Student pharmacists' attitudes toward complementary ...

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Participants: 887 student pharmacists in 10 U.S. colleges/schools of phar- macy. Intervention: ... Meeting, Kissimmee, FL, July 16, 2012. Published online ahead of print at ..... dents, lack of incentives, and technical issues in survey distribution.
RESEARCH

Student pharmacists’ attitudes toward complementary and alternative medicine Marwa Noureldin, Matthew M. Murawski, Holly L. Mason, and Kimberly S. Plake Received November 5, 2012, and in revised form May 28, 2013. Accepted for publication June 18, 2013.

Abstract Objectives: To explore student pharmacists’ attitudes toward complementary and alternative medicine (CAM) and examine factors shaping students’ attitudes. Design: Descriptive, exploratory, nonexperimental study. Setting: Electronic survey of student pharmacists between March and October 2011. Participants: 887 student pharmacists in 10 U.S. colleges/schools of pharmacy. Intervention: Cross-sectional survey. Main outcome measures: Student pharmacists’ attitudes regarding CAM using the attitudes toward CAM scale (15 items), attitudes toward specific CAM therapies (13 items), influence of factors (e.g., coursework, personal experience) on attitudes (18 items), and demographic characteristics (15 items). Results: Mean (±SD) score on the attitudes toward CAM scale was 52.57 ± 7.65 (of a possible 75; higher score indicated more favorable attitudes). Students agreed that a patient’s health beliefs should be integrated in the patient care process (4.39 ± 0.70 [of 5]) and that knowledge about CAM would be required in future pharmacy practice (4.05 ± 0.83). Scores on the attitudes toward CAM scale varied by gender (women higher than men, P = 0.001), race/ethnicity (nonwhite higher than white, P < 0.001), type of institution (private higher than public, P < 0.001), previous CAM coursework (P < 0.001), and previous CAM use (P < 0.001). Personal experience, pharmacy education (e.g., coursework and faculty attitudes), and family background were important factors shaping students’ attitudes. Conclusion: Student pharmacists hold generally favorable views of CAM, and both personal and educational factors shape their views. These results provide insight into factors shaping future pharmacists’ perceptions of CAM. Additional research is needed to examine how attitudes influence future pharmacists’ confidence and willingness to talk to patients about CAM. Keywords: Complementary and alternative medicine, student pharmacists, perceptions, attitudes, surveys. J Am Pharm Assoc. 2013;53:618–625. doi: 10.1331/JAPhA.2013.12212

Marwa Noureldin, PharmD, MS, is a graduate student, College of Pharmacy and Center on Aging and the Life Course, Purdue University, West Lafayette, IN. Matthew M. Murawski, BSPharm, PhD, is Associate Professor of Pharmacy Administration; and Holly L. Mason, PhD, is Senior Associate Dean and Professor of Pharmacy Administration, College of Pharmacy, Purdue University, West Lafayette, IN. Kimberly S. Plake, BSPharm, PhD, is Associate Professor of Pharmacy Practice, College of Pharmacy and Center on Aging and the Life Course, Purdue University, West Lafayette, IN. Correspondence: Marwa Noureldin, PharmD, MS, College of Pharmacy, Purdue University, Heine Pharmacy Bldg., 575 Stadium Mall Dr., West Lafayette, IN 47907. Fax: 765-496-1886. E-mail: mnoureld@ purdue.edu Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To the following faculty members for assistance with data collection: Emily Ambizas, BSPharm, PharmD (St. John’s University); Karen Bastianelli, BSPharm, PharmD (University of Minnesota); Yasmin Grace, BS, PharmD, Erin Dorval, PharmD (Palm Beach Atlantic University); Youness Karodeh, PharmD (Howard University); Stefanie Ferreri, PharmD (University of North Carolina at Chapel Hill); Shanna O’Connor, BA, PharmD (at the time of the study University of North Carolina at Chapel Hill, currently University of Washington ); Katherine Kelly Orr, PharmD (University of Rhode Island); Kimberly Plake, PhD, BSPharm (Purdue University), Megan Thompson, PharmD (University of New Mexico); Jenny Van Amburgh, BSPharm, PharmD (Northeastern University); and Terri Warholak, PhD, BSPharm (University of Arizona). Also to the Purdue University Statistical Consulting Services for assistance with analysis. Previous presentations: American Association of Colleges of Pharmacy Annual Meeting, Kissimmee, FL, July 16, 2012. Published online ahead of print at www. japha.org on October 18, 2013.

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he National Center for Complementary and Alternative Medicine (NCCAM) defines complementary and alternative medicine (CAM) as a collection of medical and health care systems, practices, services, and products that are not considered part of a country’s conventional medical system.1 Complementary therapies are used alongside conventional medicine, while alternative therapies are used instead of conventional medicine; however, the terms are typically combined into CAM in the literature.1 According to NCCAM, approximately 38% of American adults use CAM.1 Patients often use CAM therapies along with their prescription medications to treat chronic conditions or to prevent illness, and many do not inform their physicians about CAM use.1–3 CAM use by patients has been associated with decreased adherence to prescription medications and increased risk for drug interactions.3 Pharmacists are considered among the most accessible members of the health care team and are frequently approached by patients for health- and medicationrelated questions.4,5 Despite the frequency of CAM use and patient inquiries to pharmacists regarding these therapies, many pharmacists do not feel they are well equipped to handle questions regarding CAM,5,6 believe they lack sufficient knowledge about CAM, and rarely initiate conversations with patients about CAM use.5,7

At a Glance

Synopsis: The results of this study indicated that student pharmacists believe that knowledge regarding complementary and alternative medicine (CAM) is essential to their future practice of pharmacy and feel that patients’ health beliefs should be integrated in the patient care process. Several factors shape student pharmacists’ attitudes toward CAM, including personal experience with CAM therapies, pharmacy education (e.g., coursework, faculty attitudes), family background, and demographic characteristics (e.g., gender and race/ethnicity). Analysis: Pharmacists can play an active role in advising patients about CAM and providing evidencebased information regarding the safety and efficacy of these therapies. Given the prevalence of CAM use, future pharmacists should develop adequate knowledge regarding such therapies and be able to confidently communicate with patients about CAM. Future studies focused on how students’ attitudes influence their confidence and willingness to talk to patients about CAM therapies may provide insight into factors shaping student pharmacists’ behavior and how that may impact their behavior as pharmacists.

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Pharmacists’ perceived limited knowledge regarding CAM therapies may affect their attitudes toward CAM and influence whether they are willing to advise patients about CAM therapies.8 To address pharmacists’ lack of knowledge of CAM, the Accreditation Council for Pharmacy Education issued guidance on adding CAM topics to pharmacy curricula, including “dietary supplements, alternative medical treatments, evaluation of alternative and complementary medicine purity, safety, and efficacy, herbal-drug interactions, and the Dietary Supplement Health and Education Act.”9 In addition, the North American Pharmacist Licensure Examination has a competency addressing dietary supplements.10 Although no recent studies have examined the status of CAM education in U.S. pharmacy schools, Shields et al.11 reported that 80% of pharmacy schools offered some form of CAM education in 2003. However, CAM-related education often was not integrated into pharmacy schools’ core curricula.10–12 Few studies have examined student pharmacists’ attitudes toward CAM in U.S. colleges/schools of pharmacy, and these studies have been geographically limited, typically assessing attitudes at one or two universities.12–14 In addition, factors shaping students’ attitudes toward CAM have not been explored in depth. Previous studies have suggested that student pharmacists have an overall favorable view of CAM therapies and believe knowledge about CAM is important to them as future health care practitioners.10,12–14 Baugniet et al.14 reported that 98% of student pharmacists agreed that practitioners should have some knowledge regarding common CAM therapies and should be able to advise patients about complementary therapies (88.1%). In addition, Harris et al.12 reported that 85% of student pharmacists believed “clinical care should integrate the best of conventional and CAM practices.”

Objectives The objectives of this study were to explore (1) student pharmacists’ attitudes regarding CAM across multiple U.S. colleges/schools of pharmacy and (2) factors associated with these attitudes (e.g., demographic characteristics, coursework, faculty, peers, friends, family, culture, media).

Methods A 61-item electronic survey was developed and distributed using Qualtrics Survey Software (Qualtrics Lab, Provo, UT) to first-, second-, and third-professional-year students at 10 colleges/schools of pharmacy across the United States between March and October 2011. Fourthprofessional-year students were excluded to minimize variability associated with experiential learning experiences and focus on the role of didactic components and personal experiences on attitudes toward CAM. The study protocol was approved by the institutional review j apha.org

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boards (IRBs) of Purdue University and the participating universities. Pharmacy faculty who were willing to participate in the study were recruited from the Self-Care Therapeutics/Nonprescription Medicine Special Interest Group of the American Association of Colleges of Pharmacy (AACP). Ten faculty members indicated their willingness to participate; however, because of variation in the IRB approval process across universities, survey administration was not simultaneous across institutions. Participating universities included a mix of public and private institutions, as well as institutions from different geographic regions in the United States. Data collection started in March 2011 and ended in October 2011. Faculty members at the participating institutions served as the primary contact person and were responsible for forwarding an e-mail with a survey link to their college/school’s listserv of first-, second-, and thirdprofessional-year students. To encourage participation in the e-survey, two follow-up e-mails were sent and primary contact persons were asked to announce the survey to students in class. No incentives were offered to faculty or students for study participation. The survey (Appendix 1 in the electronic version of this article, available online at www.japha.org) consisted of five main sections. The first section was the attitudes toward CAM scale (15 items), which uses a five-point Likert-type scale (from 1, strongly disagree, to 5, strongly agree) for each item. Nine items were adapted from the CAM Health Belief Questionnaire, which was developed and validated for medical students15 and has been used in studies assessing health professional students’ attitudes toward CAM.12–14,16 Additional items were developed based on surveys used in previous studies assessing attitudes toward CAM.10,13,17 According to Fishbein and Ajzen,18 use of Likert scaling allows for measurement of attitudes based on the 15 belief statements in this section. The second section assessed students’ attitudes toward 13 CAM therapies, specifically their views regarding the acceptability of using certain CAM therapies with conventional medical therapies. A five-point Likert-type scale (from 1, strongly disagree, to 5, strongly agree) was again used allowing for measuring attitudes. The 13 CAM therapies chosen are representative of the five CAM domains defined by NCCAM: (1) biologically based therapies (e.g., dietary supplements, vitamins/ minerals), (2) manipulative and body-based therapies (e.g., massage, chiropractic care, acupuncture), (3) mind– body interventions (e.g., hypnosis, biofeedback, spirituality/prayer), (4) energy therapies (e.g., Reiki, Qigong), and (5) alternative medical systems (e.g., homeopathy, Traditional Chinese Medicine [TCM], Ayurvedic medicine).1 The third section focused on nine factors that may shape students’ attitudes toward CAM. A four-point scale (from 1, not at all influential, to 4, highly influential) 620 JAPhA | 5 3:6 | NOV/DEC 2013

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was used to assess the influence of each factor on attitudes toward CAM. In addition, a three-point scale (negative, neutral, or positive) was used to explore whether the factors influenced students’ attitudes in a positive or negative direction. The nine factors included coursework, faculty, family background, cultural background, peers, friends, personal experience with CAM, professional experience with CAM (e.g., attitudes of pharmacists in a work setting), and media (e.g., Internet, television). Although family and culture are related, family referred to the influence of attitudes or behaviors of the students’ immediate family members on students’ view of CAM, while cultural background was used to indicate a broader concept (encompassing family but also including ethnic, religious, or social background). The last section consisted of 15 demographic items: age, gender, race/ethnicity (i.e., American Indian or Alaska Native; Asian; black; Hispanic, Latino, or Spanish origin; Native Hawaiian or other Pacific Islander; white; other), year in the professional program (first, second, or third), college/school currently attending, students’ country or state of origin, previous CAM coursework (yes or no), previous CAM use by the student (yes or no), and previous pharmacy work experience (i.e., none, community, hospital, other). The instrument underwent two phases of pretesting, as well as review by the project committee, before administration. The project committee consisted of three faculty members with experience in survey development; they evaluated the instrument for face validity. Pretesting occurred among convenience samples of fourth-year-professional students (n = 10) and pharmacy practice graduate students (n = 5) from Purdue University (West Lafayette, IN) to assess length and format of the survey, functionality of the Web survey, and clarity of instructions and questions. Data analysis Statistical analysis was performed using SPSS version 18.0 (SPSS, Chicago). Descriptive statistics were used to summarize the data. Independent t tests were used to identify differences in students’ attitudes toward CAM based on gender, race/ethnicity (white versus nonwhite), type of institution (public versus private), previous CAM use, previous CAM coursework, and previous pharmacy work experience (no experience versus work experience). Previous pharmacy work experience was collapsed for ease of reporting and because sample sizes were not always adequate for analysis. Because of the small sample sizes of several racial/ethnic groups (American Indian or Alaska Native; black; Hispanic, Latino, or Spanish origin; Native Hawaiian or other Pacific Islander; and other) race/ethnicity was collapsed in two ways: (1) as a dichotomous variable (white versus nonwhite) for ease of reporting and (2) as white versus Asian versus other due to the adequate sample size of students Journal of the American Pharmacists Association

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Table 1. Demographic characteristics of student pharmacist respondents Characteristic Age, years (n = 807) ≤21 22 23 ≥24 Gender (n = 816) Men Women Race/ethnicity (n = 842) White Asian Hispanic, Latino, or Spanish origin Black American Indian or Alaska Native Native Hawaiian or Pacific Islander Other International student (n = 818) Yes No Year in the professional program (n = 808) 1st 2nd 3rd Geographic region of college of pharmacy (n = 805) Northeast Midwest South West Type of institution (n = 805) Public Private Previous pharmacy work experience (n = 887) None Community Hospital Other Taken CAM elective course (n = 816) Yes No Used CAM therapy (n = 814) Yes No CAM therapy used (n = 887) Vitamins/minerals Dietary supplements Massage Spirituality/prayer Chiropractic care

No. (%) 191 (23.7) 145 (18.0) 128 (15.9) 343 (42.5) 264 (32.4) 552 (67.6) 534 (60.2) 153 (17.2) 64 (7.2) 57 (6.4) 10 (1.1) 1 (0.1) 23 (2.6) 34 (4.2) 784 (95.8) 288 (35.6) 250 (30.9) 270 (33.4)

375 (46.6) 248 (30.8) 55 (6.8) 127 (15.8) 537 (66.7) 268 (33.3) 101 (11.4) 623 (70.2) 270 (30.4) 83 (9.4) 139 (17.0) 677 (83.0) 609 (74.8) 205 (25.2) 567 (63.9) 427 (48.1) 344 (38.8) 298 (33.6) 194 (21.9)

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Table 1 continued Homeopathic products Traditional Chinese Medicine Acupuncture Biofeedback Ayurvedic medicine Reiki Qigong Hypnosis Other

116 (13.1) 87 (9.8) 74 (8.3) 45 (5.1) 40 (4.5) 22 (2.5) 22 (2.5) 14 (1.6) 28 (3.2)

Abbreviation used: CAM, complementary and alternative medicine.

who identified as Asian. Analysis of variance was used to determine whether differences in students’ attitudes toward CAM existed based on year in the program and race/ethnicity (white versus Asian versus other). Bonferroni-corrected multiple comparison tests were used to determine between-group differences post hoc. An a priori alpha of 0.05 was used for all statistical tests. To assess the internal reliability of the 15-item attitudes toward CAM scale, a Cronbach’s alpha was calculated and found to be 0.833. Based on Nunnally’s recommendations, a Cronbach’s alpha of 0.7 or greater was considered acceptable and to indicate good reliability.19

Results A total of 1,262 of an estimated 3,879 students from 10 colleges/schools of pharmacy (raw response rate 32.5%) received and opened the link to the e-survey. A total of 887 students responded to survey questions (usable response rate 22.9%), and their responses were included in data analysis. Demographic characteristics are presented in Table 1. The mean (±SD) age was 25.0 ± 6.1 years, and 60.2% of respondents were white. The distribution of first- (35.6%), second- (30.9%), and third- (33.4%) professional-year students was relatively equal. The majority of respondents (70.2%) had community pharmacy experience, while 11.4% stated that they did not have any pharmacy work experience. A majority of students (74.8%) indicated that they had used CAM therapies in the past, with vitamins and minerals being the most commonly used therapy (63.9%), followed by dietary supplements (48.1%), massage (38.8%), and spirituality/prayer (33.6%). Attitudes toward CAM Student pharmacists’ attitudes regarding CAM were assessed using the attitudes toward CAM scale, which has a possible range of 15 to 75 (higher score indicating a more favorable overall attitude18) (Table 2). The overall mean (±SD) for the scale was 52.57 ± 7.65. The statement “A patient’s health beliefs and values should be integrated into the patient care process” had the highest mean (4.39 ± 0.70 of a possible 5), with 91.7 % of students agreeing (i.e., agreeing or strongly agreeing) with it. A majorj apha.org

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Table 2. Students’ responses to attitudes toward CAM scalea (n = 885) Mean ± SD 3.55 ± 0.97 3.53 ± 0.97 2.99 ± 1.12 3.92 ± 0.78 3.81 ± 0.76 4.39 ± 0.70 3.95 ± 0.79 3.19 ± 0.97 2.80 ± 0.88 2.06 ± 0.79 2.37 ± 1.05 3.34 ± 1.05 2.80 ± 1.14 2.68 ± 1.16 4.05 ± 0.83 52.57 ± 7.65

Item A patient’s symptoms should be regarded as a manifestation of a general imbalance or dysfunction affecting the whole body. The body is essentially self-healing and the task of a health care provider is to assist in the healing process. Health and disease are a reflection of balance between positive life-enhancing forces and negative destructive forces. CAM therapies include ideas and methods from which conventional medicine could benefit. There are limitations to conventional approaches in health care. A patient’s health beliefs and values should be integrated into the patient care process. Patients should have the right to choose between conventional and alternative approaches in health care. Treatments not tested in a scientifically recognized manner should be discouraged. Effects of CAM therapies are usually the result of a placebo effect. Complementary medicine is a threat to public health. Alternative medicine is a threat to public health. I am personally interested in CAM therapies. CAM is an important aspect of my family’s health care. CAM is an important aspect of my culture. Knowledge about CAM will be required in my future practice of pharmacy. Overall scorea Abbreviation used: CAM, complementary and alternative medicine. Scale: 5, strongly agree; 4, agree; 3, neutral; 2, disagree; 1, strongly disagree. a Total score (of 75 possible).

Table 3. Student pharmacists’ views regarding acceptability of 13 CAM therapies (n = 823) Item Biologically based therapies Vitamins and minerals Dietary supplements Manipulative and body based Massage Chiropractic care Acupuncture Mind–body interventions Spirituality/prayer Biofeedback Hypnosis Energy therapies Qigong Reiki Alternative medical systems Traditional Chinese Medicine Ayurvedic medicine Homeopathy

5 %

4 %

3 %

2 %

1 %

Mean ± SD

35.8 24.1

58.2 57.6

5.5 13.6

0.5 3.9

0.0 0.9

4.29 ± 0.59 4.00 ± 0.78

30.7 23.1 17.7

56.1 52.7 47.0

11.2 17.9 26.9

1.8 4.7 6.2

0.2 1.6 2.2

4.15 ± 0.70 3.91 ± 0.85 3.72 ± 0.90

23.6 11.4 6.7

45.9 41.7 27.3

21.1 36.7 43.0

5.8 8.1 17.6

3.5 2.1 5.3

3.80 ± 0.98 3.52 ± 0.88 3.12 ± 0.96

7.4 7.3

27.5 26.9

48.4 48.8

11.7 11.5

5.1 5.5

3.20 ± 0.92 3.19 ± 0.93

8.6 6.9 10.1

36.0 29.6 32.5

41.8 50.7 37.0

10.1 9.6 12.6

3.5 3.2 7.8

3.36 ± 0.90 3.28 ± 0.85 3.25 ± 1.05

Abbreviation used: CAM, complementary and alternative medicine. Scale: 5, strongly agree; 4, agree; 3, neutral; 2, disagree; 1, strongly disagree.

ity of students (79.9%) also agreed with the statement “Knowledge about CAM will be required in my future practice of pharmacy” (4.05 ± 0.83). In addition, 77.8% of students agreed “There are limitations to conventional approaches in health care” (3.81 ± 0.76). Demographic variables, including gender, race/ethnicity, type of institution, and previous CAM course or 622 JAPhA | 5 3:6 | NOV/DEC 2013

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CAM use, were associated with differences in attitudes toward CAM. Female students had statistically significantly higher mean scores than male students (53.25 ± 7.29 and 51.30 ± 8.27, respectively, P < 0.001). Students identified as Asian (56.63 ± 5.98) and other (55.73 ± 6.87) race/ethnicity had statistically higher mean scores than white students (50.81 ± 7.67, P < 0.001); however, differJournal of the American Pharmacists Association

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Table 4. Factors influencing student pharmacists’ attitudes toward CAM (n = 821) Item Personal experience with CAM Coursework Faculty attitudes Family background Professional experience with CAM Cultural background Peer attitudes Friend attitudes Media (Internet, TV)

4 % 39.8 31.8 29.8 29.3 27.6 27.6 13.2 11.3 9.1

3 % 32.7 39.0 34.0 34.5 36.6 32.7 34.7 34.1 26.5

2 % 17.5 20.3 25.7 25.3 22.6 24.3 35.1 37.2 39.4

1 % 10.0 8.9 10.5 10.8 13.2 15.5 17.1 17.4 24.9

Mean ± SD 3.02 ± 0.99 2.94 ± 0.94 2.83 ± 0.97 2.82 ± 0.97 2.79 ± 0.99 2.72 ± 1.03 2.44 ± 0.92 2.39 ± 0.90 2.20 ± 0.92

Abbreviation used: CAM, complementary and alternative medicine. Scale: 4, highly influential; 3, moderately influential; 2, slightly influential; 1, not at all influential.

ences in mean scores between Asian and other were not statistically significant (P = 0.74). Students attending private universities had higher mean scores (54.94 ± 7.87) compared with students attending public institutions (51.46 ± 7.32, P < 0.001). Furthermore, students who had previous elective CAM coursework (55.89 ± 6.83) or had previously used CAM (53.89 ± 7.33) had higher mean scores compared with those who never had CAM elective coursework (51.97 ± 7.64) or never used CAM (48.87 ± 7.39) (P < 0.001). In contrast, student pharmacists’ attitudes toward CAM did not differ based on year in the professional program (P = 0.752) or previous pharmacy experience (P = 0.908). Attitude toward specific CAM therapies Student pharmacists were asked to assess their attitudes toward 13 specific CAM therapies and whether they considered these therapies acceptable for use with conventional medicine (Table 3). Of students, 94% agreed with the acceptability of vitamins and minerals (4.29 ± 0.59), 86.8% with the acceptability of massage (4.15 ± 0.70), and 81.7% with the acceptability of dietary supplements (4.00 ± 0.78), which mirrored students’ use of these therapies. Examination of association between attitudes and demographic variables revealed statistically significant differences between white and Asian students (P < 0.05) toward the acceptability of TCM (3.18 ± 0.85 vs. 3.51 ± 0.75) and Ayurvedic medicine (3.23 ± 0.90 vs. 3.72 ± 0.78). Sources of influence Student pharmacists were asked about sources of influence on their attitudes toward CAM (Table 4) and the direction of this influence (positive or negative). Of student pharmacists, 40% indicated that personal experience highly influenced their attitudes toward CAM (3.02 ± 0.99 of a possible 4). Other influential sources included coursework (2.94 ± 0.94), faculty attitudes (2.83 ± 0.97), and family attitudes (2.82 ± 0.97). None of the factors had a negative influence on student pharmacists’ attitudes toward CAM. Cultural background was significantly Journal of the American Pharmacists Association

correlated with family attitudes (r = 0.8, P < 0.001), indicating that the two factors were highly related. In addition, nonwhite students were more likely to indicate that family attitudes (2.52 ± 1.97) and cultural background (2.62 ± 1.92) highly influenced attitudes toward CAM compared with white students (0.894 ± 2.17 and 0.442 ± 2.02, respectively, P < 0.001).

Discussion Studies assessing student pharmacists’ attitudes regarding CAM have been limited to one or two universities and suggested that students have a favorable view of CAM.12–14 The current work confirmed previous findings and indicated that student pharmacists across the 10 universities surveyed held an overall favorable attitude toward CAM and regarded certain CAM therapies as acceptable for use. Students recognized that CAM knowledge will be required in their future practice of pharmacy and that a patient’s health beliefs should be integrated in the patient care process. Previous studies among pharmacists have reported mixed attitudes toward CAM and indicated that some pharmacists believed CAM can be integrated with conventional medicine, while other pharmacists have concerns about the safety and efficacy of CAM products.8 Demographic characteristics played a role in student pharmacists’ attitudes toward CAM. Female student pharmacists had more favorable attitudes toward CAM compared with male students. These results are consistent with previous findings in the medical literature indicating that female medical students and practitioners tend to have more favorable view of CAM compared with male counterparts.20 These results may be an indication of gender differences in pharmacists’ views of CAM, though future research is needed to confirm these results among pharmacists. Racial/ethnic background also may play a role in shaping attitudes toward CAM. Freymann et al.21 reported that student pharmacists from ethnically diverse backgrounds are more open to CAM therapies given j apha.org

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that many CAM therapies are acceptable in other countries’ mainstream medicine, such as the use of TCM in China, Ayurvedic medicine in India, and folk medicine in Latino cultures. Similarly, Asian students in the current study were more likely to indicate that TCM and Ayurvedic medicine are acceptable for use with conventional medicine compared with white students. Previous studies in pharmacists have not typically reported whether the pharmacists’ racial or ethnic background are associated with attitudes toward CAM,5–8,22 and it may be worthwhile to examine such associations and whether they are related to pharmacists’ willingness to talk to patients about CAM. Along with gender and race/ethnicity, the results also suggested that student pharmacists’ personal experience, pharmacy education (e.g., coursework, faculty attitudes), and family background were important factors shaping their attitudes toward CAM and may have influenced how they perceive CAM and may inform how they respond to patients’ inquiries regarding CAM as future pharmacists. Krietzer et al.13 reported that personal use of or training in CAM has an impact on attitudes toward CAM. Future studies focused on how students’ attitudes influence their willingness to talk to patients about CAM therapies may provide insight into factors shaping student pharmacists’ behavior and how that may impact their behavior as pharmacists.

Limitations A limitation of this study was the relatively low response rate (22.9% [n = 887]). Several factors may have led to a low response rate, including salience of the topic to students, lack of incentives, and technical issues in survey distribution. Determining an exact denominator to calculate a response rate was difficult because it was not known whether every eligible student in the 10 colleges/ schools received the e-mail invitation and/or was able to open the link. Given the low response rate, nonresponse bias likely was present in this study despite attempts to increase participation by sending follow-up e-mails. Data for nonresponders were not collected; however, no differences in student demographics or other results were observed when comparing early versus late responders. Previous studies assessing students’ attitudes toward CAM have had high response rates (80–90%), as they have been conducted within one or two study sites; however, studies assessing pharmacists’ attitudes have had fairly low response rates (e.g., 26%).22 According to Cook et al.,23 sample representativeness is more important than response rate in survey research unless response rates affect the representativeness of the data. Based on demographic characteristics (e.g., gender, race/ethnicity), the respondents were representative of students attending U.S. colleges/schools of pharmacy as reported by

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AACP’s profile of student pharmacists.24 Another limitation was the nonrandom nature of the study sample. Because of the nature of the study, survey distribution depended on faculty who were willing to administer the survey at their institution. However, steps were taken to ensure that both public and private universities were surveyed, as well as universities from different regions in the United States. The use of fourth-year students for survey pretesting was an additional limitation. Although the main objective of the pretest was to assess survey format and clarity of survey instructions, how this limitation may have affected survey development is unknown. Another potential limitation to the study is the use of the word “attitude” rather than “belief.” As defined by Fishbein and Ajzen,18 beliefs link an object or idea to a set of attributes while “a person’s attitude toward some object is determined by his beliefs that the object has certain attributes and by his evaluation of those attributes.” The use of a Likert-type scale, as used in the current study, is considered an indirect approach to measuring attitudes.18 However, some discussion has occurred in the psychology literature on the distinction between the two terms, and some scholars may argue that the study assessed beliefs rather than attitudes toward CAM.

Conclusion This is the first study to provide information regarding student pharmacists’ attitudes toward CAM and factors associated with those attitudes across a large number of geographically dispersed institutions. Similar to previous findings, the results of the present study indicated that student pharmacists’ attitudes toward CAM are generally favorable. Factors possibly influencing student pharmacists’ attitudes included personal experience (e.g., previous CAM use), education-related factors (e.g., coursework, faculty attitudes), family or cultural background, and demographic characteristics (e.g., gender, racial/ethnic background). Previous studies in pharmacists have indicated that many have mixed attitudes toward CAM (both favorable and unfavorable) and rarely initiate conversations with patients about CAM use.5–8 In addition, studies have not typically examined factors shaping students’ or pharmacists’ attitudes. These results have implications for pharmacy practice, as they provide insight into how future pharmacists perceive CAM therapies and what factors shape these perceptions. Pharmacists can play an active role in advising patients about CAM therapies and providing evidence-based information regarding the safety and efficacy of these therapies.4,8 The current results may be used to understand what shapes future pharmacists’ attitudes toward CAM and inform future research on how to improve pharmacists’ knowledge of and their confidence and willingness to communicate with patients about CAM.

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STUDENTS’ ATTITUDES TOWARD CAM RESEARCH

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12. Harris IM, Kingston RL, Rodriguez R, Choudary V. Attitudes towards complementary and alternative medicine among pharmacy faculty and students. Am J Pharm Educ. 2006;70(6):129. 13. Kreitzer MJ, Mitten D, Harris I, Shandeling J. Attitudes toward CAM among medical, nursing, and pharmacy faculty and students: a comparative analysis. Altern Ther Health Med. 2002;8(6):44–7, 50–3. 14. Baugniet J, Boon H, Ostbye T. Complementary/alternative medicine: comparing the view of medical students with students in other health care professions. Fam Med. 2000;32(3):178–84. 15. Lie D, Boker J. Development and validation of the Cam Health Belief Questionnaire (CHBQ) and CAM use and attitudes amongst medical students. BMC Med Educ. 2004;4:2. 16. Desylvia D, Stuber M, Fung CC, et al. The knowledge, attitudes and usage of complementary and alternative medicine of medical students. Evid Based Complement Alternat Med. 2011;2011:728902. 17. Dutta AP, Miederhoff PA, Pyles MA. Complementary and alternative medicine education: students’ perspectives. Am J Pharm Educ. 2003;67(2):46. 18. Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: an introduction to theory and research. Reading, MA: Addison-Wesley;1975:12, 14, 53–73. 19. Nunnally JC. Psychometric theory. 2nd ed. New York: McGraw-Hill; 1978. 20. Greenfield SM, Brown R, Dawlatly SL, et al. Gender differences among medical students in attitudes to learning about complementary and alternative medicine. Complement Ther Med. 2006;14(3):207–12.

9. American Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf. Accessed May 28, 2013.

21. Freymann H, Rennie T, Bates I, et al. Knowledge and use of complementary and alternative medicine among British undergraduate pharmacy students. Pharm World Sci. 2006;28(1):13–8.

10. Evans E, Evans J. Changes in pharmacy students’ attitudes and perceptions toward complementary and alternative medicine after completion of a required course. Am J Pharm Educ. 2006;70(5):105.

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Appendix A-CAM Survey

Attitudes towards Complementary and Alternative Medicine (CAM)

On a scale from 5=strongly agree to 1=strongly disagree, please indicate your level of agreement with the following statements at the present time: Please use the following definitions as you answer the questions: Complementary medicine (CM): medicines and therapies used ALONGSIDE conventional medicine Alternative medicine (AM): medicines and therapies used INSTEAD OF conventional medicine

Strongly agree 5

Agree 4

Neutral 3

Disagree 2

Strongly disagree 1

Strongly agree 5

Agree 4

Neutral 3

Disagree 2

Strongly disagree 1

Strongly agree 5

Agree 4

Neutral 3

Disagree 2

Strongly disagree 1

A patient’s symptoms should be regarded as a manifestation of general imbalance or dysfunction affecting the whole body. The body is essentially self-healing and the task of a health care provider is to assist in the healing process. Health and disease are a reflection of balance between positive life-enhancing forces and negative destructive forces. CAM therapies include ideas and methods from which conventional medicine could benefit. A patient’s health beliefs and values should be integrated into the patient care process.

Treatments not tested in a scientifically recognized manner should be discouraged to patients. Effects of CAM therapies are usually the result of a placebo effect. Complementary medicine is a threat to public health. Alternative medicine is a threat to public health. There are limitations to conventional approaches in health care.

Patients should have the right to choose between conventional and alternative approaches in health care. I am personally interested in using CAM therapies. CAM is an important aspect of my family’s health care. CAM is an important aspect of my culture. Knowledge about CAM will be required in my future practice of pharmacy.

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Attitudes regarding Complementary and Alternative Medicine (CAM) therapies On a scale from 5=strongly agree to 1=strongly disagree, please indicate your level of agreement regarding the acceptability of using each of the following therapies with conventional medicine.

Strongly Strongly agree Agree Neutral Disagree disagree 5 4 3 2 1 Dietary supplements (products taken orally and used to supplement the diet) are an acceptable CAM therapy for use with conventional medicine. Vitamins and minerals (products taken orally and used to supplement dietary intake) are an acceptable CAM therapy for use with conventional medicine. Massage (the manipulation of muscle and soft tissue to promote relaxation and flow of blood and oxygen) is an acceptable CAM therapy for use with conventional medicine. Chiropractic care (the adjustment of the spine and other body parts to promote healing and health) is an acceptable CAM therapy for use with conventional medicine. Acupuncture (a set of procedures involving the stimulation of specific points on the body to restore and maintain health) is an acceptable CAM therapy for use with conventional medicine. Strongly Strongly agree Agree Neutral Disagree disagree 5 4 3 2 1 Hypnosis (an altered state of consciousness where the individual has increased responsiveness to suggestions) is an acceptable CAM therapy for use with conventional medicine. Biofeedback (a technique to consciously regulate bodily functions, such as breathing, to improve overall health) is an acceptable CAM therapy for use with conventional medicine. Spirituality/ Prayer (mind-body techniques where spiritual/religious beliefs and practices are used to improve health) are an acceptable CAM therapy for use with conventional medicine. Reiki (an energy medicine practice originating in Japan used to promote health) is an acceptable CAM therapy for use with conventional medicine. Qigong (an energy medicine practice originating in China used to promote health) is an acceptable CAM therapy for use with conventional medicine. Strongly Strongly agree Agree Neutral Disagree disagree 5 4 3 2 1 Homeopathy (a holistic system of medical practices originating in Germany) is an acceptable CAM therapy for use with conventional medicine. Traditional Chinese Medicine (a holistic medical system originating in China) is an acceptable CAM therapy for use with conventional medicine. Ayurvedic medicine (a holistic medical system originating in India) is an acceptable CAM therapy for use with conventional medicine.

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Sources of influence on Complementary and Alternative Medicine (CAM) attitudes On a scale from 4=highly influential to 1=not at all influential, please indicate how influential each of the following items is on your attitudes towards CAM.

Highly influential 4

Moderately Influential 3

Coursework Faculty attitudes Peer attitudes Friend attitudes Family background Cultural background Personal experience with CAM Professional experience with CAM (Attitudes of pharmacists I have worked with) Media (Internet, television, etc)

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Slightly influential 2

Not at all influential 1

Sources of influence on Complementary and Alternative Medicine (CAM) attitudes

On a scale from -5= negative to 5=positive, please indicate the type/direction of influence each of these sources has on your CAM attitudes:

Negative Influence

Neutral

-5 Coursework

Faculty attitudes

Peer attitudes

Friend attitudes

Family background

Cultural background

Personal experience with CAM

Professional experience with CAM (Attitudes of pharmacists I have worked with)

Media (Internet, Television, etc.)

Demographics

Age

Gender Male Female

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0

Positive Influence 5

Race/Ethnicity [check all that apply] American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Asian

White/Caucasian

Black or African American

Other, please specify

Hispanic, Latino, or Spanish origin

College or School of Pharmacy you are currently attending

Year in the Professional (PharmD) Program 1st Professional Year (OR 3rd year in a direct entry pharmacy program) 2nd Professional Year (OR 4th year in a direct entry pharmacy program) 3rd Professional Year (OR 5th year in a direct entry pharmacy program)

Which state did you live in prior to entering pharmacy school?

Are you an international student? Yes No

If yes, what is your country of origin?

Previous Pharmacy Work Experience greater than one month [check all that apply] None Retail Hospital Other, please specify

Do you receive CAM information as part of your REQUIRED pharmacy curriculum? Yes No Don't know

Does your college/school of pharmacy offer ELECTIVE CAM coursework? Yes No Don't know

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Have you taken a CAM elective course? Yes No

Have you ever used any CAM therapies? Yes No

What CAM therapies have you used? [check all that apply] Dietary supplements Vitamins/minerals

Spirituality/Prayer Homeopathic products

Massage

Reiki

Chiropractic care

Qigong

Acupuncture

Traditional Chinese Medicine

Hypnosis

Ayurvedic Medicine

Biofeedback

Other, please specify

Additional comments:

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