Group 1 (low level of CM recommendation)
The main subcategories in this group were ‘condition-based recommendation’ and ‘health benefit’ with a lesser emphasis on ‘customer demand’, ‘company profile’ and ‘cost’.
Each Group 1 pharmacist mentioned between one and four specific CMs and related indications they felt comfortable with. They all mentioned that they stick to this narrow range of CMs:
‘B group vitamins to stressed students or professionals. Glucosamine and fish oils to people with osteoarthritis. Fish oils to people with hypertension. They are my safe zones.’
Customer demand was not mentioned as a strong reason to recommend, except for one respondent who said that if a customer asked for something in particular, that would be their primary reason for selling a CM product.
The profile of a company in terms of reputation and quality of products and services also had some impact on which products were recommended:
‘Credibility and availability long term are things…if considering three or four companies that look after us reasonably well, at least in regards to supply, after that criteria (sic) is met I try to provide value for customers.’
Responses to whether cost was an issue for them or their customers varied:
‘I might spend too much time in trying to give value to people. I’ll walk around to find three brands of fish oil and give them the cheapest at the time.’
‘I found where I was working before, people didn’t find the cost an issue.’
Group 2 (medium level of CM recommendation)
The most consistent motives for CM recommendation in this group related to health benefits for patients and companion selling a CM product with a pharmaceutical medication. Subcategories were ‘condition-based recommendation’, ‘health benefit’, ‘customer demand’, ‘evidence for efficacy’, ‘companion selling and pharmacy protocols’, ‘profitability’, ‘demographics’, ‘company profile’, ‘ethical responsibility’ and ‘holistic care’. Cost was mentioned as a factor in their decisions of which CM to recommend, but was not seen as a particularly important one.
Each Group 2 pharmacist discussed between four and ten different CMs they recommended for specific conditions, although they mentioned being comfortable with many more products:
‘A lot [of my recommendations] would be in the top twenty, like fish oil, glucosamine, acidophilus, coming to winter season now, things for the immune system, olive leaf, that I would usually recommend.’
Subcategories of ‘health benefit’, ‘customer demand’ and ‘evidence for efficacy’ were linked for pharmacists in this group. They valued clinical evidence, but feedback from customers also gave them more incentive to recommend CMs:
‘…[I’d like to see] the trials that have been done…but also, if the patient takes it and finds it works, you’ve got to go with that… the most important thing is that it works.’
‘…customers and consumers want to have alternative medicines. They’re actively seeking something else apart from orthodox medicine, so I guess you just have to know about them, and as a pharmacist you have to find whether certain things are evidence based.’
Personal experience of benefit was also described as a motivator to recommend CMs:
‘I think another thing that would influence me is if I’ve had personal experience with a product, so for example if I’ve used something that I’ve found very useful,… and if you tell a customer, “Oh, I’ve used this product and this is what happened” they are more receptive to that product.’
All pharmacists in this group described a preference for a CM over a pharmaceutical medicine in some instances, and they felt quite comfortable talking to customers about this:
‘…the one that probably comes to mind most is for restless legs and cramping. I’ll always pick a calcium-magnesium instead of a sedating antihistamine to relax the muscles.’
Two respondents mentioned benefits in relation to insomnia:
‘If they came in with a sleep issue, I’d think about a natural product first…(because of) side effects, addictiveness.’
Companion sales and pharmacy protocols were a major reason to recommend CMs in both Group 2 and 3. All pharmacists in Group 2 described protocols in their workplace to recommend a particular CM with a particular prescription or over-the-counter (OTC) medication, either to ameliorate side effects or to provide an adjunct therapeutic benefit. The most commonly mentioned combinations were probiotics with antibiotics, co-enzyme Q10 with cholesterol-lowering ‘statin’ medications, glucosamine and/or fish oil with various arthritis medications, and CMs for cold and ‘flu with OTC products:
‘We have a system where if I’m dispensing a prescription medicine, lets say a cholesterol-lowering product, we have tags we put in the basket saying, “Your pharmacist recommends you take CoQ10” or things like that, so even if I am busy doing other things, there is some pharmacist intervention to recommend a product…’
Respondents who worked in banner pharmacies described a corporate policy of companion selling:
‘It’s all written down in the [pharmacy group] protocols, so if you work for [pharmacy group] you’re expected to follow this.’
The benefits to patients of recommending CMs along with conventional medicines was clear to respondents in this group:
‘I’m always in favour of adding something, as long as it doesn’t interact with other medicines… Adding something into their medication profile just to make sure they’re getting a little bit of extra help, and… they don’t need to go on another or higher dose cholesterol tablet, when they can start fish oil instead.’
Whilst they were aware that companion selling was potentially profitable for the pharmacy, respondents denied that would be a reason for following a protocol:
‘If there’s an opportunity to companion sell and they don’t need it, I won’t do it.’
Pharmacists were less likely to recommend CMs when they worked in a pharmacy in a lower socioeconomic area. All respondents currently worked in urban or suburban pharmacies; however, those who had previously worked in regional areas described a greater acceptance of CM in the city. One respondent mentioned that the conservative nature of the suburb where their pharmacy was located influenced recommendation patterns and made them less likely to recommend in some instances. Another pharmacist working in an area with a higher Asian population reported:
‘With the higher Asian population we do sell a lot more vitamins, compared to where I have been previously… The Asian population seems to be much more into natural health and vitamins.’
The respondents’ impression of a CM company’s reputation had some impact on their choice of product. They were as a group more comfortable with brands that were well established and had a larger portfolio of products:
‘…it’s to do with their reputation too…they have good products, they have a good range of products. I’d be less likely to trust a company that put out one wonder product and that’s all they have. So larger companies and more reputable companies I do trust and am more receptive to their new products.’
Some pharmacists in this group expressed the opinion that it was their ethical responsibility in some cases to recommend CM in order to provide proper care to their patients. The term ‘holistic’, a term commonly used by complementary medicine practitioners, was used in regard to their recommendations a number of times:
‘…trying to think holistically how you can improve their health outcomes…that’s one of the main driving factors for me.’
‘…my conscience tells me that I really do need to offer that [advice on CM] to those people who are really interested, and also to educate those people who have been to some degree fobbed off [by orthodox approaches to medicine].’
Finally, Group 2 pharmacists were aware that when they recommended a CM, this recommendation was likely to be taken more seriously because of their status as a trusted healthcare professional:
‘I think coming from a pharmacist, if I am recommending a complementary product as opposed to an assistant, it provides more credibility, trusting that product, they will give it a go, will be more compliant to it as well.’
Group 3 (high level of CM recommendation)
Pharmacists in Group 3 had similar reasons for recommending CM to those in Group 2, hence the subcategories describing these reasons were the same for both groups. The most common primary motive for recommending a CM was health outcomes, and whilst they were more candid than pharmacists in other groups about potential profitability, they did not describe this as their primary motive for recommendation of CMs, but rather a beneficial spin-off of good customer service:
‘Well, [I recommend CM] because it works and your customer will come back, and you’ve got a happy customer. A happy customer talking to all their friends, saying, “this chemist really knows what they’re talking about” is the best kind of advertising you can get.’
‘…it’s a twofold thing. You’re helping your customer, and it is important to your pharmacy, so I can’t understand why pharmacists wouldn’t want it.’
Like Group 2, condition-based recommendations were frequently mentioned, and the number of CMs mentioned was similar. Recommendations alongside pharmaceutical medicines were also very common. There were protocols in place in all pharmacies to promote this, and this practice was seen as providing considerable health benefits to the customer:
‘I’d use it as a first line too, but I’d say that probably 80-90% would be as a combination… you give them what they’ve asked for, and then you add in something that will actually help them.’
The Group 3 pharmacists agreed that recommending companion products provides a holistic solution, whatever those products might be:
‘…it’s about health outcomes. It’s not about selling products for the sake of selling products. If you’ve got a really bad dermatitis, it’s no good just giving you a tube of cream. We’ve got to give [companion products]. So it’s about a … healthcare solution. Now if I just gave you that tube of ointment, it might clear it up today, but it would be back tomorrow, [but] if we’d sold the three products at once there’s every chance that will never recur, and you can keep it under control. The patient’s happy as Larry, and it will have cost them less as well.’
A preference for a CM over a pharmaceutical was reported by several respondents:
‘…pain medications with tension headaches. You get a lot of that…from computer use… so I get them onto a magnesium supplement…. and the number of people who will come back within three days and say “that’s the first time I’ve never taken Mersyndol in my life and I’m just ecstatic!”’
Like the pharmacists in Groups 1 and 2, Group 3 respondents wanted good quality evidence, and they felt confident in the evidence they had found:
‘…say a medication is depleting something in the system, say your statins and your CoQ10s… everything that’s evidence-based.’
This group had similar opinions to Group 2 about the importance of the profile of the company and the quality of its products:
‘I think you do have a level of safety…a brand like [mentions three brands] are the brands that have a lot to lose, if they bring out dodgy products into the market. A company that has only one item, they have to work a lot harder to convince me to recommend that product.’
‘You’ve got to have a good product. It’s not about selling something just for the sake of selling something. You’re selling a product you believe in.’