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Exploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural… Kwan, Della; Boon, Heather S; Hirschkorn, Kristine; Welsh, Sandy; Jurgens, Tannis; Eccott, Lynda; Heschuk, Shirley; Griener, Glenn G; Cohen-Kohler, Jillian C Jul 14, 2008

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ralBMC Complementary and ssBioMed CentAlternative MedicineOpen AcceResearch articleExploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural health products: a study of focus groupsDella Kwan1, Heather S Boon*2, Kristine Hirschkorn2, Sandy Welsh3, Tannis Jurgens4, Lynda Eccott5, Shirley Heschuk6, Glenn G Griener7 and Jillian C Cohen-Kohler2Address: 1Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada, 2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada, 3Department of Sociology, Faculty of Arts and Science, University of Toronto, Toronto, Canada, 4College of Pharmacy, Dalhousie University, Halifax, Canada, 5Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada, 6Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada and 7School of Public Health & Department of Philosophy, University of Alberta, Edmonton, CanadaEmail: Della Kwan -; Heather S Boon* -; Kristine Hirschkorn -; Sandy Welsh -; Tannis Jurgens -; Lynda Eccott -; Shirley Heschuk -; Glenn G Griener -; Jillian C Cohen-Kohler -* Corresponding author    AbstractBackground: Natural health products (NHPs) such as herbs, vitamins and homeopathicmedicines, are currently available for sale in most Canadian pharmacies. However, mostpharmacists report that they have limited knowledge about these products which have beenregulated in Canada as a specific sub-category of drugs. In this paper, consumers' and practicingpharmacists' perceptions of pharmacists' professional responsibilities with respect to NHPs areexamined.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 areimpacted by changing consumer needs. Many consumers in the study utilized a wide range ofinformation resources that may or may not have included pharmacists. Nevertheless, the majorityof consumers and pharmacists agreed that pharmacists should be knowledgeable about NHPs andfelt that pharmacists should be able to manage drug-NHPs interactions as well as identify andevaluate the variety of information available to help consumers make informed decisions.Conclusion: This paper demonstrates that consumers' expectations and behaviour significantlyimpact pharmacists' perceptions of their professional responsibilities with respect to NHPs.Published: 14 July 2008BMC Complementary and Alternative Medicine 2008, 8:40 doi:10.1186/1472-6882-8-40Received: 30 April 2008Accepted: 14 July 2008This article is available from:© 2008 Kwan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 11(page number not for citation purposes)BMC Complementary and Alternative Medicine 2008, 8:40 health products such as herbs, vitamins andhomeopathic products are a growing Canadian productcategory worth over $400 million annually [1] and arewidely available in Canadian pharmacies. Since pharma-cists are readily accessible to consumers at the point wherethey are making decisions about purchasing NHPs, phar-macists are potentially in a good position to provide con-sumers with evidence-based information about NHPs,especially regarding potential interactions with conven-tional medications[2]. Pharmacists have the knowledgeand experience to help consumers determine when self-medication is appropriate and when the expertise ofanother health care provider is needed[2]. However, it isnot clear that consumers want this kind of advice. Withgreater access to health-related information, consumershave become more literate, better educated, and increas-ingly capable of making their own decisions regardingtheir health care [3-5]. The current situation is the focus ofour paper: with NHPs widely available and with engagedand informed consumers demanding access to them,what is the role of pharmacists regarding NHPs? In thispaper, we seek to understand how pharmacists' profes-sional responsibilities with respect to NHPs are influ-enced by consumers who have access to increasingamounts of health information.Natural health products in pharmacy practiceSelf-medication with natural health products (NHPs),such as herbal medicines and other supplements, hasbecome very popular among Canadians. Based on datafrom the 2005 Baseline Natural Health Products Surveyconducted by Health Canada, seven in ten Canadianshave used a NHP at some time in their lives. A majorityagree that NHPs can be used to maintain or promotehealth or to treat illness (68%) [6]. Fewer agree that NHPsare better than conventional medicines (43%) [6]. NHPsare used to treat an existing health condition or in anattempt to prevent illness and often consumed in tandemwith conventional medicines [7].In Canada, NHPs have been governed by the NaturalHealth Products Regulations since January 2004. Underthe Regulations, a NHP is defined as a product found innature that is "manufactured, sold or represented for usein: (a) the diagnosis, treatment, mitigation or preventionof a disease, disorder or abnormal physical state or itssymptoms in humans; (b) restoring or correcting organicfunctions in humans; or (c) modifying organic functionsin humans, such as modifying those functions in a man-ner that maintains or promotes health" [8] (p. 1573).Products that fall within this category include herbal rem-edies, homeopathic medicines, vitamins, minerals, tradi-Tobacco, marijuana and biologics (e.g., blood-basedproducts, insulin) are excluded. By definition, to be con-sidered a NHP, a product must be safe for sale over-the-counter (OTC) and thus be available for self-care and self-selection [8]. More importantly, NHPs are classified as"drugs" at the level of the Federal Food and Drugs Act,which would appear to make them part of the pharma-cist's professional scope of practice[8].Much of the research on NHPs and pharmacy practice todate has focused on describing pharmacists' attitudestowards, and personal use of, NHPs. A systematic reviewfound that Canadian and U.S. pharmacists do not per-ceive their knowledge of NHPs to be adequate and that amajority of pharmacists would like to receive additionaltraining on NHPs, especially in the areas of interactions,side effects/adverse events, patient counseling, therapeuticuses, and dosing [9]. This is largely the result of the lim-ited NHP-related curriculum in many pharmacy schoolsuntil very recently[10]. In addition, survey data reviewedindicate that pharmacists do not routinely document,monitor, or inquire about patients' use of NHPs despitereceiving questions about NHPs from patients and otherhealth care providers [9]. Although these surveys providesome description of how pharmacists behave with respectto NHPs, they do not provide any insight into what phar-macists should do or what factors influence how pharma-cists' professional responsibilities are determined.The patient as consumerThe perspective of the consumer is important to considerwhen exploring pharmacists' responsibilities in relationto NHPs. An analysis of patients' perceived needs regard-ing information about NHPs brings into focus the inade-quacy of the traditional paternalistic view of the 'patient'as occupying a subject position and demonstratingdependency and unquestioning compliance with medicalexpertise [11]. Instead, we argue that the majority of con-sumers interested in NHPs are best understood throughthe concept of the 'new consumer'. For several decades,the social science and marketing literature have describedthe existence and influence of "new consumers"[5,12].New consumers are defined as being information strong,information seeking, and increasingly demanding [4,5].Compared to 20–30 years ago, current consumers aremore literate, better educated, and have more informationresources at their disposal [5]. For example, the majorityof Canadians are heavy Internet users (56% report beingonline seven or more hours per week) with researchingmedical information being one of their most popularInternet activities [13]. Linked to this is the establishedtrend where expert knowledge in areas such as medicinePage 2 of 11(page number not for citation purposes)tional medicines (e.g., traditional Chinese medicines),probiotics, amino acids, and essential fatty acids.and science is no longer simply accepted on face value.Expert knowledge is now open to skepticism and to chal-BMC Complementary and Alternative Medicine 2008, 8:40 on the part of lay people due to an increasing publicawareness of the uncertainties that arise from applyinggroup results from clinical trials to individual patients andincreasing range of medical care options [14,15].Much emphasis has been placed in recent literature on theimpact of consumerism on the roles and status of health-care professions in society [15-21]. Eysenbach and Jadad,in their discussion of consumers' increasing access toInternet based resources and the consequences for patientchoice, propose a changing role for health professionals[17]. Specifically, they profile a shift from an information'filter' role of the professional to a 'consumer as partner'model of practitioner-patient relations. In other words,the practitioner and the patient engage in a model of deci-sion making that is more equitable in terms of power rela-tions. Similarly, Fournier argues that the diffusion ofprofessional knowledge to the consumer has eroded theboundary between professionals and clients/lay persons[18]. However, she concludes that the boundary is noteliminated but rather, it is shifted with professions havingthe capacity to redefine their boundaries as they adapt tochanges. Several empirical studies that explored theimpact of consumerism on the patient-provider relation-ship found the situation to be very complex, in that a con-tinual tension exists between seeking dependency andwanting autonomy, which constrains the patient-providerrelationship from moving too far in the direction of con-sumerism [15,19-21]. Although previous literature hasprovided valuable insights into the impact of consumer-ism on the roles and status of healthcare professions, onlya few studies have investigated how consumer behaviorsmight be relevant to pharmacy practice [3,5,11].Most notably, Traulsen and Noerreslet found an increasein 'new consumers' in Danish community pharmacies [5].The new consumers of medicines actively seek informa-tion on side effects, the efficacy and price of products; andin general no longer blindly accept the authority of thepharmacy staff. Seen in light of the theory of risk, theauthors concluded that new consumers' behavior is anattempt to minimize the risk of pharmaceuticals, whichthey have learned about from the media and Internetsources [5]. Hibbert, Bissell, and Ward considered howthe presence of new consumers has affected the profes-sional role and status of the community pharmacist inrelation to the sale of over-the-counter medicines[11].They found that consumerism represents a significantchallenge to medicine surveillance and professional workin the community pharmacy [11].Here we investigate how consumers shape pharmacists'responsibilities with respect to NHPs. In the analysis toceptions of the professional responsibilities of the phar-macist with respect to NHPs. Doing so allows us tocompare the views of the two groups and to illustrate theways in which pharmacists' professional responsibilitiesare influenced by changing consumer patterns.MethodsTwo focus group discussions with consumers and twowith practicing pharmacists were held in University meet-ing rooms in four different cities across Canada (Vancou-ver, Edmonton, Toronto, and Halifax) for a total of 16focus groups. The research was conducted from May toNovember in 2006. Focus groups were chosen becausethey provide a forum for participants to discuss a widerrange of ideas and issues than would arise in individualinterviews [22]. They have also been shown to be anextremely useful tool, especially where researchers seek toaccess community and public views [23].A recruitment agency was hired to recruit consumers forthe focus groups using random digit dialing. Consumerswith a range of age, education, and income were selected.Community pharmacies in Vancouver, Edmonton,Toronto, and Halifax were selected purposefully from thetelephone book/Internet listings to recruit a mix of phar-macists practicing in a range of locations, including inde-pendent pharmacies, chain drug stores and hospitalpharmacies across each city. A pharmacist-investigatorcontacted each pharmacy by telephone to recruit commu-nity pharmacists who met eligibility criteria. (Due to spe-cific ethics requirement in Vancouver, each communitypharmacy was faxed a study information sheet before thecontact phone call.) In order to recruit both full-time andpart-time pharmacists, pharmacies were contacted at dif-ferent times of the day and at different days of the week.Pharmacists were asked about their years of practice inorder to obtain a group with different levels of experience.Hospital pharmacists were recruited by first e-mailing aninformation letter to the director of selected hospitalpharmacies to request recommendations of pharmaciststo contact. Each hospital pharmacist was then contactedindividually by e-mail.In total, 50 consumers and 47 pharmacists participated inthe study. Please refer to Tables 1 and 2 for a summary ofparticipants' demographics. All the focus groups were ledby the same moderator whose main function was to keepthe discussion on track, to encourage an open and relaxeddiscussion, and to probe into areas that needed clarifica-tion. The moderator was a pharmacy professor with noties to community or hospital pharmacy. Current andpotential professional (including legal and ethical)responsibilities of pharmacists with respect to NHPs werePage 3 of 11(page number not for citation purposes)follow, we use data from focus groups of pharmacists andconsumers to explore consumers' and pharmacists' per-discussed in each group. See Appendix for specific ques-tions.BMC Complementary and Alternative Medicine 2008, 8:40 focus group discussions were recorded and tran-scribed verbatim. Qualitative content analysis was used toidentify specific responsibilities for pharmacists withrespect to NHPs. Qualitative content analysis involvedanalyzing the focus group transcripts by categorizing seg-ments of the transcripts into topic areas called "themes"[24]. Each theme was then placed in a topic categorybased on its content. Large categories were further dividedinto sub-categories creating a tree-diagram. (See Figure 1for the pharmacist coding tree.) Each transcript was codedindependently by at least two members of the researchteam who met repeatedly to compare and discuss the cod-ing until consensus was achieved. Computer software(NVivo 7, QSR International Pty. Ltd. © 1999–2006) wasused to facilitate this process.The identity of the participants has been kept confidentialby the research team and participants of the groups wereinstructed not to disclose the identity of other participantsand not to discuss anything that occurred during the focusgroup. All data related to the project has been stored inpassword projected files and will be destroyed after fiveyears. This research was approved by the Health SciencesResearch Ethics Board at the University of Toronto. Inaddition, ethical approval was provided by each of theUniversities where data were collected: Dalhousie Univer-sity, University of Alberta and University of BritishColumbia.ResultsA consistent pattern of responses emerged despite the geo-graphical differences of the participants. Consumers andpharmacists agreed that there is a need for pharmacists totake on a consultative responsibility for NHPs, whichtakes into account the characteristics of the 'new con-sumer'. In particular, both agreed that this responsibilityis especially important in terms of pharmacists' tradi-tional responsibilities for ensuring patient safety fromadverse events and drug interactions associated withNHPs. Not all consumers are information strong though,as we found some evidence for the continued existence ofpassive patients who rely on their pharmacists for infor-mation about NHPs.Consumers and NHPsConsumers in this study generally did not rely on pharma-cists for information about NHPs. Many consumers dis-played characteristics of the 'new consumer'. Theyperceived themselves as being capable of making theirown decisions regarding the use of NHPs and utilized awide range of information resources (that may or may notinclude pharmacists) to make those decisions.The majority of consumers in our study believed that theywere well informed prior to coming to the pharmacy.Many found information from the Internet, friends orfamily, newspapers, magazines, books, health food stores,Table 1: Summary of Pharmacists' DemographicsTotal Number of ParticipantsNumber of Full TimeNumber of Part TimeNumber of Pharmacists who have practiced > or = 5 yearsNumber of Pharmacists who have practiced < 5 yearsNumber of Hospital PharmacistsNumber of Chain PharmacistsNumber of Pharmacists who work for Independent PharmaciesToronto 16 13 NB. 1 works both full & part time2 13 3 4 *1 works in drug information9 N.B. 1 works in hospital & chain2Halifax 13 13 1 11 2 0 10 3Edmonton 13 9 3 N.B. 1 just sold pharmacy so was not working at time of data collection9 4 2 5 5 N.B. 1 just sold pharmacy so was not working at time of data collectionVancouver 5 5 0 4 1 0 2 3Table 2: Summary of Consumers' DemographicsTotal Number of ParticipantsAge Gender Education Income25 to 34 NB. Toronto 18 to 3435 to 54 Over 54 Male Female Completed High SchoolUniversity or CollegePost GraduateUnder 50 000Over 50 000Toronto 12 9 2 1 7 5 4 6 2 5 7Halifax 12 3 5 4 7 5 3 3 6 5 7Page 4 of 11(page number not for citation purposes)Edmonton 14 3 5 6 6 8 4 10 0 6 8Vancouver 12 2 5 5 6 6 1 11 0 2 10BMC Complementary and Alternative Medicine 2008, 8:40 other healthcare professionals (e.g., physicians, naturo-paths):Well, I'll do research, I'll have a look on the Internet, andthen I'll ask people questions. I'll go into their shops, andI'll ask customer service or whoever is working in that areaabout questions.... Then I'll think about is it going to begood for me, looking at my whole, like what's happeningwith my own symptoms or whatever, and then I'll choosewhether to try it, or whether to not try it. – Toronto con-sumerSome consumers said they never even thought of askingthe pharmacist about NHPs:It never really would have occurred to me to have asked apharmacist about anything that was natural. I would havegone to [health food store name]... for that type of informa-tion. Most of the stuff I would want to know would probablybe more from a nutritional, preventative point of view andthat I would think of more of a dietitian or something as alogical source to go for that type of thing as opposed to apharmacist. – Vancouver consumerWell they come with pre-conceived ideas of what is or is notgood and... I find myself in the position where I am eitherexplaining why not or trying to understand the basis of theclaims that these people are saying these particular productshad made about them; I mean it's just very difficult. – Hal-ifax pharmacistConsumers also emphasized their skepticism about rely-ing on expert advice:We need to be open minded. You have to take some activecontrol yourself, and these are people that you are consult-ing, not Gods that know everything. – Edmonton con-sumerThe Pharmacist as an NHP "consultant"Despite the fact that most consumers do not rely on phar-macists for NHP-related advice, the majority of both con-sumers and pharmacists agreed that pharmacists need tobe knowledgeable about NHPs. Our participants sug-gested that pharmacists could adopt a consultative role tohelp consumers identify and assess the range of informa-tion available, but not necessarily make the final decisionfor them regarding use.Pharmacist coding treeFigure 1Pharmacist coding tree    Pharmacists    Perceptions  Pharmacists’  Pharmacist  Pharmacists’  Hospital Pharmacy Ethical Issues  of Pharmacists  Responsibilities Education  Knowledge  Pharmacy Practice Related to  Pharmacists                Specialty  Innovations               Pharmacist              Trust General          Role  Liability/  Selling  Counseling Referring Drug-Herb Interactions Healthcare Accountability     & Adverse Events  Practitioners  Education        Control over Availability    Investigation/  Reporting      Merchandizing     Counseling          Pharmacists Other       Support   No Barriers  Compensation    Approach Recommending Documenting/ Patient  Drug/ For Role  Role            Monitoring Education NHP                 History Page 5 of 11(page number not for citation purposes)Pharmacists made the observation that consumers todayare information strong and critical of professional advice:BMC Complementary and Alternative Medicine 2008, 8:40 was high agreement among consumers that phar-macists need to be knowledgeable about NHPs becauseusage of NHPs is common among the general public:Pharmacists should know that alternative medicines arepart of our life, they are reality, and when they sell or fill aprescription, they should be aware that people are likelydoing other things as well, and they need to know about it.They need to have a basic understanding about what alter-native medicines are. – Edmonton consumerMore importantly, both consumers and pharmacistsagreed that if NHPs are sold in the pharmacy, pharmacistsshould be responsible for, and knowledgeable about,them.I would think that pharmacists should be responsible for theproducts that their store is selling and not just being onewhere you need a prescription; they should also be responsi-ble for the vitamins and they should be responsible for thenon-prescription drugs... the range of their responsibility isnot just the things that are on prescription... – Halifax con-sumerIn my practice, I don't carry things that I don't know about.- Edmonton pharmacistSeveral consumers argued that pharmacists who are notknowledgeable about NHPs are not fulfilling their profes-sional responsibilities:When I talk to pharmacists who don't know about herbalremedies, I kind of think that they must not take their jobvery can you help people if you don't know?– Vancouver consumerOur participants suggested that pharmacists could adopt aconsultative role to help consumers integrate all types ofinformation when making decisions about the use ofNHPs. As one pharmacist described the role:I see that one of the roles we have as pharmacists that is veryimportant is to help people to tie in all of their sources ofinformation into something meaningful and useful forthemselves. So, we really do need to have some kind of ageneral education regarding all the different modalitiesthat are available to people so that we can help them makesense of all of the information they are being bombardedwith for their own safety, but also for assisting and directingthem to alternative choices that might be appropriate forthem to use and to still keep it in a safe place and refer themon. – Edmonton pharmacistConsumers expected pharmacists to assist them in theappropriate use of NHPs as they do for over-the-countermedications. They would like pharmacists to providehelpful information, but not necessary make the finaldecision about use:I do expect them to give me suggestions. I will read the labelbut it doesn't always tell me what it's supposed to do for me.So if I expect that for the over the counter stuff, if the herbalthings come in, I do expect that they should be able to tellme about the herbal things. If they are going to sell it and Iam going to ingest it, I want to know. – Halifax consumerConsumers perceived this to be especially important sinceNHPs can be pharmacologically active and the dosinginstructions and safety information for NHPs are oftenconfusing or missing from labels of products....particularly those that are [over] the counter I wouldthink like knowing the most up-to-date literature and whya person would take vitamin C supplement and how muchand what are the effects of taking too much...I don't thinkthat information is readily available at the thatmay be a good role for pharmacist – to answer some of thosequestions – Halifax consumerIn addition, consumers would like pharmacists to helpthem identify trustworthy information sources.Basically he is going to the same source as I could go to, butI would feel a little more comfortable that the pharmacistmight be able to differentiate the fake web site from the realweb site. – Edmonton consumerPharmacists also described themselves in a consultativerole:I think we have a responsibility to look up the informationfor them because we are supposed to be the accessible infor-mation provider. We know where to look for it and givethem unbiased information. I think we are pretty good atthat. – Vancouver pharmacistThe idea is to try to give them a bit of education. If theywant to take something certainly they don't have to come toa pharmacy.... So I try to say look this is what we know, andI don't want to make the decision for them because it's notmy decision to make. – Vancouver pharmacistOverall, the majority of consumers and pharmacistsagreed that pharmacists should be knowledgeable aboutNHPs and could adopt a consultative or advisory role tohelp consumers identify and assess the range of informa-Page 6 of 11(page number not for citation purposes)tion available about a particular NHP.BMC Complementary and Alternative Medicine 2008, 8:40 patient safetyAlthough pharmacists recognized the need to respect con-sumers' expertise and knowledge regarding NHPs, theyalso placed a great emphasis on their responsibility aspharmacists to ensure patient safety. When asked abouttheir first priority with respect to patient care, the majorityof pharmacists clearly identified patient safety, especiallywith respect to potential drug-herb interactions. This wasalso identified as a topic that generated many patientquestions:My first priority is making sure that whatever they are usingis not interacting or we are watching for side effects, it isnot going to affect their sugars; it is not going to cause anytype of unfortunate effect... my first priority as a pharmacistis their safety. – Edmonton pharmacistConsumers also agreed that pharmacists are in the bestposition to manage potential drug-NHPs interactions andto ensure the safe use of NHPs because they have expertisein conventional medications:I know the pharmacy here, the pharmacists they have sit-ting rooms, a little room, and if they give you a prescriptionthat you haven't had before they bring you in and sit youdown and discuss it with you, and he's got, you know,records of what I take. If I want to try something new nowbecause I am taking all these other medications, I checkwith him and he's got it all on the computer and he checksit all out and makes sure that I'm not on anything that isgoing to make my head burn off or something. – Edmon-ton consumerHe [the pharmacist] knows what I am taking, and becausehe has that knowledge, I'll ask, I would like to take this,what do you think? Is it going to react with something I amalready taking, or you know is it worth it, or do you knowof any studies? Because sometimes they will know studies ofsome new herbal stuff that is being really pushed on themarket, and he can tell me it's not worth it. – EdmontonconsumerPharmacists were comfortable with letting the consumermake the final decisions only if they were assured that theproduct would not cause harm:So I guess it depends on what they are using it for andwhether they have any medical conditions and whether theyare on any medications; if they were otherwise healthy andwant to try it I would say it's up to you. If they have somemajor medical conditions and I am not certain if it willcause any adverse reactions then I would probably recom-mend that they don't try it. – Toronto pharmacistThere is always that proviso if you are interested, it is cer-tainly at this point for you, it does not look like it is goingto conflict with anything else, if you want to try it, andassess it.... You know I don't know of anything that is goingto hurt, so you know let's see how it goes. – EdmontonpharmacistWhen dispensing prescriptions, some pharmacists areproactive and ask for information about NHP use. Thisallows the pharmacist to check for possible interactions sothat they can intervene to protect the consumer. Pharma-cists are very unlikely to actively recommend an NHP if aconsumer does not first express interest in taking it:I ask the patient what kind of herbal product they are onand then I would check the drug interaction, whether theyagree with the prescription medication. This I would do, butas far as recommendation, I wait for the customer to askme, rather then recommend an herb to them. – VancouverpharmacistHowever, the amount of input a pharmacist can have isultimately determined by the patient because NHPs areavailable for self-selection. Thus, consumers may pur-chase these products without seeking the advice of a phar-macist. More importantly, NHPs are available for sale in arange of retail locations (i.e. health food stores, grocerystores). Consequently, checking for potential drug-NHPinteractions is difficult or all but precluded, if the con-sumer does not approach the pharmacist.The problem generally though is people shop at differentplaces. So you know I buy this in here and this in there andI am not telling people when I am buying it; unless some-body points it out to me, I don't know that there is an inter-action. – Toronto consumerI think people just grab them and go. – Edmonton phar-macistOverall, pharmacists tended to place a great emphasis onensuring patient safety in terms of their responsibility. Incontrast, most consumers emphasized the importance ofmaking their own decisions, while acknowledging thatpharmacists could play an important role in helping themto make choices that would not result in harm.Consumers as patientsAlthough many of our participants fit the descriptions ofthe "new consumer" in the literature, some clearly wantedmore of a partnership model of relationship with theirpharmacists. What appears to differentiate these consum-ers is their view of a longer-term relationship betweenPage 7 of 11(page number not for citation purposes)'patients' and pharmacists:BMC Complementary and Alternative Medicine 2008, 8:40[Jay] said the relationship between the pharmacist and the"client" and [Jen] has said the relationship between thepharmacist and "customer"; and to me, I don't want to bea "client". I mean, I know that I am, but I don't want mypharmacist to see me as a "client" or a "customer". I wantthem to see me more like a "patient" as opposed to a revenuesource. – Toronto consumerI do use the internet as well and I have some natural kindof books at home... but I do go to my pharmacist quite abit...I have been going to the same pharmacist for the lastfive years since I live near her... so I kind of have a goodrelationship with her and I trust her and she knows that Ihave some allergies and things like that so I do talk to herabout alternatives sometimes... – Vancouver consumerPharmacists made similar observations:I also think it depends on the relationship each pharmacisthas with their patient [s]. You know you were talking abouthow people are just going to go out and take whatever theywant anyway. You know I don't find my patients are asmuch like that. If they trust you and you have a continuityof care relationship, they are more likely to ask you first. Alot of my patients won't take anything, even if they get aprescription from their doctor, they are like, and "Do youthink this is okay? You know I don't trust them as much asI trust you". So, it really depends on the kind of practice youhave. – Edmonton pharmacistIn the context of NHPs, the relationship between a con-sumer and the pharmacist matters. The degree of involve-ment a pharmacist has in the NHP decision-makingprocess is ultimately controlled by the consumer. Butsince NHPs are sold in pharmacies, both consumers andpharmacists agreed that pharmacists have a responsibilityto provide basic advice about NHPs, especially regardingtheir safety.DiscussionThe findings presented in this paper demonstrate thatboth consumers' and pharmacists' perceptions of the pro-fessional responsibilities of the pharmacist with respect toNHPs are affected by the changing behaviour of consum-ers. Many consumers in the focus groups perceived them-selves as being capable of making their own decisionsregarding the use of NHPs and utilized a wide range ofinformation resources that may or may not include phar-macists. However, some consumers preferred to adopt amore traditional patient role, seeking a partnership with aparticular pharmacist that has earned the consumer'strust.consumers integrate different sources of information, butnot necessarily make the decision for them about the useof NHPs. The consultative role appears similar to theinterpretive or informed choice decision making model[17,25]. In this model, the professional supplies the con-sumer with relevant information and helps to elucidateand articulate the consumer's values, but does not partic-ipate directly in decision making [17,25]. The deliberativeor shared decision making model, which researchers andpharmacy leaders advocate to be the best, describes con-sumers and professionals as active participants in the deci-sion making process with two-way exchange ofinformation and working as partners or friends[17,25,26]. The key difference between the interpretiveand deliberative models is that in the interpretive model,the professional does not participate in decision makingbut in the deliberative model, s/he does. The propensitytowards the interpretive, as opposed to the deliberativemodel, can be understood in the context that NHPs areprimarily intended for self-medication by consumers andso it is ultimately the consumers' decision whether or notthey choose to use them. One could also argue that in real-ity, it is the consumer that makes the final decision regard-ing use of all treatments (including over-the counterproducts and prescription drug therapy). The data wedescribe suggest that this is explicitly acknowledged whenconsumers and pharmacists are discussing NHP use.Pharmacists in the study tended to place an emphasis onensuring patient safety, especially with respect to potentialdrug-NHP interactions, as their first priority in patientcare. Most said they would wait for the consumer to takethe initiative to ask them for a recommendation aboutNHPs. Since pharmacists have traditionally taken on therole of gatekeepers in protecting the public from danger-ous medicines [27], the 'safety role' can be conceptualizedas an extension of this traditional role. In the originalpaternalistic description of patient-professional interac-tions, the professional ensures that patients receive theinterventions that best promote their health and well-being and adopts the role of main supplier of knowledge[17,25]. What is different in our case is that although mostpharmacists were concerned with making sure the prod-ucts are safe for consumers, they do not perceive them-selves to be the main purveyors of information on NHPs.In this context, it is important that pharmacists ask con-sumers about their NHP use when dispensing prescrip-tion medicine so pharmacists can check for interactions.The 'new consumer' is not a ubiquitous actor, but ratherone that emerges more strongly in some contexts thanothers. For example, the consultative role of pharmacistsreflects the impact of the new consumer but where safetyPage 8 of 11(page number not for citation purposes)Both consumers and pharmacists in the study suggestedthat pharmacists could adopt a consultative role to helpconsiderations emerge, a more traditional paternalisticrole of the pharmacist was supported by both consumersBMC Complementary and Alternative Medicine 2008, 8:40 pharmacists in the focus groups. This highlights thetension between seeking dependency and wanting auton-omy that exists in the "new consumer" literature[15,20,21]. Even the most information-strong consumermay not have access to detailed information about spe-cific NHP-drug interactions. A minimum responsibilityfor pharmacists appears to be providing informationabout NHPs that may interact with prescription drugs. Inaddition, the consultative role of the pharmacist maycome into play as consumers try to sort through large vol-umes of often conflicting information (and sometimesmis-information) available from a multitude of sourcesincluding the Internet.Like all studies, this one has its limitations. Focus groupdata is not designed to be generalizable. However, the factthat the themes described in this study were consistentacross four geographically disparate Canadian cities sug-gests that the findings may be applicable to urban areas. Itis not clear if Canadians in rural areas, French-speakingCanadians or populations from other countries wouldexpress similar opinions.ConclusionIn conclusion, when studying the development of profes-sional roles in health care, it is important to consider theconsumer perspective and the impact of consumerism onthe requirement for health services. Our analysis of con-sumer and pharmacist focus groups suggests that consum-ers contribute to shaping the pharmacists' role by usingthe pharmacist as a consultant and looking to the pharma-cist for help with the management of drug-NHPs interac-tions.List of abbreviationsCAM: complementary and alternative medicine; NHP:natural health product; OTC: over-the-counter.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsHSB conceived of the study, obtained funding, partici-pated in data collection, analysis and paper writing. DKparticipated in data collection, analysis and drafted theinitial paper as part of her MSc thesis work. HSB, SW, TJ,and JCC-K participated on DK's MSc supervisory commit-tee and thus provided input on the design of this study. TJ,LE, SH, GGG participated in data collection and paperrevisions. KH and SW participated in data analysis andpaper revisions. JCC-K participated in paper revisions. Allauthors read and approved the final manuscript.Appendix: Focus group questionsA. ConsumersViews about Current Situation1. To start with a general question, what are some of yourexperiences with natural health products (NHPs) likeherbal medicines, vitamins and minerals or homeopathicmedicines? Give examples.2. Where do you go for information about NHPs?• PROBE: What kind of information do you usually askabout?3. Where do you usually purchase NHPs?• PROBE: Do you buy NHPs at the pharmacy? Why orwhy not?• PROBE: How do you decide where to buy NHPs?• PROBE: Do you think it is safer to buy NHPs at the phar-macy?4. Have you ever talked to a pharmacist about NHPs? Whyor why not? Give examples.• PROBE: What do pharmacists currently do well? Whatdo pharmacists currently do poorly?Prescriptive Views (i.e. how they think things 'should' be)5. What would you like to see pharmacists do with respectto NHPs?• PROBE: Should pharmacists sell NHPs? Why or whynot?• PROBE: Should NHPs be sold only in the pharmacy?• PROBE: Should pharmacists recommend NHPs topatients? Under what circumstances?• PROBE: What kind of information should pharmacistsprovide to patients about NHPs (e.g., instructions for use,potential adverse effects, whether there is evidence to sup-port the efficacy and safety of the product, etc.)?• PROBE: Should pharmacists be responsible for detectinginteractions between NHPs and drugs?Inter-professional Responsibilities6. Who do you identify as the (other/potential) profes-sional experts in the area of NHPs?Page 9 of 11(page number not for citation purposes)• PROBE: Are these experts for NHPs in general or only forparticular NHPs?BMC Complementary and Alternative Medicine 2008, 8:40• PROBE: What do you think is the role of the physician/nurse/dietitian/naturopath with respect to NHPs?In Closing7. Do you have any advice to give to the profession ofpharmacy in regards to what their professional responsi-bilities for NHPs should be?B. Practicing PharmacistsViews about Current Situation1. To start with a general question, what are some of yourexperiences with natural health products (NHPs) likeherbal medicines, vitamins and minerals or homeopathicmedicines? Give examples.2. What do you currently do with respect to NHPs?• PROBE: Do you ask your patients if they use NHPs? Whyor why not?• PROBE: Do you recommend NHPs to patients? Why orwhy not?• PROBE: Do you provide counseling on NHPs? Why orwhy not and what information do you provide?• PROBE: Do you check for drug-herb interactions? Whyor why not and what would you do if you suspect one?3. What training or education have you had about NHPs?Prescriptive Views (i.e. how they think things 'should' be)4. What general legal and ethical responsibilities (if any)do you think pharmacists should have with respect to nat-ural health products?• PROBE: Should pharmacists sell NHPs? Why or whynot? What legal and ethical responsibilities do pharma-cists have if they sell NHPs?• PROBE: Should NHPs be sold only in the pharmacy?Why or why not?• PROBE: Should pharmacists be liable for the safety andquality of the NHPs that are sold at the pharmacy?• PROBE: Are there particular kinds of NHPs that pharma-cists should be responsible for?• PROBE: Are NHPs a part of providing pharmaceuticalcare? Why or why not?• PROBE: What kind of information do you think shouldfor use, potential adverse effects, whether there is evidenceto support the efficacy and safety of the product, etc.)?• PROBE: Should pharmacists recommend NHPs topatients? Under what circumstances?• PROBE: Should pharmacists be responsible for detectinginteractions between NHPs and drugs? Why or why not?• PROBE: Should pharmacists provide information aboutNHPs to other members of the health care team (i.e., phy-sicians, nurses, etc.)? Why or why not?• PROBE: Should all pharmacists have the same responsi-bilities or are there potentially different responsibilitiesfor different types of pharmacists?5. What training do you think is required for pharmacistson NHPs?• PROBE: In your opinion, what is the best way to helppharmacists gain the knowledge and skills necessary toperform the responsibilities discussed?6. Do you think NHPs fall within the pharmacist's scopeof practice as it is currently defined? Why or why not?7. What policy changes do you think are needed in orderfor pharmacists to adopt the responsibilities discussed(i.e., revise/expand practice standards, code of ethics, andscope of practice)?8. What challenges do you anticipate would be encoun-tered by pharmacists in adopting the responsibilities dis-cussed?Inter-professional Responsibilities9. Who do you identify as the (other/potential) profes-sional experts in the area of NHPs?• PROBE: Are these experts for NHPs in general or only forparticular NHPs?• PROBE: What do you think is the role of the physician/nurse/dietitian/naturopath with respect to NHPs?Product Regulation10. What have you heard about the new natural healthproduct regulations? Do you think these will have anyimpact on the pharmacist's professional role with respectto NHPs? Why or why not?Page 10 of 11(page number not for citation purposes)be provided in counseling about NHPs (e.g., instructionsPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central BMC Complementary and Alternative Medicine 2008, 8:40 ClosingDo you have any advice to give to the profession of phar-macy in regards to what their professional responsibilitiesfor NHPs should be?AcknowledgementsThis project was funded by a Partnerships for Health System Improvement grant from the Canadian Institutes for Health Research (200505PHE-149489). Additional funding came from the Advanced Foods and Materials Network (AFMnet).References1. Non-prescription Drug Manufacturers Association of Canada: A pro-file of the Canadian herbal market.   [http://www.ndmac.cindex.cfm?fuseaction=main.DspSubPage&PageID=10&Sub PageID=766&fkMainPage=0].2. Boon H: CAM and Pharmacists: Challenge or Opportunity?Focus on Alternative and Complementary Therapies 2005, 10(2):1-3.3. Morgall JM, Alamarsdottir AB: The new consumer -- implicationsfor pharmacy.  The International Journal of Pharmacy Practice 1999,7:198-201.4. Herzlinger RE: Market-driven health care: who wins, who losesin the transformation of America's largest service industry.New York , Addison-Wesley Publishing Co Inc.; 1997. 5. Traulsen JM Noerreslet, M.: The new consumer of medicine -the pharmacy technicians' perspective.  Pharmacy World & Sci-ence 2004, 26:203-207.6. Health-Canada: Baseline Natural Health Products SurveyAmong Consumers.   [].7. Kaufman: Recent patterns of medication use in the ambula-tory adult population of the United States.  The Slone Sur-vey.  Journal of the American Medical Association 2002, 287(3):337-344.8. Government-of-Canada: Natural Health Products Regulations.In Canada Gazette Part II Volume 137. Issue 13  Her Majesty the Queenin Right of Canada; 2003. 9. Kwan D Hirschkorn, K., Boon, H.: U.S. and Canadian pharma-cists' attitudes, knowledge, and professional practice behav-iors toward dietary supplements: a systematic review.  BMCComplementary and Alternative Medicine 2006, 6:31.10. Johnson T, Boon H, Jurgens T, Austin Z, Moineddin R, Eccott L, Hes-chuk S: Canadian pharmacy students’ knowledge of herbalmedicine.  American Journal of Pharmacy Education 2008  in press.11. Hibbert D Bissell, P., Ward, P.: Consumerism and professionalwork in the community pharmacy.  Sociology of Health & Illness2002, 24(1):46-65.12. Lewis D, Bridger D: The Sould of the new Consumer -- Authen-ticity what we buy and why in the new economy.  london ,Nicholas Brealey; 2000. 13. Zamaria C Caron, A.H., Fletcher, F.: Canada Online! A compara-tive analysis of Internet users and non-users in Canada andthe world: Behaviour, attitudes and trends 2004.  Toronto ;2005. 14. Beck U: The reinvention of politics: towards a theory ofreflexive modernization.  In Reflexive Modernization: Politics, Tradi-tion, and Aesthetics in the Modern Social Order Edited by: Beck UGALS.Polity , Cambridge; 1994:1-55. 15. Lupton D: Consumerism, reflexivity, and the medical encoun-ter.  Social Science & Medicine 1997, 45(3):373-381.16. Anderson JG Rainey, M.R., Eysenbach, G.: The impact of cyber-healthcare on the physician-patient relationship.  Journal ofMedical systems 2003, 27(1):67-84.17. Eysenbach G Jadad, A.R.: Evidence-based patient choice andconsumer health informatics in the internet age.  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Emanuel EJ, Emanuel LL: Four models of the physician-patientrelationship.  JAMA 1992, 267(16):2221-2226.26. Hepler CD, Strand LM: Opportunities and responsibilities inpharmaceutical care.  American journal of Hospital Pharmacy 1990,47:533-543.27. Prayle D, Brazier M: Supply of medicines: paternalism, auton-omy and reality.  Journal of Medical Ethics 1998, 24(2):93-98.Pre-publication historyThe pre-publication history for this paper can be accessedhere: — you keep the copyrightSubmit your manuscript here: 11 of 11(page number not for citation purposes)patient' in the changing landscapes of health information.Sociology of Health & Illness 2003, 25(6):589-607.


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