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Odili et al

Trop J Pharm Res, December 2006; 5 (2)619

Tropical Journal of Pharmaceutical Research, December 2006; 5 (2): 619-625 Pharmacotherapy Group,

Faculty of Pharmacy, University of Benin,Benin City, Nigeria.

All rights reserved.

Available online at http://www.tjpr.org

Research Artic le

Assessment of the Knowledge of CommunityPharmacists Regarding Common PhytopharmaceuticalsSold in South Western Nigeria

RasaqAdisa1 and TitilayoFakeye2*1State Ministry of Health, Osun State, NIGERIA

2Department of Clinical Pharmacy & Pharmacy Administration, University of Ibadan, Ibadan. NIGERIA.

Abstract

Purpose: The study was carried out to assess the knowledge of community pharmacists who sellherbal/phytopharmaceutical formulations in pharmacy retail outlets.Method: Questionnaires were administered to the pharmacists to gather information onphytopharmaceuticals regarding their use, side effects, potential drug-herb interactions andcontraindications of the phytopharmaceuticals sold in their retail outlets. Opinions on regulation, safetyand efficacy of herbal remedies were also obtained. Descriptive statistical tests and median scores wereused to evaluate the distribution of responses, opinions and perception of the pharmacists on their levelof knowledge of the phytopharmaceuticals, and effects of demographic data on the pharmacistsknowledge of the herbal remedies.Results: The study revealed that 31 (62%) sold imported herbal remedies and nutritional supplements.Seventy-two (72) % had received no postgraduate training on herbal medications. Most of thecommunity pharmacists agreed that they did not possess adequate knowledge of potential interactionprofiles and side effects of the herbal remedies sold. The training in pharmacy schools on herbal drugsand sale of phytopharmaceuticals in their outlets also had no influence (p>0.05) on desired knowledge.

Community pharmacists with less than 10 years of experience in the practice however possessed betterknowledge than pharmacists with more than ten years of professional practice (p=0.05)Conclusions: There was gross inadequacy in the pharmacists knowledge of the phytopharmaceuticalssold in pharmacies indicating an urgent need for intensive training in order to render better services totheir clients.

Keywords: Community Pharmacists, Herbal formulations/Phytopharmaceuticals, Knowledge base,Pharmacology

*Corresponding Author: E-mail: [email protected]; [email protected]

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Trop J Pharm Res,December 2006; 5 (2)620

INTRODUCTION

A wide range of products such as herbalpreparations, homeopathic remedies, andnutritional supplement of natural originconstitutes complementary medicine. Herbalproducts contain aerial or underground parts ofplants or other plant materials or combinationsof these. These could be in a crude state or asplant preparations, which may include juices,gums, fatty acids, essential oils and many othersubstances of nature for medicinal purposes

1

and are also referred to as

phytopharmaceuticals. Most patients usuallythink of herbal drugs as a risk-free option, andas a safe and natural alternative toconventional orthodox drugs

2,3. Health

professionals generally face the problem ofassessing the effectiveness and safety of naturalremedies. Information regarding these productsis not readily available in official references.Some of these products have not been asextensively studied as allopathic drugs and areusually sold without much knowledge of their

mechanisms of action or side effects1

.Though the use of complementary medicines issometimes beneficial and the evidence for theefficacy of some of these medicines in literatureis limited, they are often sold alongsideallopathic drugs in pharmacies

4. The sale and

use of phytopharmaceuticals in combination withallopathic medicines are on the increase andhave also found major use in self medication.The role of the community pharmacists in theuse of complementary medicines cannot be

undermined since these medicines are soldover-the-counter in pharmacies in somecountries and as prescription medicines inothers. Furthermore, patients generally dependon pharmacists for advice and information ondrugs, including herbal remedies. In mostdeveloping countries, however, there is aserious lack of regulation of herbal medicationsbeyond their safety. This is unlike what obtainsin some developed countries

5which also seek

to ensure that some of the claims of efficacy onthe labels are met.

Imported herbalremedies/phytopharmaceuticals, which arewidely sold in pharmacies in Nigeria, are not

made to undergo rigorous efficacy screening,

except for safety. Sometimes, few locally madeherbal formulations are also sold in registeredpharmacies. In a study carried out in the USA,there was observed a deficiency in knowledgebase of pharmacists on the pharmacology ofphytopharmaceuticals

2. Literature is scanty on

studies carried out on the level of knowledge ofpharmacology possessed by pharmacists in thearea of herbal formulations in developingcountries, especially Nigeria, where lately therehas been a trend to sell imported packagedherbal medicines alongside allopathic

medicines. Therefore, there is a need to assessthe level of knowledge of the communitypharmacists who are, in developing countries,the custodians of these medications.This study was carried out to assess the level ofcompetence and knowledge of communitypharmacists in southwestern Nigeria on theuse,safety profile, drug interaction potential andeffectiveness of herbal remedies sold inpharmacies. The pharmacists opinions aboutregulatory issues, professional responsibilities in

the sale and use of herbal formulations, andlevel of training required for competence werealso investigated.

METHODSThe list of Association of CommunityPharmacists of Nigeria (ACPN) in the statesavailable as at time of study was used as thesource for selection of pharmacists in the study.Informed consent of the pharmacists taking partin the study was obtained. From the available

records of 250 licensed premises in the year2004 in the two states as at the time of thestudy, seventy registered communitypharmacists in the region were selected withone Pharmacist being chosen per premises.Every third pharmacy on the list was chosen.The inclusion criteria included a registeredpharmacy with a superintendent pharmacist inattendance at least 8 hours daily. In caseswhere a pharmacy has branches or otheroutlets, only one of its outlets was selected.Pharmacies in rural areas were excluded.

Study design and data collection:-Questionnaire, which was the instrument usedfor collecting information, was designed to

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obtain demographic data such as year of

qualification, year of practice as a communitypharmacist; elicit relevant information on theirlevel of awareness, attitude and relevant trainingreceived on the use of herbal drugs, legal andethical values, and their perceived professionalresponsibilities towards complementarymedicines especially herbal drugs. In this study,we tried to differentiate herbs from vitamins andminerals. A herbal drug was defined as a refinedor raw extract from plant origin excludingmultivitamins or minerals. This however includesmultivitamin or mineral preparations containing

ingredients such as Gingko biloba or ginseng ofany origin. A survey of herbal remedies sold inthose pharmacies was collected from thepharmacies. The most common ten of thesewere chosen for the study.The knowledge baseof the community pharmacists on the uses,contraindications and potential drugherbinteractions was tested by the use of fifteen (15)questions which were based on commoninteractions of these herbs. Each question hadone correct answer, two incorrect answers and a

no idea response. The questionnaires weregiven to the selected community pharmacists tobe filled in their respective pharmacies. Thename of the pharmacy or pharmacist was notrequested for on the questionnaire to ensureanonymity of the respondents. The pharmacistswere informed that their response would help indetermining whether there is adequate trainingor there is need for additional training forpharmacists in the area of herbal remedies.The questionnaires were pre-tested among five

experienced leading community pharmacists inthe locality who were not included in the study.

Data Analysis: The correct answers to thequestions were obtained using peer-reviewedjournal articles on the subjects

6-11. Responses

to questions on pharmacology of specific herbswere graded. Each correct answer was assigneda score of 1 while a non-response, a wronganswer or a no idea response was scored 0.The maximum obtainable score was 15 and thepass mark was set at 8 out of 15 (53%).

Descriptive statistics was used for the responsesof the community pharmacists. Comparison ofthe median scores obtained by respondents was

used to evaluate if the difference observed in

scores was due to influence of certain variableson the knowledge base of the pharmacists onthe pharmacology of herbal medicine. Statisticalsignificance was set at p0.05.

RESULTSA total of 70 questionnaires were given out tothe respondents but only 50 (71.4%) wereproperly filled and analyzed. Table 1 shows thesummary of the respondents scores based oncertain variables.Majority of the respondents, 37 (74%), scored

less than 53% (i.e. below 8 out of 15) on thequestions on the use, adverse effects andinteraction potentials of the commonly soldherbal formulations/ nutritional supplements intheir area. Only 1 (2%) scored above 70% while5 (10%) and 7 (14%) scored 53-59% and 60-69% respectively. It was observed that only 14respondents (28%) had earlier received a formof training on complementary medicines usuallyin form of workshop and seminars while 36respondents (72%) had not received any. Forty-

two (84%) pharmacists had less than 10 yearsof experience in community pharmacy practicewhile only 8 respondents (16%) had put morethan 10 years of practice into communitypharmacy. Respondents with less than ten yearspost graduation experience showed betterknowledge (p

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given by the patients. Only 2 (4%) sold based onprescription or recommendation by medicaldoctors. On the question of what group ofcomplementary medicines should be sold onlyby pharmacists, 16 (32%), responded that bothherbal remedies and nutritional supplementsshould be sold only by pharmacists.A large number of respondents, 39 (78%) were

of the opinion that the National Agency for Food& Drug Administration & Control (NAFDAC)should also be charged with the responsibility forregulating the sales and supply of

complementary medicines in the country as it isbeing presently done for allopathic medicines.Five (10%) were however of the opinion that theregulation on complementary medicines shouldbe the responsibility of the Pharmacists Councilof Nigeria (PCN) while one respondent (2%)believed that the Traditional Medical Councilshould be responsible for the regulation of the

sale and supply of these medicines. Somerespondents, 36 (72%) agreed that the code ofethics of pharmacy profession is in support of

Table 1: Scores obtained by different groups of respondents

Basis ofClassification

Group ofrespondents

Frequency (%frequency)

Mean score SD Median P value

Postgraduationtraining

(workshops,seminars etc)

14 (28) 6.43 2.44 6.50Training

Withoutpostgraduation

training

36 (72) 5.36 2.18 5.00

0.13

Yes 31 (62) 5.94 2.41 5.00Carrying ofcomplementary

medicines No 19 (38) 5.37 0.65 5.00

0.40

> 10 years 8 (16) 4.25 1.67 5.00Postgraduationexperience

10 years 42 (84) 6.00 2.35 6.00

0.13

Yes 23 (46) 5.48 2.35 5.00Relationship wi thtraditional

medical doctor No 27 (54) 5.93 2.34 6.00

0.42

Pharmacists 39 (81) 5.62 2.72 5.00Who shouldstock

complementarymedicines

TraditionalMedical

Practitioners

9 (19) 6.00 1.416.00

0.47

10 years42 (84) 6.00 2.35 5.50Years of practice

as communitypharmacist

> 10 years 8 (16) 4.25 1.67 4.00

0.05*

* - significant at p=0.05

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community pharmacists handling the sale andsupply of complementary medicines.The majority, 47 (94%), cited basicpharmacognosy courses done duringundergraduate pharmacy training in theuniversity as the only formal training they hadreceived in herbal remedies. They alsosuggested the incorporation of complementary

medicine training into the undergraduatePharmacy curriculum. Many (43, 86%) believedthat pharmacists should acquire adequate andformal training on complementary medicines asthis would enhance their professional skill andknowledge of complementary medicines.However, 7 (14%) believed that constantreading of available up-to-date literature and notnecessarily formal training is required. Some 24(48%) believed that herbal medicines andnutritional supplements should be classified asover-thecounter (OTC) medicines, 17 (34%) as

prescription-only-medicines (PoM) while 9 (18%)were of the opinion that they should be classifiedas dietary supplements.It was observed that respondents had differentopinions on the safety and efficacy of thesemedicines as shown in Table 2. Only 13 (26%)claimed to have observed gastrointestinaldisturbances such as diarrhea as the only formof adverse reactions in some patients usingcomplementary medicines.

DISCUSSIONThe pharmacists involved in this study wereselected from the list of registered pharmacistsin two of the states located in southwestern part

of Nigeria. However, the list contained thenames of pharmacists who had completed theirregistration as at September, 2004 only. Thereexists the possibility that the list was notrepresentative of the pharmacists in the regionsince finance is one of the factors which maycause late registration. Also, there might havebeen more knowledgeable pharmacists (in the

area of complementary medicines) in the otherfive geo-political zones of the country, thoughthis is not likely since the region studied has fourof the approved pharmacy schools in thecountry.Though a majority of the pharmacists claimedthat the only training they had received onherbal drugs was the basic pharmacognosycourse, pharmacists with less than 10 years postgraduation experience scored higher than theircounterparts who had graduated earlier. Thismay either be due to more relevant topics on the

subject which were introduced while they wereunder training, or that this group of pharmacists,being younger and more recent graduates, hadkept up to date by reading scientific publicationsthat had to do with herbal remedies. Thisquestion was however not raised during thecourse of the study. The undergraduate trainingin pharmacognosy received by the majority ofrespondents included topics on unorganized andorganized vegetable drugs, separationtechniques, and drugs of biological origin.

Knowledge of medicinal plants and traditionalmedicine was perceived by the respondents tobe elementary compared to the neededknowledge especially in the area of

Table 2: Opinion of community pharmacists to the effectiveness and safety of herbal

medications

Opinion (Safety) Frequency (%)

Highly safe 28Moderately safe 34Mildly safe 18Not Safe 8Opinion (Effectiveness)Highly effective 18Moderately effective 44Mildly effective 22

Not effective 4

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pharmacology of herbal medications. A similar

study carried out in 2000

2

in some cities ofUnited States of America showed that continuingeducation in herbal remedies placedpharmacists at an advantage in their knowledgebase. Majority of the respondents recognizedtheir inadequacies with phytopharmaceuticalsand observed a need for incorporating trainingon the pharmacology of phytopharmaceuticalsinto the undergraduate pharmacy curriculum.The Pharmacists Council of Nigeria (PCN) andthe National Universities Commission (NUC),which are the bodies responsible for the training

of pharmacists in Nigeria, have in recent timecalled for review and upgrading of coursestaught in pharmacy to reflect the recent trends inpharmacy programme worldwide, and thisincludes pharmacognosy and pharmacologycourses as well. Previous studies

4,12have

shown that though undertaking training does notnecessarily reflect adequate knowledge orcompetence, the content, relevance, quality andduration of training are also important.Although herbal medicines are not sold by some

respondents due to their limited knowledge,majority of the respondents believed thatpharmacists are the most qualified professionalto handle the sale and supply of complementarymedicines and therefore should take up thechallenge of re-education in the use andpotential interaction profile of complementarymedicines generally and herbal remediesspecifically. This response was similar to thoseobserved by Chang et al

2and were in line with

the submission of Barnes4

where it was

emphasized that the issue of complementarymedicines is an area that pharmacists cannotafford to ignore and it is obvious that communitypharmacists need to develop their knowledgebase on herbal remedies in order to be able toadvise patients appropriately

2,13.

Most of the pharmacists rightly believed there isneed for a more intensive effort on the part ofNAFDAC to ensure the safety and efficacy ofherbal drugs. Safety issues are not sufficient forherbal drugs. The efficacy of the herbal drugsimported into the country should also be

ensured by making sure that they areaccompanied by a certificate that properpharmacological and quality control have been

carried out on these groups of drugs and that

honest claims about the efficacy are being made(as they are being presently being done forallopathic drugs). The ones that are formulatedand advertised for public use locally should alsoundergo tests that will establish or refute theefficacy claims. Another problem that may becausing the seeming inaction of NAFDACregarding herbal drugs may be due to the factthat in Nigeria, as in a number of countries,some botanical products are sold as food orfood supplements, meaning that no claims onthe efficacy of the products can be made. In

practice, this means that there are a largenumber of botanical products which are freelyavailable in the country. In some other countrieshowever, these preparations are seen asmedicine with full or simplified registrationrequirements. In a number of countries, theseproducts are automatically linked to a pharmacy-only status

14-19. These differences indicate that

there may be no consensus on the classificationof botanical products, since basically twodifferent approaches are followed namely:

botanical health products under food legislation,and herbal medicinal products underpharmaceutical legislation. Though countriessuch as Brazil have been able to put up rulesthat will ensure the efficacy and safety issues ofsome of their herbal drugs, ineffectiveness ofGovernmental Inspection Agencies is however aproblem in such places

20.

This study revealed a gross deficiency in theknowledge base of community pharmacists onpharmacology of herbal remedies especially

since it is this group of pharmacists that havemore contact with members of their communitieseither for advice / consultation on drugs. Futureplan will involve the evaluation of the pre- andpost impact of an intervention programme on theknowledge base of community and hospitalpharmacists on pharmacology and relevantquestions on phytopharmaceuticals.

CONCLUSIONThis study revealed that most communitypharmacists interviewed generally had poor

knowledge of the commonphytopharmaceuticals sold in their pharmacies.There is a need for community pharmacists to

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constantly educate themselves in order to be

properly equipped to face the challenge ofproviding optimal care and counseling forpatients who use herbal remedies. Pharmacistsalso need to get more familiar with the safety,drug interaction potentials and efficacy of herbalremedies sold in their pharmacies.

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15. WHO. Regulatory situation of herbal medicines. WorldHealth Organisation, Geneva 1998; pp1-25

16. EAS Marketing food supplements, fort ified andfunctional food in Europe. European AdvisoryServices, Brussels. 2000

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