15% of all community pharmacies in the city. The questionnaire composed of 8 items about patients’ views and satisfaction with the pharmacists’ role in the current community pharmacy practice. The questionnaire was coded, checked for accuracy and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0 for Windows (SPSS Inc., Chicago, Illinois).
Results
The response rate was almost 85% where 2000 patients were approached and 1699 of them responded to our questionnaire. The majority of respondents is young adults and adults (82.8%), male (67.5%) and married (66.9%). Seventy one percent of respondents assured that community pharmacist is available in the working while only 37.3% of respondents perceived the pharmacist as a mere vendor. About 38% assured sou moto counseling by the pharmacist, 35% reported pharmacist plays an active role in their compliances to treatments, 43% acknowledged the role of pharmacist in solving medication related problems, 34% considered the pharmacist as a health awareness provider and 44.6% felt that pharmacist is indispensable and an effective part of the health care system.
Conclusion
The image and professional performance of community pharmacist are improving in Saudi Arabia. The Saudi patients show better satisfaction, perception and appreciation of the pharmacists’ role in the health care team. However, extra efforts should be paid to improve the clinical skills of the community pharmacists. Community pharmacists need to be able to reach out to patient, assess their hesitations and promptly offer solution which was appreciated by the patients as the survey indicates. They should play a pro-active role in becoming an effective and indispensable part of health care. Furthermore, they should be able to advice, guide, direct and persuade the patient to comply correct usage of drugs. Finally, community pharmacists should equip themselves with appropriate knowledge and competencies in order to tender efficient and outstanding pharmaceutical health care.
doi:10.1016/j.jsps.2012.05.007
PMCID: PMC3745196  PMID: 23960807
Community; Pharmacist; Satisfaction; Care; Drug; Perception
20.  The Role of the Pediatric Pharmacist in Personalized Medicine and Clinical Pharmacogenomics for Children 
With the initiatives by the National Institutes of Health and the Food and Drug Administration, pharmacogenomics has now moved from the laboratory to the patient bedside. Over 100 drug-products now contain pharmacogenomic information as part of their labeling. Many of these are commonly used in the pediatric population. Direct-to-consumer genetic test kits also require intervention and guidance from healthcare professionals. This increased trend towards personalized medicine mandates that healthcare professionals develop a working knowledge about pharmacogenomics and its application towards patient care. Because pharmacogenomic testing can provide patient-specific predictors for response to and safety of medications, pharmacists are positioned to play an active role in pharmacogenomic testing, clinical interpretation of results, and recommendations for individualization of drug therapy. Opportunities for pharmacists exist in both inpatient and outpatient settings, such as pharmacist-managed clinical pharmacogenomics consultation services and educating patients and families about pharmacogenomic testing. In addition to clinical roles, pharmacists may also be involved in genetically-influenced drug discovery and development. Given the potential for genetic and age-dependent factors to influence drug selection and dosing, pediatric pharmacists should be involved in the development of dosing recommendations and interprofessional practice guidelines regarding pharmacogenomic testing in pediatric patients. Opportunities to become knowledgeable and competent in pharmacogenomics span from coursework as part of the pharmacy curriculum to postgraduate education (e.g., residencies, fellowships, continuing education). However, there exists a need for additional postgraduate learning opportunities for practicing pharmacists. As a result, the Pediatric Pharmacy Advocacy Group (PPAG) acknowledges a need for increased education of both student and practicing pharmacists, with consideration of special patient populations, such as infants and children. PPAG endorses and advocates for the involvement of pediatric pharmacists in pharmacogenomic testing and in using those results to provide safe and effective medication use in pediatric patients of all ages. Additionally, PPAG strongly encourages pediatric pharmacists to take responsibility for educating patients and their families about the importance of pharmacogenomic testing and its role in the safe and effective use of medications.
doi:10.5863/1551-6776-16.2.118
PMCID: PMC3208440  PMID: 22477836
pediatrics; personalized medicine; pharmacist; pharmacogenomics; testing
21.  Pharmacists’ Expectations for Entry-level Practitioner Competency 
Objective. To determine if defined subgroups of pharmacists’ have variability in their expectations for competency of entry-level practitioners.
Methods. Rating scale data collected from the 2009 National Pharmacy Practice Survey were analyzed to determine to what extent pharmacists' degree, practice setting, and experience as a preceptor were associated with the ratings they assigned to 43 competency statements for entry-level practitioners. The competency statements determine the content on the North American Pharmacist Licensure Examination (NAPLEX).
Results. Pharmacists with a doctor of pharmacy (PharmD) degree rated the co mpetency statements higher in terms of criticality to entry-level practice than did those with a bachelor of science (BS) degree (p< 0.05). Pharmacists working in inpatient settings gave slightly higher ratings to the competency statements than did pharmacists working in outpatient settings, pharmacists without direct patient care responsibilities, and those in academia. However, there were no significant differences among practitioner subgroups' criticality ratings with regard to practice setting. Preceptor pharmacists' criticality ratings of the competency statements were not significantly different from those of non-preceptor practitioners.
Conclusion. Pharmacists exhibited a fair amount of agreement in their expectations for the competence of entry-level practitioners independent of their practice sites and professional roles. As the pharmacy profession embraces patient-centered clinical practice, evaluating practicing pharmacists’ expectations for entry-level practitioners will provide useful information to the practitioners and academicians involved in training future pharmacists. Stakeholders in pharmacy education and regulation have vested interests in the alignment of the education of future practitioners with the needs of the profession.
doi:10.5688/ajpe7715
PMCID: PMC3578337  PMID: 23459441
pharmacist; NAPLEX; competency; performance standards
22.  Interactions between Non-Physician Clinicians and Industry: A Systematic Review 
PLoS Medicine  2013;10(11):e1001561.
In a systematic review of studies of interactions between non-physician clinicians and industry, Quinn Grundy and colleagues found that many of the issues identified for physicians' industry interactions exist for non-physician clinicians.
Please see later in the article for the Editors' Summary
Background
With increasing restrictions placed on physician–industry interactions, industry marketing may target other health professionals. Recent health policy developments confer even greater importance on the decision making of non-physician clinicians. The purpose of this systematic review is to examine the types and implications of non-physician clinician–industry interactions in clinical practice.
Methods and Findings
We searched MEDLINE and Web of Science from January 1, 1946, through June 24, 2013, according to PRISMA guidelines. Non-physician clinicians eligible for inclusion were: Registered Nurses, nurse prescribers, Physician Assistants, pharmacists, dieticians, and physical or occupational therapists; trainee samples were excluded. Fifteen studies met inclusion criteria. Data were synthesized qualitatively into eight outcome domains: nature and frequency of industry interactions; attitudes toward industry; perceived ethical acceptability of interactions; perceived marketing influence; perceived reliability of industry information; preparation for industry interactions; reactions to industry relations policy; and management of industry interactions. Non-physician clinicians reported interacting with the pharmaceutical and infant formula industries. Clinicians across disciplines met with pharmaceutical representatives regularly and relied on them for practice information. Clinicians frequently received industry “information,” attended sponsored “education,” and acted as distributors for similar materials targeted at patients. Clinicians generally regarded this as an ethical use of industry resources, and felt they could detect “promotion” while benefiting from industry “information.” Free samples were among the most approved and common ways that clinicians interacted with industry. Included studies were observational and of varying methodological rigor; thus, these findings may not be generalizable. This review is, however, the first to our knowledge to provide a descriptive analysis of this literature.
Conclusions
Non-physician clinicians' generally positive attitudes toward industry interactions, despite their recognition of issues related to bias, suggest that industry interactions are normalized in clinical practice across non-physician disciplines. Industry relations policy should address all disciplines and be implemented consistently in order to mitigate conflicts of interest and address such interactions' potential to affect patient care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Making and selling health care goods (including drugs and devices) and services is big business. To maximize the profits they make for their shareholders, companies involved in health care build relationships with physicians by providing information on new drugs, organizing educational meetings, providing samples of their products, giving gifts, and holding sponsored events. These relationships help to keep physicians informed about new developments in health care but also create the potential for causing harm to patients and health care systems. These relationships may, for example, result in increased prescription rates of new, heavily marketed medications, which are often more expensive than their generic counterparts (similar unbranded drugs) and that are more likely to be recalled for safety reasons than long-established drugs. They may also affect the provision of health care services. Industry is providing an increasingly large proportion of routine health care services in many countries, so relationships built up with physicians have the potential to influence the commissioning of the services that are central to the treatment and well-being of patients.
Why Was This Study Done?
As a result of concerns about the tension between industry's need to make profits and the ethics underlying professional practice, restrictions are increasingly being placed on physician–industry interactions. In the US, for example, the Physician Payments Sunshine Act now requires US manufacturers of drugs, devices, and medical supplies that participate in federal health care programs to disclose all payments and gifts made to physicians and teaching hospitals. However, other health professionals, including those with authority to prescribe drugs such as pharmacists, Physician Assistants, and nurse practitioners are not covered by this legislation or by similar legislation in other settings, even though the restructuring of health care to prioritize primary care and multidisciplinary care models means that “non-physician clinicians” are becoming more numerous and more involved in decision-making and medication management. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers examine the nature and implications of the interactions between non-physician clinicians and industry.
What Did the Researchers Do and Find?
The researchers identified 15 published studies that examined interactions between non-physician clinicians (Registered Nurses, nurse prescribers, midwives, pharmacists, Physician Assistants, and dieticians) and industry (corporations that produce health care goods and services). They extracted the data from 16 publications (representing 15 different studies) and synthesized them qualitatively (combined the data and reached word-based, rather than numerical, conclusions) into eight outcome domains, including the nature and frequency of interactions, non-physician clinicians' attitudes toward industry, and the perceived ethical acceptability of interactions. In the research the authors identified, non-physician clinicians reported frequent interactions with the pharmaceutical and infant formula industries. Most non-physician clinicians met industry representatives regularly, received gifts and samples, and attended educational events or received educational materials (some of which they distributed to patients). In these studies, non-physician clinicians generally regarded these interactions positively and felt they were an ethical and appropriate use of industry resources. Only a minority of non-physician clinicians felt that marketing influenced their own practice, although a larger percentage felt that their colleagues would be influenced. A sizeable proportion of non-physician clinicians questioned the reliability of industry information, but most were confident that they could detect biased information and therefore rated this information as reliable, valuable, or useful.
What Do These Findings Mean?
These and other findings suggest that non-physician clinicians generally have positive attitudes toward industry interactions but recognize issues related to bias and conflict of interest. Because these findings are based on a small number of studies, most of which were undertaken in the US, they may not be generalizable to other countries. Moreover, they provide no quantitative assessment of the interaction between non-physician clinicians and industry and no information about whether industry interactions affect patient care outcomes. Nevertheless, these findings suggest that industry interactions are normalized (seen as standard) in clinical practice across non-physician disciplines. This normalization creates the potential for serious risks to patients and health care systems. The researchers suggest that it may be unrealistic to expect that non-physician clinicians can be taught individually how to interact with industry ethically or how to detect and avert bias, particularly given the ubiquitous nature of marketing and promotional materials. Instead, they suggest, the environment in which non-physician clinicians practice should be structured to mitigate the potentially harmful effects of interactions with industry.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001561.
This study is further discussed in a PLOS Medicine Perspective by James S. Yeh and Aaron S. Kesselheim
The American Medical Association provides guidance for physicians on interactions with pharmaceutical industry representatives, information about the Physician Payments Sunshine Act, and a toolkit for preparing Physician Payments Sunshine Act reports
The International Council of Nurses provides some guidance on industry interactions in its position statement on nurse-industry relations
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice website, which describes what is required of all registered doctors in the UK
Understanding and Responding to Pharmaceutical Promotion: A Practical Guide is a manual prepared by Health Action International and the World Health Organization that schools of medicine and pharmacy can use to train students how to recognize and respond to pharmaceutical promotion.
The Institute of Medicine's Report on Conflict of Interest in Medical Research, Education, and Practice recommends steps to identify, limit, and manage conflicts of interest
The University of California, San Francisco, Office of Continuing Medical Education offers a course called Marketing of Medicines
doi:10.1371/journal.pmed.1001561
PMCID: PMC3841103  PMID: 24302892
23.  Pharmacy study of natural health product adverse reactions (SONAR): a cross-sectional study using active surveillance in community pharmacies to detect adverse events associated with natural health products and assess causality 
BMJ Open  2014;4(3):e003431.
Objectives
To investigate the rates and causality of adverse event(s) (AE) associated with natural health product (NHP) use, prescription drug use and concurrent NHP-drug use through active surveillance in community pharmacies.
Design
Cross-sectional study of screened patients.
Setting
10 community pharmacies across Alberta and British Columbia, Canada from 14 January to 30 July 2011.
Participants
The participating pharmacy staff screened consecutive patients, or agents of patients, who were dropping or picking up prescription medications.
Primary outcome measures
Patients were screened to determine the proportions of them using prescription drugs and/or NHPs, as well as their respective AE rates. All AEs reported by the screened patients who took a NHP, consented to, and were available for, a detailed telephone interview (14%) were adjudicated fully to assess for causality.
Results
Over a total of 105 pharmacy weeks and 1118 patients screened, 410 patients reported taking prescription drugs only (36.7%; 95% CI 33.9% to 39.5%), 37 reported taking NHPs only (3.3%; 95% CI 2.4% to 4.5%) and 657 reported taking prescription drugs and NHPs concurrently (58.8%; 95% CI 55.9% to 61.6%). In total, 54 patients reported an AE, representing 1.2% (95% CI 0.51% to 2.9%), 2.7% (95% CI 0.4% to 16.9%) and 7.3% (95% CI 5.6% to 9.6%) of each population, respectively. Compared with patients who reported using prescription drugs, the patients who reported using prescription drugs and NHPs concurrently were 6.4 times more likely to experience an AE (OR; 95% CI 2.52 to 16.17; p<0.001). Combined with data from Ontario, Canada, a national proportion was calculated, which found that 45.4% (95% CI 43.8% to 47.0%) of Canadians who visit community pharmacies take NHPs and prescription drugs concurrently, and of those, 7.4% (95% CI 6.3% to 8.8%) report an AE.
Conclusions
A substantial proportion of community pharmacy patients use prescription drugs and NHPs concurrently; these patients are at a greater risk of experiencing an AE. Active surveillance provides a means of detecting such AEs and collecting high-quality data on which causality assessment can be based.
doi:10.1136/bmjopen-2013-003431
PMCID: PMC3975764  PMID: 24682573
Complementary Medicine; Toxicology
24.  Use of natural health products in children 
Canadian Family Physician  2013;59(8):e372-e378.
Abstract
Objective
To gain a more thorough understanding of why parents choose to give their children natural health products (NHPs), parents’ sources of information about NHPs, and the extent of disclosure and conversation with family doctors about the use of NHPs.
Design
Qualitative study.
Setting
Newfoundland and Labrador.
Participants
Parents of children who were using NHPs (N = 20).
Methods
Individual, semistructured interviews were carried out with parents to obtain a better understanding of the reasoning behind the use of NHPs. Key themes emerging from the qualitative data were identified according to a number of criteria, including relevance to the research objectives, frequency with which a theme was mentioned, relative importance of the themes based on the amount of text taken up to address an issue, and emphasis (eg, emphatic or emotional speech).
Main findings
The types of NHPs used by parents participating in this study varied, except for the use of multivitamins. In addition, use of the products themselves was variable and inconsistent. Parents reported few concerns about the use of NHPs. The most commonly reported source of information about NHPs was family and friends. Most participants had not spoken to their family doctors about the use of NHPs.
Conclusion
Participants considered NHPs to be “natural” and seemed to equate this assessment with safety. This might explain why these parents sought advice and information from family and friends rather than from their family doctors and often failed to disclose the use of NHPs to their children’s family doctors.
PMCID: PMC3743714  PMID: 23946044
25.  New Canadian natural health product regulations: a qualitative study of how CAM practitioners perceive they will be impacted 
Background
New Canadian policy to regulate natural health products (NHPs), such as herbs and vitamins were implemented on January 1st, 2004. We explored complementary and alternative medicine (CAM) practitioners' perceptions of how the new regulations may affect their practices and relationships with patients/consumers.
Methods
This was an applied ethnographic study. Data were collected in fall 2004 via qualitative interviews with 37 Canadian leaders of four CAM groups that use natural products as a core part of their practises: naturopathic medicine, traditional Chinese medicine (TCM), homeopathic medicine and Western herbalism. All interviews were transcribed verbatim and coded independently by a minimum of two investigators using content analysis.
Results
Three key findings emerged from the data: 1) all CAM leaders were concerned with issues of their own access to NHPs; 2) all the CAM leaders, except for the homeopathic leaders, specifically indicated a desire to have a restricted schedule of NHPs; and 3) only naturopathic leaders were concerned the NHP regulations could potentially endanger patients if they self-medicate incorrectly.
Conclusion
Naturopaths, TCM practitioners, homeopaths, and Western herbalists were all concerned about how the new NHP regulations will affect their access to the products they need to practice effectively. Additional research will need to focus on what impacts actually occur as the regulations are implemented more fully.
doi:10.1186/1472-6882-6-18
PMCID: PMC1481533  PMID: 16686960

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