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An evaluation of senior pharmacy students' perceptions and knowledge of complementary and alternative medicine at a Malaysian university.

INTRODUCTION

The popularity of complementary and alternative medicine (CAM) utilization and practice has dramatically increased in a number of countries during the past decade. CAM therapies are usually promoted on the basis of both their therapeutic and economic values. The growth of CAM is demonstrated by the number of visits to alternative care practitioners, which rose from 427 million in 1990 to 629 million in 1997 in the United States, as well as by estimated spending there on alternative therapies not covered by health insurance (termed out-of-pocket spending) of 27 billion dollars in 1997. (1) According to a World Bank report, the global herbal and natural products market is expected to grow to US$5 trillion by 2050. Use of CAM among women in mid-life, particularly those with high educational levels, is the highest of all groups in the US. (2) A study by Wilson et al. (3) reported that 79% of 1280 adolescents had used CAM in their lifetime. CAM may include acupressure, acupuncture, Alexander technique, applied kinesiology, anthroposophic medicine, aromatherapy, ayurveda, chiropractic, environmental medicine, healing, herbal medicine, homoeopathy, hypnosis, massage therapies, meditation, naturopathy, nutritional therapy, osteopathy, reflexology, reiki, relaxation and visualization, shiatsu, therapeutic touch and yoga. (4) In the United Kingdom at least one in 10 specialist physicians is actively involved in CAM treatments, but only 13% have received any kind of CAM training. (5) In 1997 herbal products sales in the US were estimated to be as high as $5.1 billion and many of these occurred in community pharmacies. (6) Discussions about CAM with patients are important because of the potential for dangerous adverse interactions between CAM and other pharmacotherapeutic agents. It is therefore important to ascertain what pharmacists and pharmacy students know and believe about CAM so as to assess whether they receive sufficient information about CAM. Malaysia is rated in the top 12 countries with the widest diversity of plants in the world. Malaysia has about 15,000 known plant species, of which 3700 have medicinal value and are used for traditional therapy and to produce food and food additives. (7) Several studies related to CAM courses, usage, perception and knowledge have been conducted in other countries, including the US (6,8,9), UK (10,5,11), Australia (12,13), Singapore (14), Thailand (15,16), and Hong Kong (17). In the US, for example, 36 schools offered didactic courses in herbal medicine or other areas of CAM. (9) A study by Mackowiak et al. (6) which examined the extent of use and knowledge of herbal drugs by United States pharmacy students found that the average score was 32%. A study in Singapore found that the training in Traditional Chinese Medicine (TCM) in a 3 year pharmacy curriculum was apparently inadequate to meet students' needs. (17) Most pharmacy schools in Malaysia do not include in-depth courses related to CAM in their curricula. Pharmacists may therefore be inadequately equipped to provide effective patient education and to guide the selection of CAM products. This study was conducted among senior pharmacy students at Universiti Sains Malaysia (USM) to ascertain their perceptions of CAM and the adequacy of their course in CAM training.

METHOD

A cross-sectional survey using a 20-item questionnaire was conducted among senior (fourth year) pharmacy students at USM. The data were collected from December 2007 to February 2008. The questionnaire was developed from relevant literature review and previous studies. It was subjected to face and content validation and later pre-tested among 10 pharmacy students to ensure clarity and lack of ambiguity of content. The validations were carried out by four pharmacy faculty members involved in teaching the CAM course. The survey instrument comprised 3 parts: demographic data of the respondents; 10 items to evaluate the students' perceptions about CAM and curriculum using a 5-point Likert scale; and 10 items to assess knowledge involving therapeutic use of herbal products and plants that are popular in Malaysia such as Gnoderma, Gingko Biloba, St John's Wort, Tongkat Ali (Eurycoma longifolia) and green tea.

The results were analyzed using SPSS, version 14.0 and Microsoft[R] Excel. Descriptive statistics involving frequencies and percentages were used for data analysis. The five-point scale used for the items on perception was collapsed into a three-point scale (i.e. disagree, undecided, agree). Non-parametric tests including the Mann-Whitney U-test and the Kruskal-Wallis test were used whenever appropriate. The level of significance was set at p < 0.05. This study was approved by the Dean of School of Pharmaceutical Sciences, USM in 2007. Participants were informed in the cover letter of the questionnaire that their answering the questionnaire implied voluntary consent.

RESULTS

One hundred and thirty-two questionnaires were distributed among final year pharmacy students, of whom 96 responded (response rate 72.7%). The sample consisted of 66 females (69%) and 30 males (31%). Ninety students (94%) students did not use any form of CAM. The mean age of students was 22.92 ([+ or -] 0.72) years. Seventy-nine percent of the students agreed that CAM is an area that pharmacy should pursue aggressively and about 53% believed that there is sufficient evidence to support the use of some alternative therapies. However, more than half of the students did not know whether they would refer a patient to a CAM practitioner. The majority (69.4%) plan to stock natural products in their pharmacies. A large proportion (84%) of the students believed that clinical care should integrate the best of conventional and CAM practice. Furthermore, about 44% of respondents did not agree that CAM is very safe to use and 46.9% were unsure. Nearly 90% of respondents agreed that health professionals should be able to advise their patients about commonly used CAM practices and that knowledge about CAM is important to them as future pharmacy practitioners. Concerning respondents' perceptions about school curricula. 36.5% did not agree that they had received sufficient knowledge to advise patients about use of CAM. Details of the students' responses are presented in Table 1.

The analysis of total scores on knowledge about CAM showed that the majority of the students scored an average of 7.18 [+ or -] 1.41 out of 10. The knowledge questions were divided into two categories (elementary and advanced), with 5 questions in each. For the elementary questions, the students were asked to answer five general questions about CAM that are popular in Malaysia, such as herbal medicines Kacip Fatima and Gingko Biloba, and chiropractic. The students' accuracy in answering elementary-type questions was good: approximately 48% scored 100% (mean [+ or -] SD score was 4.26 [+ or -] 0.86. Only 31% achieved 80% or above for the advanced questions which included more specific disease-herb and drug-herb interactions and some contraindications.

DISCUSSION

This study found that senior pharmacy students at USM have a great interest in and positive perceptions about CAM. The findings were to some extent similar to those reported in another study which focused on CAM education in US' pharmacy schools. (9) This might be explained by the USM students having taken a core (required) course which had exposed them to common CAM during their third academic year.

CAM is important to the respondents as future pharmacy practitioners. Most respondents admitted that they would stock and sell natural products in their pharmacies in their future practices. There was a difference in plans for CAM use between the students in the present study and those at a school of pharmacy in Hong Kong (6% vs. 50%). (17) Morgan et al. (11) assessed the provision of education in CAM in medical schools, faculties of nursing and science/health studies in the UK and found that the total number of modules in CAM was more common in nursing than medical courses. Another study found that nursing students' knowledge and understanding about CAM therapies in general, was limited.(18) Despite the fact that some herbal medicines possess outstanding safety and efficacy profiles and often outsell prescription medications in countries like Germany and France, potential adverse effects or harmful interactions between CAM and conventional therapies (e.g. between St. John's Wort and serotonin reuptake inhibitors) may occur. (4,10,16,18) In order to provide comprehensive pharmaceutical care, pharmacists must have knowledge of such issues concerning CAM therapy. Fewer than one-third of the senior pharmacy students in this study could achieve a score of 80% and above (considered good knowledge) in the advanced questions. The majority, therefore, were not deemed to have attained the knowledge needed to demonstrate competence in CAM. This might reflect the inadequacy of training in CAM in the current pharmacy curriculum at USM. Even though all the students had taken a compulsory course related to CAM in their third year of study, the findings suggested that a review of the current course is warranted. A study by Rickert et al. (19) reported that, except for students who did personal research on herbal remedies, all students' mean scores in knowledge assessment questions were less than 50% of possible marks. In his 1999 study, he showed that pharmacy students scored a mean of 32% when questioned on the therapeutic use and adverse effects of many herbal remedies. Pharmacists often need to discuss CAM with their customers and help them differentiate useful approaches/remedies that have been shown by clinical evidence to be beneficial from those that have not. Similar studies need to be conducted in other pharmacy schools in Malaysia since curricula vary and the generalizability of our findings is somewhat limited.

CONCLUSION

This study showed that senior pharmacy students at USM overall had a positive perception of CAM, but the level of their knowledge about CAM was inadequate. A review of the pharmacy curriculum at USM is warranted in order to introduce comprehensive CAM courses.

REFERENCES

(1.) Neldner HK. Complementary And Alternative Medicine. Dermatologic Clinics. 2000;18(1):189-93.

(2.) Gollschewski S, Kitto S, Anderson D, Lyons-Wall P. Women's perceptions and beliefs about the use of complementary and alternative medicines during menopause. Complementary Therapies in Medicine. In Press, Corrected Proof:1378.

(3.) Wilson KM, Klein JD, Sesselberg TS, Yussman SM, Markow DB, Green AE, et al. Use of complementary medicine and dietary supplements among U.S. adolescents. Journal of Adolescent Health. 2006;38(4):385-94.

(4.) Vickers C. ABC of complementary medicine. BMJ. 1999;319(693):696.

(5.) Lewith GT, Hyland M, Gray SF. Attitudes to and use of complementary medicine among physicians in the United Kingdom. Complementary Therapies in Medicine. 2001;9(3):167-72.

(6.) Mackowiak ED, Parikh A, Freely J. Herbal Product Education in United States Pharmacy Schools: Core or Elective Program? AJPE 2001;65.

(7.) Muhammad BY, Awaisu A. The need for enhancement of research, development, and commercialization of natural medicinal products in Nigeria: Lessons from the Malaysian experience. Afr J Trad. 2008;5(2): 120 - 30.

(8.) Frye AW, Sierpina VS, Boisaubin EV, Bulik RJ. Measuring what medical students think about complementary and alternative medicine (CAM): A pilot study of the complementary and alternative medicine survey. Adv Health Sci Educ Theory Pract. 2006;11(1):19-32.

(9.) Donna M, Rowell, J. D, Kroll. Complementary and Alternative Medicine Education in United States Pharmacy Schools. AJPE. 1998;62.

(10.) Scott JA, Kearney N, Hummerston S, Molassiotis A. Use of complementary and alternative medicine in patients with cancer: A UK survey. European Journal of Oncology Nursing. 2005;9(2):131-7.

(11.) Morgan D, Glanville H, Maris S, Nathanson V. Education and training in complementary and alternative medicine: a postal survey of UK universities, medical schools and faculties of nurse education. Complement Ther Med 1998;6(2):64-70.

(12.) Braun LA, Cohen MM. Australin hospital pharmacists' attitudes, perceptions, knowledge and practices of CAM. J Pharm Pract Res. 2007;37(3).

(13.) Dean A. Managing requests for complemantary and alternative medicines: What is the pharmacist's role? Aust Pharm. 2005;24(7).

(14.) Lim MK, Sadarangani P, Chan HL, Heng JY. Complementary and alternative medicine use in multiracial Singapore. Complementary Therapies in Medicine. 2005;13(1):16-24.

(15.) Riewpaiboon A. Increasing herbal product consumption in Thailand. Pharmacoepidemiol Drug Saf. 2006;15:683-6.

(16.) Kanjanarach T, Krass I, Cumming RG. Exploratory study of factors influencing practice of pharmacists in Australia and Thailand with respect to dietary supplements and complementary medicines. IJPP. 2005;14:123-8.

(17.) Hon EKL, Lee K, Tse HM, Lam LN, Tam KC, Chu KM, et al. A survey of attitudes to Traditional Chinese Medicine in Hong Kong pharmacy students. Complementary Therapies in Medicine. 2004;12(1):51-6.

(18.) Uzun O, Tan M. Nursing students' opinions and knowledge about complementary and alternative medicine therapies. Complement Ther Nurs Midwifery. 2004;10(4):239-44.

(19.) Rickert K, Martinez, R.R., Martinez TT. Pharmacist knowledge of common herbal preparations,. Proc West Pharmacol Soc. 1999;42:1-2.

Sarmed Nabhan Yaseen Al-Dulaimy, B.Pharm, M.Pharm (Clin Pharm); Mohamed Azmi Ahmad Hassali M.Pharm (Clin Pharm), Ph.D, School of Pharmaceutical Sciences, Universiti Sains Malaysia; Ahmed Awaisu M.Pharm (Clin. Pharm), Ph.D, School of Pharmaceutical Sciences, Universiti Sains Malaysia
Table 1: Perceptions of CAM *SA: Strongly Agree, AG: Agree,
NT Neutral, DA: Disagree, SD: Strongly Disagree

Item                                                      STA*,n (%)

1. Alternative therapies are an area I believe             24 (25%)
pharmacy as a profession should pursue aggressively.

2. Sufficient evidence exists which supports the use       11 (11.5%)
of some alternative therapies.

3. I would refer a patient/ client to an alternative        2 (2.1%)
therapy practitioner.

4. In my future practice, I'll stock natural products       9 (9.4%)
related to naturopathy in my pharmacy.

5. Clinical care should integrate the best of              24 (25%)
conventional and CAM practice.

6. CAM is very safe to use.                                 0 (0%)

7. Health professionals should be able to advice their     26 (27.1%)
patients about commonly used CAM methods.

8. Knowledge about CAM is important to me as a future      34 (35.4%)
pharmacy practitioner.

9. Topics on CAM are well covered in my school.             1 (1%)

10. I have received sufficient knowledge to advice          1 (1%)
patient about usage of CAM.

Item                                                      AG*, n (%)

1. Alternative therapies are an area I believe             52 (54%)
pharmacy as a profession should pursue aggressively.

2. Sufficient evidence exists which supports the use       40 (41.7%)
of some alternative therapies.

3. I would refer a patient/ client to an alternative       24 (25%)
therapy practitioner.

4. In my future practice, I'll stock natural products      58 (60%)
related to naturopathy in my pharmacy.

5. Clinical care should integrate the best of              57 (59.4%)
conventional and CAM practice.

6. CAM is very safe to use.                                 8 (8.3%)

7. Health professionals should be able to advice their     60 (62.5%)
patients about commonly used CAM methods.

8. Knowledge about CAM is important to me as a future      52 (54.2%)
pharmacy practitioner.

9. Topics on CAM are well covered in my school.            32 (32.3%)

10. I have received sufficient knowledge to advice         16 (16.7%)
patient about usage of CAM.

Item                                                      NT*, n (%)

1. Alternative therapies are an area I believe             16 (16.7%)
pharmacy as a profession should pursue aggressively.

2. Sufficient evidence exists which supports the use       29 (30.2%)
of some alternative therapies.

3. I would refer a patient/ client to an alternative       52 (54%)
therapy practitioner.

4. In my future practice, I'll stock natural products      25 (27.1%)
related to naturopathy in my pharmacy.

5. Clinical care should integrate the best of              12 (12.5%)
conventional and CAM practice.

6. CAM is very safe to use.                                45 (46.9%)

7. Health professionals should be able to advice their      9 (9.4%)
patients about commonly used CAM methods.

8. Knowledge about CAM is important to me as a future       9 (9.4%)
pharmacy practitioner.

9. Topics on CAM are well covered in my school.            50 (52.1%)

10. I have received sufficient knowledge to advice         42 (43.8%)
patient about usage of CAM.

Item                                                      DA*, n (%)

1. Alternative therapies are an area I believe              4 (4.2%)
pharmacy as a profession should pursue aggressively.

2. Sufficient evidence exists which supports the use       16 (16.7%)
of some alternative therapies.

3. I would refer a patient/ client to an alternative       16 (16.7%)
therapy practitioner.

4. In my future practice, I'll stock natural products       3 (3.1%)
related to naturopathy in my pharmacy.

5. Clinical care should integrate the best of               2 (2.1%)
conventional and CAM practice.

6. CAM is very safe to use.                                37 (38.5%)

7. Health professionals should be able to advice their      1 (1%)
patients about commonly used CAM methods.

8. Knowledge about CAM is important to me as a future       0 (0%)
pharmacy practitioner.

9. Topics on CAM are well covered in my school.            13 (13.5%)

10. I have received sufficient knowledge to advice         35 (36.5%)
patient about usage of CAM.

Item                                                      SD*, n (%)

1. Alternative therapies are an area I believe              0 (0%)
pharmacy as a profession should pursue aggressively.

2. Sufficient evidence exists which supports the use        0 (0%)
of some alternative therapies.

3. I would refer a patient/ client to an alternative        0 (0%)
therapy practitioner.

4. In my future practice, I'll stock natural products       0 (0%)
related to naturopathy in my pharmacy.

5. Clinical care should integrate the best of               0 (0%)
conventional and CAM practice.

6. CAM is very safe to use.                                 5 (5.2%)

7. Health professionals should be able to advice their      0 (0%)
patients about commonly used CAM methods.

8. Knowledge about CAM is important to me as a future       1 (1%)
pharmacy practitioner.

9. Topics on CAM are well covered in my school.             1 (1%)

10. I have received sufficient knowledge to advice          2 (2.1%)
patient about usage of CAM.
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Article Details
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Author:Dulaimy, Sarmed Nabhan Yaseen Al-; Hassali, Mohamed Azmi Ahmad; Awaisu, Ahmed
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Report
Geographic Code:9MALA
Date:Mar 1, 2012
Words:2937
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