Re: Knowledge and Use of Herbal Medicine in Ethiopia by Community Pharmacists

Herbal Medicine Use and Knowledge Pharmacists Ethiopia Date: 06-30-2018 HC# 111746-595 Asmelashe Gelayee D, Binega Mekonnen G, Asrade Atnafe S, Birarra MK, Asrie AB. Herbal medicines: personal use, knowledge, attitude, dispensing practice, and the barriers among community pharmacists in Gondar, Northwest Ethiopia. Evid Based Complement Alternat Med. August 2017;2017:6480142. doi: 10.1155/2017/6480142. In Ethiopia, about 80% of the population depends on traditional medicines. The sale of traditional medicines is unregulated, with most sold in supermarkets and other shops.. As herbal medicines remain important at the local level, and of growing importance in the global market, there remains concern over product quality and safety and possible interactions with other herbs, drugs, and foods. A lack of appropriate patient/consumer education has spurred calls for more healthcare professional involvement with patients interested in herbal treatments. Community pharmacists in Ethiopia could be ideally situated to offer such involvement and counseling. In Ethiopia, "community pharmacies" include both "pharmacies" and "medicine stores," the former staffed by degreed pharmacists and the latter by pharmacy technicians. Most pharmacists work in these community settings. However, the undergraduate pharmacy programs in Ethiopia are perceived to offer "inadequate" education in alternative and herbal medicine, with only nine credit hours in the curriculum. The authors conducted this study to assess the personal use, attitude, and dispensing practice of herbal medicines by community pharmacists in Ethiopia. In this cross-sectional study, the authors administered a structured questionnaire to community pharmacists, including bothdegreed pharmacists and pharmacy techs, working in Gondar Town, Northwest Ethiopia, between October 2016 and January 2017. There were 53 community pharmacies in Gondar during the survey, but the number of community pharmacists approached was not included. The report says "all" were asked to participate and "about" 47 ("all of them") took part. The questionnaire queried sociodemographic data, practice related to herbal medicine, attitudes toward herbal medicine, knowledge of herbal medicine, and miscellaneous yes/no questions related to perceived barriers in dispensing herbal medicines. Several statistical comparisons were made, with P<0.05 considered significant for all. Most respondents were male (n=31, 61%), between 23 and 28 years of age (n=25, 53.2%), had at least a Bachelor of Pharmacy degree (n=27, 57.4%), had worked as a pharmacists for four years or less (n=25, 53.2%), and were employees of their workplace (n=28, 59.6%). Most had no additional training in herbal medicines (n=42, 89.4%) and said their access to herbal information was limited (n=36, 76.6%). Women respondents were more likely to say they had easy access to herbal information (P<0.001). Strikingly, given Ethiopia's lack of regulations, a majority (n=33, 70.2%) thought that pharmacists were "unauthorized" to dispense herbs. Cited in sociodemographic results, a majority "reported" the sale of herbs in non-pharmacy settings, with women being more likely to note such sales (P=0.016) and 43 (91.5%) subjects regarding such sales as inappropriate. In practice, nearly half of these community pharmacists used herbal medicines themselves (n=22, 46.8%), but only six (12.7%) said that they frequently dispensed herbs. Most, never or rarely counseled clients about herbal products (n=34, 72.3%); only 11 (23.4%) have ever been asked about them. Women were more likely than men (P=0.013) to report engagement with clients about herbal products, as were more experienced employees (5-16 years of work) compared to less experienced (1-4 years, P=0.041). Attitudes toward herbal medicine were generally positive, with 44 (93.7%) agreeing or strongly agreeing that herbal preparations are beneficial. A majority agreed that herbal preparations may exert a placebo effect (n=33, 70.2%). More experienced pharmacists were more likely (P=0.03) to agree with the existence of an herbal placebo effect. Of the respondents, 24 (51.1%) disagreed/strongly disagreed that herbs have fewer adverse effects (AEs) than conventional drugs, 38 (80.9%) agreed/strongly agreed that herbs can have serious interactions with drugs, and 35 (74.5%) disagreed/strongly disagreed that herbs have been sufficiently studied. Those between 23-28 years, degreed pharmacists, and employees were more likely than others to agree that herbs interact significantly with drugs (P=0.024, =0.035, and =0.045, respectively). Women were more likely than men to say herbs have been studied enough (P=0.006). While 21 (44.7%) respondents self-rated their knowledge of herbal medicine as acceptable, 13 (27.7%) said it was poor. Around half described their knowledge of herb/drug interactions, herbal AEs, and/or precautions for herbal use as poor. Women were more likely to have a better opinion of their herbal knowledge (P<0.001) than men. Women were more likely than men to better rate their knowledge of interactions (P=0.000), AEs (P=0.026), and/or precautions (P=0.008), as were less experienced pharmacists (P=0.021, =0.037, and =0.031, respectively). This study raises many issues for pharmacist involvement in herbal counseling and sales in Ethiopia, while the authors caution that it may be applicable only in Gondor. While limited access to information is identified as a barrier to practice in dispensing herbs, no reason is given for this lack. While many herbal resources are available on the internet, access to the internet is not mentioned by community pharmacists as a limitation. Reasons for the apparent dearth of herbal products in these community pharmacies are not explored; it would be interesting to explore the owners' views of this potential market. Similarly, no reason is given for most subjects' belief that they are unauthorized to dispense herbs, a belief that may extend to consumers. The authors suggest development of a formulary of herbal goods that are or could be sold in Ethiopian pharmacies, as was done in Malta with good results, as an "intervention." Schools of pharmacy should upgrade herbal curricula and consider adding continuing education programs to improve pharmaceutical care with herbal therapies. —Mariann Garner-Wizard