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JPHS 2019, 10; 57–66 ª 2018 Royal Pharmaceutical Society Received January 29, 2018 Accepted May
JPHS 2019, 10; 57–66 ª 2018 Royal Pharmaceutical Society Received January 29, 2018 Accepted May
JPHS 2019, 10; 57–66 ª 2018 Royal Pharmaceutical Society Received January 29, 2018 Accepted May

JPHS 2019, 10; 57–66 ª 2018 Royal Pharmaceutical Society Received January 29, 2018 Accepted May 5, 2018 DOI 10.1111/jphs.12238 ISSN 1759-8885

Correspondence: Phantipa Sakthong, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Phayathai Road, Pathumwan, Bangkok 10330, Thailand. E-mail:

phantipa.s@pharm.chula.ac.th

Research Paper

Qualitative exploration of pharmacist care for herbal and dietary supplement users in Thai community pharmacies

Mohd Shahezwan Abd Wahab a,b Win Winit-Watjana c

a Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand, b Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA Cawangan Selangor, Puncak Alam, Malaysia and c Department of Clinical Pharmacy, Faculty of Pharmacy, Srinakharinwirot University, Nakhon Nayok, Thailand

Srinakharinwirot University, Nakhon Nayok, Thailand , Phantipa Sakthong a and Abstract Objectives Herbal

, Phantipa Sakthong a and

Abstract

Objectives Herbal and dietary supplements (HDS) can cause adverse effects or interact with diseases and medications. Community pharmacists have a role in ensuring the safe use of HDS, but they have been reported to not being proactive in providing pharmacist care (PCare) for HDS users. The reasons for this warranted investigation. The study aimed to explore pharmacists understanding of PCare for HDS users, and to investigate the underlying beliefs or factors in uencing its provision by community pharmacists, guided by the theory of planned behaviour. Methods A qualitative study using a semi-structured interview guide was conducted in a purposive sample of community pharmacists working in Bangkok, Thailand, from December 2016 to June 2017. All interviews were audio-recorded, transcribed and anal- ysed using qualitative content analysis. Key findings Twenty-two pharmacists were interviewed. Several professional pharmacy activities were regarded as PCare for HDS users. The pharmacists reported that the provi- sion of such care was advantageous in terms of promoting rational use of HDS, ensuring safety of users, enhancing own knowledge and promote customers loyalty. Facilitators for PCare included the initiation of conversation about HDS by the users, professional training and the availability of reference materials. The reluctance of HDS users to accept pharmacists opinions, insufcient education in HDS and limited sources of information were identied as barriers. Most pharmacists believed that PCare for HDS users is part of their responsibilities. Conclusions The pharmacists expressed their views on the meaning of PCare for HDS users, and described the beliefs and factors that facilitate or impede its provision. Infor- mation from this study can be used to inform strategies that can promote pharmacists to become more proactive in providing PCare for HDS users. Keywords community pharmacist; herbal and dietary supplements; pharmacist care; Thailand; theory of planned behaviour

Introduction

Herbal and dietary supplements (HDS) have been commonly perceived as effective, and safe. [ 1 ] Many individuals use HDS to prevent or treat diseases, or enhance the effects of conventional therapies. [ 2 ] The use of HDS is generally driven by the motivation to have more control over one s health. [ 3 ] Although some HDS have been shown to be effective in certain health conditions, [ 4 ] many of the products lack clinical evidence. [ 5 ] Moreover, the use of HDS can also bring about a number of complications that can be the cause for emergency department visits and hospitalisations. [ 6 ] The use of HDS is common in many countries, including the United States, Australia, Denmark, Germany, and South Korea. [ 7 ] In Thailand, based on the purpose for which the HDS are intended, and the availability of evidences for safety, ef cacy, and quality, the products can be classi ed as foodor medicineby the Thai Food and Drug Administra- tion. [ 8 ] These products are predominantly available over the counter in community phar- macies in Thailand. [ 9 ] In a survey by Tangkiatkumjai et al., the prevalence of HDS use among the Thai general population was 52%. [ 10 ] Of these HDS users, 58.4% consumed

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58 Journal of Pharmaceutical Health Services Research 2019; 10: 57–66

herbal medicines to treat illnesses, whereas 65.3% made use

of dietary supplements to enhance their well-being. More-

over, the consumption of HDS was also reported to be com- mon in Thai patients with chronic diseases who were also using modern medicines. [ 2,3 ] This pattern of consumption poses a potential problem because prescribed medicines may interact with the HDS, and thus may cause treatment failure or toxicity. [ 11 ] Additionally, patients with chronic dis- eases are not likely to disclose their HDS consumption to the healthcare providers and therefore, HDS-drug or HDS-

disease interactions, together with the resultant adverse effects, may go unnoticed. [ 2,12 ] Since community pharmacies are the main providers of HDS for the public, community pharmacists can have a vital role in ensuring the safe use of HDS. [ 13 ] A few systematic reviews indicated that although pharmacists generally have positive attitudes towards their role in providing pharmacist

care (PCare) for HDS users, their engagement in the PCare activities was found to be low. [ 13,14 ] In particular, pharma- cists seldom assess the needs of HDS use among users, mon- itor the ef cacy and safety of HDS, or communicate with

the users about their HDS use. There is a paucity of informa-

tion as to why pharmacists were not proactive in providing

PCare for HDS users, warranting further investigation.

The theory of planned behaviour (TPB) has been shown

to be useful in predicting the behavioural intentions and

actual behaviours of healthcare professionals including the pharmacists. [ 15 ] Compared to the other decision-making models, the TPB also highlights social in uences on beha- vioural performance. Previous studies showed that the social in uences are essential determinants for pharmacists inten- tions to perform various pharmacist activities. [ 16,17 ] The TPB therefore is considered a useful theoretical framework for

the present study. To date, there is a lack of study that uti- lises the TPB to uncover beliefs and factors in uencing the provision of PCare for HDS users. Additionally, previous studies were mainly focused on the attitudes of pharmacists towards the HDS in general, and rarely put emphasis on the behaviour of providing PCare for HDS users. This study was therefore aimed to explore the understanding about PCare for HDS users, and to investigate the beliefs and fac- tors underlying the behaviour among a sample of Thai com- munity pharmacists. In order to gain insights into the

pharmacists beliefs, and other internal and external factors,

a qualitative rather than quantitative exploration was adopted.

Methods

The qualitative study was approved by the Research Ethics Review Committee for Research Involving Human Research Participants at Chulalongkorn University (COA: 189/2016). Findings of the study were reported in accordance with the consolidated criteria for reporting qualitative research check- list (Appendix S1). [ 18 ] The study was conducted in Bang- kok, Thailand, from December 2016 to June 2017. HDS refers to products containing plant-derived materials, or con- taining dietary ingredients e.g., vitamins, minerals, amino acids and substances such as enzymes, organ tissues,

glands, metabolites, extracts and concentrates in the form of pills, capsules, tablets, powder or liquids that are taken to treat and/or prevent diseases or maintain health. [ 19,20 ] In this study, all professional activities carried out by pharmacists when dealing with HDS users e.g., the collection of HDS users medication and medical history, and the provision of counselling were referred to as pharmacist care . This de - nition was chosen to avoid confusion with the term phar- maceutical care that concerns on the optimisation of medication use. [ 21 ] Moreover in Thailand, pharmaceutical care has been frequently associated with activities such as advice about medicines, home medical care, and lifestyle modi cation, and rarely incorporate the aspects of HDS use. [ 22 ] The term PCare has been used in previous published studies. [ 23 ]

Study design

A face-to-face semi-structured interview was used to elicit pharmacists beliefs about PCare for HDS users. For this study, an extended TPB framework was adopted (Figure 1). The framework proposes that the intention to provide PCare for HDS users is the antecedent to its actual provision. The intention is fundamentally predicted by three determinants i.e., attitudes, subjective norms and perceived behavioural control. [ 24 ] Attitudes refer to the pharmacists overall evalua- tion of the behaviour (the provision of PCare for HDS users), which includes the advantages and drawbacks of the behaviour performance. Subjective norms relate to the phar- macists feeling of social pressure from signi cant people to perform the behaviour. Perceived behavioural control is the perceived ability of pharmacists to perform the target beha- viour. Three salient beliefs i.e., behavioural, normative and control beliefs are the underlying factors that in uence atti- tudes, subjective norms and perceived behavioural control respectively. Apart from the original constructs of the TPB framework, a construct for the professional norm was included as this element has been shown to be an important determinant for pharmacists intention to engage in various pharmacists activities. [ 25,26 ] The phenomenology approach which focuses on the understanding of pharmacists subjec- tive experiences was chosen as the methodological orienta- tion to underpin the present study. This premise was considered apt due the descriptive nature of this research. [ 27 ]

Community pharmacists

Community pharmacists who were working in Bangkok, Thailand were purposively sampled. Pharmacists were included if they were registered pharmacists working in any type of community pharmacy that supplies the HDS, and were able to communicate in the English language. Excluded were those who only performed administrative or procurement duties without any interaction with the cus- tomers. Initially, ve pharmacists who were the key persons in community pharmacy practice in Bangkok, Thailand were recommended from the researchers professional net- work. The subsequent informants were recruited using the snowball technique. Additionally, the maximum variation sampling was employed to ensure the informants were

PCare for HDS users in Thai community pharmacies

Mohd Shahezwan Abd Wahab et al.

59

community pharmacies Mohd Shahezwan Abd Wahab et al. 59 Figure 1 Conceptual framework guided by the

Figure 1 Conceptual framework guided by the extended Theory of Planned Behavior for exploring the provision of phar- macist care for herbal and dietary supplement (HDS) users.

diversied in terms of characteristics (e.g., gender, years of working experiences, and employment status). The number of informants was nalised when the answers to all queries were saturated with no new or valuable information emerged from the interviews. Of all the pharmacists con- tacted, only two refused to be interviewed due to other commitments.

Study tool

For the semi-structured interviews, an interview guide was developed based on the extended TPB framework (Table 1). The face validity of the guide was checked by four experts in PCare from Chulalongkorn University and one experi- enced community pharmacist. It was then piloted among four registered community pharmacists. The questions were then amended accordingly to improve the clarity.

Data collection

The eligible pharmacists were contacted via telephone to arrange for the time and place of interview. All informants had no previous relationship with the authors. The inter- views took place either at the investigators site or at the informants workplaces. Prior to each session, the infor- mants were briefed about the study, and completed a writ- ten consent form. MSAW, a male researcher who is also a pharmacist, performed all interviews in English, using the interview guide described earlier to reduce interviewer bias by maintaining the consistency in the ow and technique of interview. The use of interpreter was not necessary since all of the informants were uent in English. To min- imise the possibility of inuencing the way the informants responded to questions, the interviewer simply introduced himself as a researcher. Probing questions were used to clarify the meaning of the informants responses. Each of the interview was audio-recorded, and eld notes were taken. An interview session lasted approximately 1 h. At

Table 1 Interview guide for interviews with community pharmacists

Category

Question

Behavioural understanding

In your opinion, what is PCare for HDS users? Can you provide examples?

Behavioural

Positive

In your opinion, what are the benets

belief

(or advantages) of PCare for HDS

 

Negative

users? In your opinion, what are the disadvantages (or drawbacks) of PCare for HDS users?

Normative

Approval

Who do you believe would encourage

belief

you to provide PCare for HDS users?

 

Disapproval Who would discourage you to provide PCare for HDS users?

Control belief

Facilitator

What are the factors that help (or

Barrier

facilitate) you to provide PCare for HDS users? What are the factors that make it

Professional

difcult for (or prevent) you to provide PCare for HDS users? As a pharmacist do you think you

normative

have to provide PCare for HDS

belief

users? Why or why not?

Other factors

Would you like to provide any other opinions or information about PCare for HDS users?

HDS, herbal and dietary supplement; PCare, pharmacist care.

the end of the interviews, all informants were debriefed, and requested to ll out a short questionnaire to record their demographic details. No repeat interviews were required. As the primary researcher, MSAW has received the necessary training to conduct a qualitative research, and had previously involved in multiple research projects related to the HDS.

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Journal of Pharmaceutical Health Services Research 2019; 10: 57–66

Table 2 Characteristics of community pharmacists

Informant

Age Gender Years working at current pharmacy

Pharmacy

type

Employment

Approximate daily number of customers

Daily number of customers requesting for HDS*

Number of HDS users provided with PCare

code

status

CP01

28

Female

3

Chain

Full-time

1300

3

7

CP02

32

Female

3

Independent Full-time

30

3

3

CP03

28

Male

3

Chain

Part-time

100

5

5

CP04

29

Female

5

Chain

Part-time

100

7

10

CP05

35

Female

5

Independent Full-time

20

6

6

CP06

29

Male

3

Chain

Full-time

100

2

6

CP07

33

Female

1

Independent Full-time

70

1

5

CP08

29

Male

3

Chain

Full-time

150

5

8

CP09

34

Female

7

Independent Full-time

150

6

8

CP10

32

Male

1

Independent Full-time

60

2

10

CP11

29

Female

5

Chain

Part-time

60

2

8

CP12

26

Female

1

Chain

Full-time

80

5

2

CP13

26

Male

1

Chain

Part-time

50

3

8

CP14

24

Female

1

Chain

Full-time

500

2

7

CP15

26

Male

1

Chain

Full-time

500

3

8

CP16

65

Male

33

Independent Full-time

100

3

7

CP17

34

Female

1

Independent Full-time

30

5

5

CP18

27

Female

4

Chain

Part-time

400

7

4

CP19

30

Male

6

Independent Part-time

300

8

5

CP20

26

Female

4

Independent Part-time

50

7

7

CP21

42

Male

2

Independent Part-time

400

2

1

CP22

37

Female

2

Independent Full-time

30

4

2

HDS, herbal and dietary supplements; PCare, pharmacist care. *Estimated for daily customers requesting for the HDS based on 10 customers. Estimated for HDS users provided with PCare based on 10 HDS users.

Data analysis

All audio les were given identication codes to maintain the informants con dentiality, and were then transcribed by one of the researchers. The accuracy of the transcription was con rmed by a co-researcher. The data were entered into ATLAS.ti version 7.5.17 (GmbH, Berlin, Germany), and were analysed line-by-line using qualitative content analysis (QCA). Using the QCA, data that were relevant to the research questions, were organised and grouped together under an appropriate category based on the extended TPB framework described earlier. [ 28 ] The QCA was conducted by the primary author. Check coding (peer audit) was employed to promote rigor by comparing the primary authors interpretations with those of the other research- ers. [ 29 ] The research team convened in multiple meetings to discuss data coding, categorisation, and interpretations, thereby ensuring the credibility and con rm-ability of the ndings.

Results

A total of 22 community pharmacists were interviewed. Sat- uration of answers was achieved after the 20th interview. Additional two interviews, one with a male and another with a female pharmacist, con rmed data saturation. As demonstrated in Table 2, 59.1% (13/22) of the informants were female. The mean age of the informants was 32 years old (range: 24 65 years). The average working years at the

pharmacy was 4.32 years (range: 133 years). Half of the informants were working in independent community phar- macies, and the rest were employed by chain community pharmacies. About two-thirds of them (14/22, 63.6%) were full-timers. For their pharmacies, the approximate daily number of customers ranged from 20 to 1300 persons. According to their estimation, out of 10 customers, one to eight persons would request for HDS. When asked to approximate their provision of PCare based on 10 HDS users, only two pharmacists asserted they were able to deli- ver PCare for all 10 users. About 40% (9/22) of the infor- mants estimated that they were able to provide PCare only to ve or fewer people out of 10 HDS users. The main themes of behavioural understanding, and the underlying beliefs or factors inuencing the provision of PCare for HDS users are summarised in Table 3. Although the phar- macists were diverse in characteristics, the understanding of PCare for HDS users, and the underlying beliefs and factors for its provision were generally congruent.

Understanding of pharmacist care for herbal and dietary supplement users

The pharmacists expressed their views on what constitutes PCare for HDS users . Six main themes were extracted for the pertinent activities. Giving advice or counselling on HDS use was the most common activity reported by the pharmacists. The advice was focused on the instruction for

PCare for HDS users in Thai community pharmacies

Table 3 Main themes of behavioural understanding, and the underly- ing beliefs and factors inuencing the provision of PCare for HDS users

Main theme

Understanding of PCare for HDS users Giving advice or counselling on HDS use (18/22) Gathering relevant information from HDS users (17/22) Making a professional decision or suggestion for HDS use (15/22) Performing thorough assessment of HDS use (12/22) Providing sufcient information for assisting customersdecisions

(12/22)

Fostering pharmacist customer relationship (8/22) Underlying beliefs and factors inuencing the provision of PCare for HDS users Behavioural beliefs Advantages Related to HDS users Ensuring the rational use of HDS (16/22) Ensuring the safety of HDS users (14/22) Related to pharmacists Improving pharmacistsown knowledge (8/22) Making pharmacists more trustworthy (5/22) Providing pharmacists with self-satisfaction (5/22) Related to community pharmacies Promoting loyalty among customers (9/22) Attracting customers (2/22) Enhancing the image of community pharmacy (2/22) Disadvantage Time-consuming (1/22) Normative beliefs Approval HDS users (13/22) Co-workers (4/22) Doctors (2/22) Thai Food and Drug Administration (1/22) Pharmaceutical companies (1/22) Disapproval Family members of HDS users (1/22) Control beliefs Facilitators Related to HDS users Conversation on HDS initiated by HDS users (15/22) HDS users with characteristics that are perceived as easy to be provided with PCare (6/22) HDS users who showed trust in pharmacists (5/22) Willingness of the HDS users to spend time for receiving PCare (4/22) Related to pharmacists Professional training (11/22) Perceived expertise in HDS (11/22) Having supporting staffs or assistants (6/22) Having more time allocation (5/22) Having sufcient education in HDS from the undergraduate program (4/22) Related to community pharmacies Availability of reference materials about HDS (14/22) Access to the Internet (10/22) Access to scientic evidence for HDS (7/22) Barriers Related to HDS users Reluctance to accept pharmacistsopinions about HDS use

(14/22)

Mohd Shahezwan Abd Wahab et al.

Table 3 (continued)

61

Main theme

Unwillingness of HDS users to communicate with pharmacists (12/22) HDS users with characteristics that are perceived as difcult to be provided with PCare (8/22) Unwillingness of HDS users to spend time for PCare (3/22) Inadequate information offered by HDS users (3/22) Related to pharmacists Busyness (6/22) Insufcient education in HDS from the undergraduate program (5/22) Limited knowledge about HDS (5/22) Lack of professional training (2/22) Related to community pharmacies Limited sources of information for HDS in the pharmacy

(5/22)

Limited access to the scientic evidence for HDS (3/22) Restrictive space available (1/22) Professional norm Job description of pharmacists (12/22) Pharmacist as a healthcare professional (9/22)

HDS, herbal and dietary supplements; PCare, pharmacist care.

HDS consumption, importance of adherence to prescribed medication, and common side effects of HDS. Second to the advice was Gathering relevant information from HDS users. In this regard, the informants mentioned that they collected information such as the purpose of HDS use, med- ical conditions, and existing medicines from the HDS users. This information allowed them to assess the appropriateness of HDS use, and assisted them in the identication of HDS- related problems. One informant stated:

Some customers have chronic diseases

Some are

on warfarin that has many interactions. I ask Do you

use any medicine at the moment?Important question to prevent interactions. (CP08)

Making a professional decision or suggestion for HDS use was identied as a crucial PCare activity for HDS users. The pharmacists mentioned that they should be able to make a professional decision to recommend (or not recom- mend) the HDS consumption. Nonetheless, they reported that some customers insisted on taking HDS products, albeit for no particular importance or having limited evidence for the effectiveness. Unless major safety issues existed, the pharmacists usually complied with the customers decisions to use the HDS. However, if the HDS was found to be harmful to the users, the pharmacists normally asserted their stance on discouraging the consumption. Performing thorough assessment of HDS use , especially for the indication and safety issues, was another activ- ity emphasised by nearly half of the informants. They pointed out that the HDS intake by their customers can be unreasonable. One pharmacist said:

62 Journal of Pharmaceutical Health Services Research 2019; 10: 57–66

Sometimes they use (it) for the wrong indication. I have some cases where patients use sh oil for dia- betes, and their blood glucose levels went out of con- trol. (CP16)

Accordingly, the informants emphasised their roles in evaluating whether the requested HDS meets their cus- tomershealth needs. Regarding the safety issues of HDS, many of the pharmacists revealed that they often checked for drug-HDS interactions but to a lesser extent for disease- HDS interactions and potential adverse effects. Providing sufcient information for assisting customers decisions was also an important part of PCare for HDS users. The informants believed that they should offer suf - cient and unbiased information to customers in order to assist them making informed decision about HDS use. This activity is important to ensure customers understanding of the bene ts and limitations of HDS consumption in advance:

We have to give the exact information to the cus- tomers so that they can decide whether to use or not to use the supplements. (CP06)

Fostering pharmacist customer relationship was another theme identi ed. The pharmacists opined the importance of listening attentively to customers inquiries or request for the HDS. Most of them indicated that pharmacists in gen- eral should be aware that many people prefer to take the HDS and thus the matter should be discussed in an open and nonjudgmental manner.

Underlying beliefs and factors influencing pharmacist care for herbal and dietary supplement users

Behavioural, normative, control and professional normative beliefs about the provision of PCare for HDS users were elicited from the pharmacists. Regarding the behavioural beliefs, the informants reported that PCare beneted not only the HDS users but also their community pharmacies and themselves. The most mentioned PCare advantages were ensuring rational use of HDS (16/22), and ensuring safety of HDS users (14/22). The pharmacists believed that they could promote rational use of the products by making sure the users received the type of HDS that is appropriate to their needs, in a suitable dose, for an adequate period of time, and at the lowest cost. One pharmacist stated:

The customers can use the best product for their symptoms and their budget. (CP07)

suitable

In the case of safety, the pharmacists af rmed that it could be assured through the prevention of HDS-drug inter- actions, overdosing, and adverse effects. Some pharmacists mentioned that PCare may prevent inappropriate HDS use particularly in pregnancy, and by patients diagnosed with kidney or hepatic problems. Regarding the bene ts for pharmacists, informants admit- ted that PCare could help them gain new knowledge about the HDS (8/22) especially when the users shared their expe- riences about a particular HDS. The informants also

mentioned that the inquiries they received about the HDS products while providing PCare often led them to search for more information. Other advantages for the pharmacists included allowing them to appear more trustworthy (5/22), and providing them with self-satisfaction (5/22). Concerning community pharmacies, the pharmacists believed that PCare promotes customer loyalty (9/22). A small proportion of the pharmacists believed that PCare could attract more customers (2/22), and enhance the image of their community pharmacies (2/22). One informant mentioned:

My drugstore only opens in the evening with short opening hours, but my customers wait for me. They like to consult me. They will tell (their) friends and family about my service, and I will get more cus- tomers. (CP05)

pharmacist

mentioned that PCare for HDS users can be time-consuming:

Customers spend 30 minutes with me. Some people spend about one hour with me, they have many ques- tions. (CP08)

With respect to the normative beliefs, the informants felt encouraged to provide PCare for HDS users by individuals such as the HDS users themselves (13/22), and their col- leagues (4/22). Very few mentioned that they were moti- vated by other external entities such as the doctors, and governmental organisations. They mostly agreed that no entity disapprove the provision of PCare for HDS users. One pharmacist however, mentioned that her efforts to pro- vide PCare for some HDS users were discouraged by the users family members. As for the control beliefs, numerous factors that were either the facilitators or barriers to the provision of PCare for HDS users were uncovered. These factors were gener- ally customer-, pharmacist- or community pharmacy- related. Regarding the facilitators, the most commonly cited customer-related factor was the conversation on HDS initiated by the HDS users themselves (e.g., by asking rec- ommendation for a HDS product) (15/22). Some infor- mants mentioned that the type of HDS users who expressed trusts in them (5/22), and the willingness of HDS users to spend time discussing with pharmacists (4/ 22), were the motivating factors for the provision of PCare for HDS users. Several informants (6/22) mentioned certain characteris- tics of the HDS users whom they regarded as the facilitating factors for the provision of PCare. The HDS users who they perceived as easier to be provided with PCare included those who have high education and middle to high incomes, and who were health professionals. To some pharmacists, HDS users of the younger age group are easier to be pro- vided with PCare, whereas to some others, the middle-aged and older adults were easier. Many pharmacists identi ed professional training as an indispensable facilitating factor (11/22) for the provision of PCare for HDS users. Such training would keep them updated with the current HDS information, and make them more con dent in dealing with the HDS users. One pharma- cist noted:

Given

all

the aforementioned

bene ts,

one

PCare for HDS users in Thai community pharmacies

The company provides training for us every month where we learn new HDS products in the market. We learn how to provide proper care. (CP01)

Additionally, many pharmacists (11/22) mentioned that they are the expert in PCare for HDS users because they own an integrated knowledge in pharmaceutical products, human diseases, and the HDS. Several pharmacists also asserted that they were more knowledgeable in the area compared to other healthcare professionals:

We provide care for them because we know about the

HDS

I think pharmacists know the best. (CP15)

Many pharmacists believed that the availability of refer- ence materials about the HDS (e.g., leaets, posters, booklets, etc.) (14/22) could assist them in providing PCare for HDS users. Many pharmacists also mentioned that the access to Internet (10/22), and access to scientic evidences for HDS (7/22) at their community pharmacies were important. According to the informants, one major barrier to PCare delivery is customers reluctance to accept pharmacists opinions about the HDS (14/22). This scenario usually occurred with assertive customers or with those who believe that they were knowledgeable about the HDS. Another problem encountered was customers unwillingness to communicate with pharmacists (12/22). The pharmacists noted:

They have some walls to receive any information

because they think they know the best listen to the pharmacists. (CP19)

They dont

Some patients just pick up, and don t want any advice. They just come and buy, and go. (CP05)

Additionally several pharmacists (8/22) mentioned certain characteristics of the HDS users as barriers for the provision of PCare. The HDS users who were perceived as uneducated, and who were ofce workers and foreigners (non-Thais), were viewed as dif cult to be provided with PCare. Some pharmacists mentioned busyness as a hindrance factor (6/22). In this regard, the pharmacists submitted that they were under pressure to execute multiple roles at their pharmacies during busy hours, resulting in inefcient provi- sion of PCare for HDS users. One pharmacist mentioned:

Sometimes we have ve people come at the same time, and we cannot provide advice for all. They lined up so we just cant. (CP20)

Other barriers included the insufcient coverage of HDS topics in their previous undergraduate pharmacy programs (5/22), and their limited knowledge in HDS (5/22):

We learned for

macognosy, that s all, its just one subject. (CP11)

ve

years.

Although we learned phar-

I sometimes dont know everything about the HDS.

(CP14)

Some barriers to the provision of PCare for HDS users were associated with the settings of the community pharma- cies. These barriers included the limited source of

Mohd Shahezwan Abd Wahab et al.

63

information in the community pharmacies (5/22), limited access to scienti c evidences for HDS (3/22), and restrictive space to conduct PCare activities (1/22). In regard to the professional normative beliefs, many informants believed that PCare was part of a pharmacist s job descriptions (12/22), and as a healthcare professional, they have roles and responsibilities distinguishable from other non-professionals e.g., salespersons/cashiers (9/22). One informant articulated her view:

You cant

just come, and get what you want, and go out. Other- wise, we are not different from the cashiers. (CP11)

We are pharmacists, and not just sellers

Discussion

The pharmacist informants had a certain understanding of PCare for HDS users, and considered the activities such as fostering relationship with the HDS users, collecting HDS users information, assessing their needs for HDS, providing suf cient information, and giving appropriate advice as important. The pharmacists readily associated the provision of PCare to a more rational and safer use of HDS, and advan- tageous for them personally, and for their community phar- macies. Despite the effort to provide PCare for HDS users, similar to ndings from the previous studies, the informants would let the customers to have the nal decision on whether to take the HDS. [ 9,30 ] Nevertheless, if the HDS products were found to be potentially harmful, i.e., causing adverse effects, or drug- and disease-interactions, the pharmacists would take a paternalistic approach [ 31 ] by discouraging its use. It is worth noting that most pharmacists did not clearly touch upon some PCare activities that are considered important in the pharma- ceutical care processes recommended by Cipolle et al., [ 21 ] such as performing the follow-up evaluations and documenta- tion of customers HDS use, providing evidence that pharma- ceutical care practices are not being fully implemented in Thai community pharmacies. The HDS users were perceived as the most signi cant individuals who pressured pharmacists into providing PCare. However, the behaviours and attitudes of the users may inuence pharmacists to provide PCare for them. In keeping with previous studies, [ 30,32 ] pharmacists in the pre- sent study were more likely to be reactive rather than proac- tive in providing PCare. As such, they tended to offer PCare to those who initiated conversation about the HDS. On the contrary, many pharmacists were hesitant to provide PCare to HDS users who they described as assertive and aggressive. These HDS users, who are frequently described as the new consumersor lay experts , [ 33 ] commonly chal- lenged their knowledge, and refused to recognise their pro- fessional opinions. Additionally, the pharmacists also mentioned that they often encounter the HDS users who just come to pick and purchase some HDS products, and avoid any advice. The pharmacists were reluctant to engage with these HDS users possibly due to the fear that their unso- licited opinion may be rejected, or fearing that their inter- vention may leave a repercussion on their relationship with the users.

64 Journal of Pharmaceutical Health Services Research 2019; 10: 57–66

The assertive HDS users and those who belonged in the pick-and-paycategory may possess a strong sense of self-perceived ability and con dence in deciding their own treatments or having a long-term devolution to a particular product. [ 34 ] Although it can be argued that these HDS users have experienced the outcomes that the products have left on their health, this experience is hardly adequate for them to understand the complexities of the effects of HDS, espe- cially when consumed together with modern medicines. Additionally, since the information obtained by the HDS users normally are obtained from unreliable sources of information (e.g., Internet, family and friends), [ 2 ] the self- selection of HDS may be inaccurate. In the absence of a mutual engagement among pharma- cists and HDS users, problems associated with HDS use cannot be identied. [ 21 ] Therefore, pharmacists should be encouraged to listen and communicate to HDS users atten- tively even if they are adamant with their pre-existing knowledge and beliefs. [ 35 ] It is crucial for pharmacists to apprehend the HDS users perspectives about the HDS, especially in regard to their desire and beliefs for HDS con- sumption. [ 13 ] There is also a need to nd new ways of com- munication with HDS users, especially with those who decline unsolicited advice. The present study showed that the pharmacists cate- gorised HDS users as easy or difcult to provide PCare according to their personal characteristics. It was noted that the pharmacists who were younger and less experienced tend to stereotype customers as easier or more difcult to be provided with PCare. It is possible that these pharmacists would only want to engage with the HDS users whom they perceived as receptive to PCare, thus avoiding those who are more challenging to deal with. Nevertheless, there is a concern that those who were negatively stereotyped may actually be the ones who need PCare. Several previous surveys [ 36 38 ] indicated that pharmacists believed that their knowledge of HDS is inadequate a notion shared by only a few pharmacists in the present study. Half of them actually regarded themselves as the expert in caring for the HDS users. This is certainly a good sign as self-ef cacy is a key predictor for the performance of behaviour. The pharmacists who were younger than 30 years old and those having < 5 years of experience in their community pharmacies appeared to be more con dent and interested in offering PCare for HDS users. These young pharmacists may be more receptive to the pharma- ceutical care provider role of pharmacists or may be more cognisant of the current trend of HDS consumption and the variety of HDS products in the market. Nevertheless, although many of the pharmacists regarded themselves as the expert in caring for HDS users, many of them still recognised the continuing professional training related to HDS as important, warranting the provision of such training on a regular basis. Information resources for HDS were construed as neces- sary to support the provision of PCare for HDS users. It is worth noting however, that most of the reference materials that pharmacists often referred to (e.g., lea ets and posters) were supplied by the HDS manufacturers. These materials can be highly promotional in nature, and may be

incomplete. A survey by Raynor et al. , [ 39 ] con rmed that many lea ets of herbal medicine products in the UK do not include key safety information, such as precautions and side effects. Pharmacists should therefore be vigilant of the refer- ence materials that can be misleading and incomplete. In addition, most pharmacists also cited the access to Internet as a facilitating factor as it serves a means to get immediate information in a busy working environment. As such, phar- macists should be made aware of the unreliable information in the Internet. Training for pharmacists to appraise HDS information obtained from the Internet should be warranted. It should be noted that several facilitators mentioned by the pharmacists such as the continuing education in HDS, reference materials about HDS, and the access to Internet can be highly dependent on the management of community pharmacies to provide. Nonetheless, none of the pharmacists in the present study regarded their managers as the individu- als who motivated them to provide PCare for HDS users, indicating that such service was not a priority from the management s perspective. Therefore in effort to optimise the provision of PCare for HDS users, the managers of community pharmacies should also be targeted by making them aware of the bene ts of the service and the require- ment needed by their pharmacists to provide such care. In a previous study, Culverhouse and Wohlmuth [ 40 ] noted that the cost of HDS appeared to be a factor that in uenced the recommendation of the products by Aus- tralian pharmacists. The study showed that pharmacists would recommend cheaper products to provide value to their customers. Similarly, Kanjanarach et al. , [ 9 ] found that cheaper HDS products were more likely to be suggested by Thai community pharmacists. On the other hand, ndings from the present study showed that the cost of HDS was neither a facilitator nor a barrier for the provision of PCare for HDS users. This implies that in the absence of other barriers, pharmacists would provide PCare for HDS users regardless of the price of the products. In addition, it should also be noted that it is common for HDS companies to pro- vide pro t incentives to community pharmacists to sell their products. However, the ndings from the present study showed that pro t incentives did not emerge as an impor- tant in uencing factor for the provision of PCare for HDS users. This nding was similar to that from an Australian study that showed the decision to sell HDS products by community pharmacists was not inuenced by prot incen- tives. [ 41 ] The professional norm emerged as a pronounced factor for the PCare delivery. This result is similar to the previous studies that suggested many pharmacists reacted positively to their role in ensuring the safe use of HDS. [ 13,30 ] This norm is in fact not part of the original TPB framework. However, in the Triandis theory of interpersonal behaviour, the professional norm is considered as part of the personal normative construct which is a pivotal determinant of beha- vioural intention. [ 42 ] In a systematic review of the studies that predict healthcare professionals intentions and beha- viours based on social cognitive theories, the professional role/identity was found to be a signi cant determinant in 8 out of 14 studies. [ 15 ] Therefore, in an effort to encourage pharmacists to be more proactive in providing PCare for

PCare for HDS users in Thai community pharmacies

HDS users, it is vital to emphasise their care responsibility for both drug therapy and the HDS.

Limitations of the study

This qualitative study was conducted only among commu- nity pharmacists working in Bangkok for ease of data col- lection. Their understanding about PCare for HDS users and the underlying beliefs and factors for its provision may be different from pharmacists in the other regions of the coun- try. In addition, all interviews were conducted in English, and therefore there might be a risk of miscommunication between the interviewer and the informants. However, due to quality referrals, all of the informants were uent in Eng- lish, and did not require the aid of an interpreter. Addition- ally, since the pharmacists were interviewed about their engagement in PCare activities, their responses may be sub- jected to social desirability bias despite being offered with anonymity and con dentiality. It should be pointed out however, that the total sample of the pharmacists also included those who admitted that they were not proactive in engaging in some PCare activities related to the HDS, pro- viding evidence that the social desirability bias was in a way reduced. Furthermore, this study could not determine the extent to which the identied underlying beliefs and fac- tors were correlated with the pharmacists intentions to pro- vide PCare for HDS users and its actual implementation. A quantitative survey with a specially designed questionnaire would be more appropriate for that purpose.

Conclusion

The study explored the understanding of community phar- macists about PCare for HDS users, and identied various underlying beliefs and factors in uencing its provision. The pharmacists interviewed, acknowledged the bene ts of pro- viding PCare for HDS users, but its implementation was mostly conditional to many facilitators and barriers related to the customers, pharmacists, and the community pharma- cies. The ndings obtained from this study can serve as an input to inform several strategies to promote the provision of PCare for HDS users, such as the offering of training programs to enhance con dence among the pharmacists, conducting campaigns to encourage pharmacists to provide PCare for HDS users, and equipping reliable information resources in the community pharmacies. Moreover, the identication of factors based on the TPB may facilitate the design of a survey questionnaire that can be used in a large, representative sample of pharmacists to quantitatively mea- sure and statistically assess the strengths of the identied beliefs and factors on their intention to provide PCare for HDS users and its actual implementation.

Declarations

Conflict of interest

The authors declares that to disclose

they

have

no

con icts

of interest

Mohd Shahezwan Abd Wahab et al.

65

Funding

This research is supported by the 90th Anniversary of Chu- lalongkorn University, Rachadapisek Sompote Fund. MSAW is funded by the 100th Anniversary Chulalongkorn University Fund for Doctoral Scholarship.

Acknowledgement

The authors thank the community pharmacists who partici- pated in the study.

Authors’ contributions

All Authors state that they had complete access to the study data that support the publication.

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Supporting Information

Additional Supporting Information may be found in the online version of this article at the publishers web-site:

Appendix S1. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.