Background: Community pharmacists are often the first health professional approached to provide treatment for health issues, including the important mental health challenge, stress. Over-the-counter products for stress almost always are complementary and alternative medicines (CAM) and in Australia no protocol exists for their recommendation and sale in community pharmacies.

Objective: To assess the quality and relevance of community pharmacists’ information gathering (questioning), counselling and product selection when interacting with customers requesting a CAM product for stress and consequently determine whether Australian pharmacy practice indicates the need for guidelines similar to those provided for ‘pharmacy only’ (S2) and ‘pharmacist only’ (S3) medicines.

Methods: A covert simulated patient was used to investigate the response of pharmacists to a request for a natural product for stress. The SPs documented the details of the pharmacist-simulated patient interaction immediately on leaving the pharmacy and then re-entered the pharmacy to debrief the pharmacist. The quality of the interaction was scored as a Total CARE (check, assess, respond, explain) Score, based on anticipated questions and counselling advice. The appropriateness of the product was scored as a Product Efficacy Score, based on evidence-based literature.

Results: Data from 100 pharmacies was provided. Information gathering illustrated by the questioning components Check and Assess (C and A) of the total CARE score by pharmacists was poor. The number of questions asked ranged from zero (13 pharmacists) to 7 (four pharmacists), the average being 3.1 (SD 1.9). Provision of advice was generally better (a description of the suggested product was offered by 87 pharmacists) but was lacking in other areas (duration of use and side effects were explained by only 41 and 16 pharmacists respectively). The most common product suggested was B-group vitamins (57 pharmacists) followed by a proprietary flower essence product (19 pharmacists). A two-step cluster analysis revealed two sub-groups of pharmacists: one cluster (74 pharmacists) with a high Total CARE score provided an appropriate product. The other cluster (20 pharmacists) had a low total CARE score and provided an inappropriate product.

Conclusions: The pharmacy visits revealed major shortcomings in questioning, counselling and product recommendation. There is a need to develop guidelines for pharmacists to make evidence-based decisions in recommending complementary and alternative medicine.

Aim: The project aimed to explore factors surrounding the purchase in community pharmacy of complementary and alternative medicine (CAM), particularly those for the mental health issue, stress. The intention was to investigate this topic from the dual viewpoints of consumers and community pharmacists.

Background: The study brings together several issues which separately have been becoming more visible in Australia. The use of complementary and alternative medicine in the Australian community has been steadily increasing over several decades. In many instances, the consumer chooses to purchase these medicines to self-treat and community pharmacy is one of the main points of supply. Complementary and alternative medicine is sought for the common mental health problem of stress, usually when the person feels that stress has reached the stage where it has become difficult to cope. At that stage the consumer has often decided that intervention is needed, but rather than seek advice from a doctor or mental health professional, they choose to initially self-treat with complementary and alternative medicine purchased from a community pharmacy. Community pharmacists often choose to stock a wide range of such medicines, including those for stress, and the consumer sees the pharmacist as an expert in medicines, including complementary and alternative medicines. There may be a variety of factors that have brought the consumer to this point but crucially they have a desire to stay in control by selftreating and they often rely on advice from the pharmacist to assist them to do so.

Some previous research has been conducted into knowledge and attitudes of both consumers and pharmacists about complementary and alternative medicine in general, but this project is unique in examining the two perspectives and bringing them together in relation to the important issue of stress.

Methods: Two research studies were undertaken: the first, a qualitative study investigating the attitudes and beliefs of consumers regarding the purchase of complementary and alternative medicine for stress and a second quantitative study exploring the knowledge and professional practice skills of pharmacists during an interaction with a consumer seeking such a product for stress. In each case, a prior literature review was undertaken to assess what was already known and in each case there was a considerable gap in the literature, particularly regarding mental health and stress.

The first (qualitative) study explored the decision making process of pharmacy customers purchasing over-the-counter complementary and alternative medicine products for stress. The study was designed as an inquiry using semi-structured interviews of approximately 45 – 60 minutes. Participants were recruited by approaching pharmacy customers who had self-selected a product for stress in this category. The interview questions were guided by the CAM Healthcare Model, a model which aims to identify factors associated with the overall use of complementary and alternative medicine, including self-directed treatments. The interviews were recorded and transcribed verbatim and the resulting transcripts were coded and analysed for themes.

A simulated patient (SP) study was chosen as the second research project. This research method is a well-established tool in pharmacy research, and has been described as a rigorous and robust method of measuring practice if used appropriately and useful in the assessment of counselling and advice provision. The study was designed to assess the quality and relevance of community pharmacists’ information gathering (questioning), counselling and product recommendation during an interaction with a consumer seeking a natural product for stress. Covert simulated patients were used to investigate the response of pharmacists to a request for such a product. After leaving the pharmacy the SP recorded the details of the interaction and then re-entered the pharmacy to debrief the pharmacist. As no convention exists to guide pharmacists in interactions involving complementary and alternative medicine, the communication assessment was based on the CARER protocol, one of the protocols recommended by the Pharmaceutical Society of Australia for the sale of pharmacy only and pharmacist only medicines. The quality of the interaction was scored using the first four elements of the CARER (check, assess, respond, explain, record) protocol. Based on anticipated questions and counselling advice, interactions were allocated a Total CARE score. (Recording of CAM sales is not required.) A score, based on monographs in evidence-based literature was also allocated to the product suggested and termed the Product Efficacy Score. The resultant data was evaluated to provide descriptive statistics regarding consent, questioning, counselling and product suggestion. A second analysis, a two-step cluster analysis, was conducted to assess the relationship between the quality of the pharmacist-simulated patient interaction (determined by the Total CARE score) and the appropriateness of the product (determined by the Product Efficacy Score).

Findings: A thematic analysis of the data collected in the qualitative study illustrated four core concepts: complementary and alternative medicine was the participants’ first choice, self-sought information was always checked, a willingness or desire to tell their doctor was evident but there was a level of dissatisfaction with conventional care. These concepts align closely with the

predisposing personal trait of self-care ability/tendency as described in the CAM Healthcare Model. On closer examination, one key theme, control, was recognised as present in, and representative of, all four themes. In dealing with stress, the informants appeared to exhibit a high internal health locus of control (HLOC) ̶ the perception of controlling one’s own health choices and outcomes. Part of this control was manifested in the desire to check safety and efficacy with someone considered knowledgeable in CAM. This person was, in many cases, a pharmacist.

The second, quantitative study, was designed to assess pharmacists’ practice skills when confronted with a simulated patient requiring a complementary and alternative product for stress. Data was provided from 100 pharmacies. Information gathering (questioning of the simulated patient) was poor with the average number of questions asked being 3.1. Provision of advice was better with 87 pharmacists offering a description of the suggested product but was lacking in other areas. For example, duration of use and side effects were explained by only 41 and 16 pharmacists respectively. The most common product suggested was B-group vitamins (57 pharmacists). However, the second most recommended product on 27 occasions was a proprietary flower essence product with no pharmacological activity. A two-step cluster analysis revealed two sub groups of pharmacists: one cluster (74 pharmacists) with a high Total CARE score provided an appropriate product and the other cluster (20 pharmacists) had a low Total CARE score and provided an inappropriate product. There were major shortcomings in questioning, counselling, and product recommendation indicating a need to develop guidelines for pharmacists to make evidence-based decisions in recommending complementary and alternative medicine.

Conclusions: The research undertaken for this thesis has provided a unique scrutiny of important aspects of the practice skills of community pharmacists and the relationship with consumers purchasing complementary and alternative medicines for a common mental health issue, stress. People who find difficulty coping with their stress levels often turn to the community pharmacist, often the most accessible primary healthcare professional. These consumers often wish to control their own health and treatment choices and in so doing may rely on the knowledge and practice skills of the pharmacist to assist their decision making in the purchase of a product to self-treat their condition. The pharmacist, who of professional necessity should have patient-centred care as a core principle of practice, needs to be proficient in several aspects of this scenario. They need adequate interpersonal skills in dealing with the consumer, an understanding of the mental health issues involved and knowledge regarding the products (which, for stress, are almost invariably complementary and alternative medicines) so that an appropriate product recommendation or referral can be offered. As shown in this thesis, this is often not the case. This situation possibly reflects a lack of education either at university level or self-administered via continuing professional development. The areas of complementary and alternative medicine and mental health represent future educational possibilities that may prove advantageous to community pharmacists, consumers and public healthcare outcomes.

Context • The use of complementary and alternative medicine ( CAM) in Australia is widespread, and self-treatment with CAM often occurs. Community pharmacies are a major supplier of CAM in Australia; consequently pharmacists may be approached by consumers in relation to self-treatment.

Objectives• The study intended to appraise peer-reviewed literature regarding the supply of CAM in retail pharmacies and pharmacists' knowledge and attitudes in relation to it.

Design • The research team performed a narrative review of peer-reviewed studies published between January 1997 and December 2017. Four electronic databases-Web of Science, ScienceDirect, CINAHL, and PubMed-were systematically searched using keywords. A search strategy was devised using 4 keywords: knowledge and attitude, complementary and alternative medicine, stress, and pharmacist. English-language, full-text studies were sought, and the team considered only the results of studies conducted in Australia or in countries with similar healthcare systems.

Setting • The study is a literature study.

Results • Performance rankings were considered, with 10 studies being identified. Pharmacists were generally positive about CAM; however, they displayed a degree of uncertainty, particularly about efficacy and safety, that pointed toward a lack of confidence and a desire for better education. Knowledge, both self-rated and assessed, was lacking. Few studies explored the use of CAMs for specific physical-health conditions and fewer still addressed mental health.

Conclusions • Pharmacists are ideally placed to interact with consumers and are often the first point of contact for those people wanting to self-treat. Pharmacists may lack the necessary practice knowledge and skills to appropriately advise consumers about CAM or about those conditions where self-treatment products fall predominantly into the CAM category, such as for stress.