Community Pharmacist's Knowledge, Attitude, and Practices towards Vitamin Supplements in Al-Khobar Region, Saudi Arabia: A Descriptive Cross-Sectional Study.

AIMS AND
OBJECTIVES: To foster a podium for assessing and evaluating knowledge, attitudes, and professional practices of Saudi community pharmacists in counseling patients regarding the safe usage of dietary supplements.
MATERIALS AND METHODS: A cross-sectional descriptive study was conducted between January 2017 and April 2017. Collection of data was carried out by using a set of 44 semi-structured self-administrated questionnaires. Study was conducted among community pharmacies in Al-Khobar Region, Saudi Arabia, with target sample of 250 pharmacists.
RESULTS: A total of 102 pharmacists contributed in this study. The mean average score of the participants in subjective assessment of knowledge was 62.45%. Half of the participants (51.96%) achieved good and excellent score in objective assessment regarding knowledge of vitamin, 66.67% of the respondents thought that pharmacists should be knowledgeable regarding vitamin supplements, and 81.37% declared that they inform the patients about possible adverse effects by the use of dietary supplements.
CONCLUSION: The study revealed a positive attitude of community pharmacists in Al-Khobar Region on their role in patients' counseling about the safe usage of vitamins as dietary supplements. However, their level of knowledge about vitamin supplements needs to be improved to meet consumer's needs regarding usage of dietary supplements. Copyright:

Introduction

The United States Food and Drug Administration defined dietary supplements (DSs) as “a product that is intended to supplement to the diet, that contains one or more of the below mentioned dietary ingredients: a vitamin, a mineral, a herb or other botanical, an amino acid, by increasing the total daily intake, or an extract, metabolite, concentrate, constituent, or combinations of these ingredients.”[1] The vitamin supplement (VS) industry is reported under the category of world’s fastest growing industries.[2] Worldwide, the market of VS is projected to grow at a calculated annual growth rate of around 6.8% during 2014 to 2020, increasing from a market rate of US$37.4 billion in 2013 to US$59.6 billion in 2020.[3] The market of VS is also increasingly growing in developing countries such that in Saudi Arabia, the market of vitamin and mineral supplements values for approximately 4% of the total pharmaceutical market sales, approximately US$80 million.[4] Contributing to this industry’s growth are increased popular awareness of the relation between disease and diet, aging of population, busier lifestyle, interest in health wellness, and adoption of preventive healthcare practices.[5] These factors, in turn, have led to consumers relying on vitamins as DSs to achieve the recommended amount of vitamins in their diets.[6] In fact, extensive usage of supplements is often a cause of alarm because of potential adverse effects such as neurologic disturbances, gastrointestinal symptoms, hepatotoxicity, birth defects, and drug interactions, which incurs liabilities of health-care professionals.[78] A recent study conducted to conclude the knowledge, attitude, and practices of the uses of VS within the public of the Northern Border Region of Saudi Arabia has pointed to the lack of awareness of proper use, indications, and harmful effects of VS, and the need to have health awareness campaign.[9] Conversely, Saudi study showed that around 7.8% of contributors in the survey used vitamins as a source of alternative medicine and most of the participants were indisposed to share and deliberate such information with their medical doctor.[10] Another research, which included 161,808 healthy postmenopausal women in the Women’s Health Initiative program, discovered that those who used multivitamins had an analogous latent for mortality or emerging cardiovascular disease, cancer of the lung, colon/rectum, breast, and/or endometrium compared to those who did not use vitamins.[11] Reliable with these outcomes, other studies have proven weak substantiation to support the endorsement of multivitamins as antioxidant protection against cancers or cardiovascular disease.[3121314] Jointly, these verdicts support the American Heart Association recommendations of a balanced diet, somewhat than the supplements of questionable usefulness and safety, especially in patients without chronic health conditions or circumstances requiring vitamin replacement.[611] Despite the widespread use of supplements, it is obvious that only a logical and optimal use of supplements can ensure appropriate improvement in the health of the consumers of these products.[15] For pharmacists, assimilating knowledge of VS on everyday practice could be professionally and financially gratifying.[16] Many studies confirmed that consumers usually seek their pharmacist’s opinion, knowledge, advice, and even recommendation regarding safe and proper use of VSs.[11718] On the contrary, studies also show that few consumers feel that pharmacists are inadequate to counsel them regarding DS.[1819] This associates with the outcomes of another research that reveal pharmacists’ own embarrassment dealing with DS inquiries and feeling inadequately knowledgeable about DS.[2021] Consequently, counseling services for pharmacists on the correct use of these products are often not enough.[2021] Possible explanations for insufficient counseling on DS by pharmacists as indicated by many studies include insufficient education and knowledge of DS, inauspicious attitude toward DS, an inadequate evidence base on DS in the literature, and paucity of time devoted to patient counseling.[20212223]

Moreover, for investigating the factors that could affect community pharmacy practice regarding DS, a qualitative study was carried out in Australia and Thailand,[24] which has shown that customer’s demand and the turnover to be made from the sale of DS influence pharmacists’ practice when recommending DS.[24] Though the number of contributors in the study was less (total 20 pharmacists) and the results could not be generalized, it confirms that community pharmacists have inadequate knowledge toward the DS. However, this study was based on the self-evaluation of the pharmacists and not on the observational strategy by the investigators, so accurate practice evaluation could not be definitely concluded.[3] Although the investigator did not point to which vitamin category or dietary supplements are the base of the study, it was the only previous study that highlights the pharmacists’ practice toward vitamins. The main aim of this research was to evaluate knowledge, attitudes, and practice of community pharmacists in Al-Khobar region in counseling patients about the safe consumption of vitamins as DS.

Materials and Methods

Methods

Between January 2017 and April 2017, a cross-sectional descriptive-designed research was organized in pharmacies situated in Al-Khobar, eastern province of Saudi Arabia. The sampling amount was well-defined as any registered pharmacists who work in community pharmacies. Collection of data was conducted using a semi-structured self-administrated questionnaire.

Study data collection

To maximize the response rate, self-completion surveys were sent to 250 community pharmacies in Al-Khobar. Pharmacists on duty from each community pharmacy were invited to partake in the survey. For respondents who did not return completed questionnaire within 2 weeks, a friendly reminder along with a copy of the questionnaire was sent out. Study was conducted from January 2017 to April 2017. Questionnaire for assessment of knowledge, attitude, and practices toward VSs was adopted from similar studies conducted previously.[31011] Raosoft online sample size calculator (http://www.raosoft.com/samplesize.html) was used in the calculation of sample size to accomplish the study objectives with target sample size of 102 community pharmacists with confidence level of 95%.

Data analysis

Data were coded and evaluated using SPSS software, version 17 (IBM, Chicago, IL). Descriptive statistics such as frequency, percentage, mean, and standard deviation (SD) were calculated using SPSS. The responses by the pharmacists to every questionnaire item were expressed as frequencies and their conforming percentages. On the basis of previous studies,[1126] the same scoring method was adopted to analyze the data. For Likert responses in the subjective assessment of knowledge, attitude, and practice sections, all responses with any degree of agreement were gathered as positive reply and all responses with any degree of disagreement were grouped together as negative responses. Likewise, mean or individual scores above 70% in the attitude or practice behavior questions were measured to reproduce more positive drifts about the statements according to previous research.[11]

Ethical approval

The ethical approval for this study was obtained (approval reference number: S63) by the Ethics Review Panel, School of Pharmacy and Life Sciences, Robert Gordon University, UK.

Results

Of the 250 distributed surveys, 102 surveys were returned complete and analyzed, whereas 6 were returned incomplete. The response rate was 41% after three reminder mails. A breakdown of respondent demographics is shown in Table 1. All the respondents (100%) were male, the predominant age group was between 20 and 29 years (43.1%), followed by 30–39 years (41.2%). The highest pharmacy degree of approximately half (52.5%) of the responded pharmacists was bachelor’s, followed by doctor of pharmacy degree (25.7%). Their experience in practice ranged from 1 to more than 20 years, the mean years of experience were 6.1 years.

Table 1

Demographic characteristics of survey participants (n = 102)

Characteristics	Categories	Respondents (%)
Gender	Male	102 (100)
Age group (years)	20–29	44 (43.1)
	30–39	42 (41.2)
	40–49	13 (12.7)
	50–59	2 (1.96)
	Above 60	1 (0.98)
Level of education	Diploma in pharmacy	5 (4.9)
	Bachelor of science in pharmacy	53 (51.96)
		14 (13.72)
	Master of science in pharmacy	26 (24.59)
	Doctor of pharmacy (PharmD) PhD in pharmacy	3 (2.94)
Experience (years)	<1	13 (12.74)
	1–5	32 (31.37)
	6–10	28 (27)
	11–15	15 (14.70)
	16–20	8 (7.84)
	>20	6 (5.88)

Knowledge about vitamins as dietary supplements

Figure 1 presents the results of the perceived knowledge (subjective self-rating) of the pharmacists toward VS. Two-third (68.63%) of the pharmacists agreed that they have sufficient information toward VS and slightly more, 70.6% have sufficient information about dosage and administration of VS.

Figure 1

Pharmacist’s knowledge about vitamin supplements

On the contrary, less than half of the surveyed pharmacists (47.1%) believed that they have sufficient information about efficiency and effectiveness of vitamins and 42.2% of the participants reported to have sufficient information about drug-supplement interactions. Moreover, 45.1% of the respondents disagreed that they have sufficient information about adverse effects of VS, whereas more than half of the participants (55.9%) agreed that they have sufficient information about contraindication of VS; and in special groups of patients, for example, with hypertension or kidney disease, 43.1% of the respondents disagreed that they have sufficient information about indications of some vitamins as DS compared to that in specific groups such as pregnancy, breastfeeding, pediatric, and geriatric. As stated previously, to assess the knowledge of pharmacists about VS, besides subjective questions mentioned in section 2 of questionnaire, 16 questions pertaining to the general and up-to-date knowledge about vitamins, signs of vitamin deficiency, recommended dietary allowances (RDA) of the vitamins, and the most common side effect of selected vitamins have been used. To categorize the practical knowledge, the score of respondents was categorized based on previous study,[25] which above 70% was considered as excellent, 60%–70% as good, 40%–60% as average, and less than 40% as poor.

As indicated in Figure 2, results show that around 29.41% of surveyed pharmacists had an average level of practical knowledge, 18.63% had poor practical knowledge, and over half of the respondents (51.96%) achieved good and excellent score.

Figure 2

Descriptive results of objective practical questions about pharmacist’s knowledge of vitamin supplements (n = 102)

In summary, the average score of all the study participants in the knowledge estimation was 62.45% ± 18.62%, which is rated as good knowledge, only 6 (5.9%) pharmacists responded all the questions correctly as mentioned in Table 2. Most of the respondents (80.39%) reported that total balanced diet is more realizable by intake of healthy diet than by VS. In addition, the majority of the pharmacists had good knowledge about signs of vitamin B2, A, and B12 deficiency (92.16%, 77.45%, and 92.16%, respectively) and had an average knowledge regarding the adverse effects of vitamins (63.73% and 43.14%, respectively).

Table 2

The frequencies and percentages of the correct responses to knowledge questions by pharmacists (n = 102)

Statement	Correct	Incorrect	I do not know
Total balanced diet is more achievable by eating healthier than by vitamin supplements	82 (80.39%)	3 (2.94%)	17 (16.67%)
Vitamins supplements may contain unlabeled toxic ingredients	42 (41.17%)	22 (21.57%)	38 (37.25%)
A growing body of research evidence supports the causality of different types of cancer by vitamins, which are often employed as antioxidants in routine practice	33 (32.35%)	13 (12.75%)	56 (54.90%)
Some lifestyle issues may reduce the absorption of vitamins or may even cause the complete depletion of vitamins	33 (32.35%)	21 (20.59%)	48 (47.06%)
Chronic consumption of some drugs may cause a significant depletion of vitamins	71 (69.61%)	8 (7.84%)	23 (22.55%)
Serious drug interactions and side effects can be potentiated due to concomitant consumption of vitamin supplements and drug therapy	65 (63.72%)	14 (13.76%)	23 (22.55%)
Recommended dietary allowances (RDA) for each vitamin for adults (19–50 years old), that is, vitamin C (for female) = 75mg/day	61 (60%)	20 (19.61%)	21 (20.59%)
RDA for vitamin K = 90 µg	57 (55.88%)	10 (9.80%)	35 (34.31%)
Excessive intake of vitamin D more than RDA can cause poor appetite, vomiting, and frequent urination	44 (43.14%)	20 (19.61%)	38 (37.25%)
RDA for folic acid = 400 µg	75 (73.53%)	10 (9.80%)	17 (16.67%)
RDA for vitamin D = 400 IU	65 (63.73%)	11 (10.78%)	26 (25.49%)
Excessive intake of vitamin E increases the chance of hemorrhagic stroke, skin bruising, bleeding, and headache	65 (63.73%)	14 (13.73%)	23 (22.55%)
Cracking at the corners of the mouth could indicate vitamin B2 deficiency	94 (92.16%)	1 (0.98%)	7 (6.86%)
Dandruff could indicate biotin deficiency	59 (57.84%)	22 (21.57%)	21 (20.59%)
Conjunctival dryness could indicate vitamin A deficiency	94 (92.16%)	3 (2.94%)	5 (4.9%)
Poor concentration could indicate B12 deficiency	79 (77.45%)	7 (6.86%)	16 (15.69%)
Mean score (SD)	62.45% (18.62)

Attitudes of community pharmacists regarding dispensing and counseling about vitamin supplement

As shown in Table 3, maximum number of participants (92.16%) perceived positive impact of VSs on public health. Two-thirds of the surveyed pharmacists (66.67%) believed that pharmacists should be knowledgeable about VS, and consulting in this field is a part of their duties, whereas, nearly three-quarters of respondents (77.45%) reported that VS should be sold in pharmacies under pharmacist’s supervision, more than half of the participants (58.82%) believed that customers are usually influenced by pharmacist’s comments about VS. Moreover, the majority of the respondents (93.14%) agreed that VS should dispense according to the prescription by nutritionists or physicians. Although the majority of the surveyed pharmacists (93.14%) agreed that price is an important factor for recommending supplements to customers, somewhat less (79.41%) were of the opinion that VSs are considered an important source of profit for pharmacies. Practice behavior of pharmacists regarding dispensing and counselling on vitamin supplements [Figure 3] presents current practices of pharmacist’s professionals toward dispensing and counselling of vitamin supplements. The achieved mean score was 70.84% (SD = 14.93%), which is considered a positive practical approach regarding counseling patients about vitamins (according to the criteria used by a similar research conducted by Shilbayeh[10], 2011). Nearly three-quarters of the participants (75.49%) allotted enough time for giving advice to customers on supplements, slightly more (78.43%) reported that they advise the customers regarding the significance of naturally available sources of vitamins. Most of the respondents (81.37%) declared that they inform the clients about possible adverse effects of VS. Similarly, 81.37% of the participants ask the consumers about their medical history when they recommend these products and 82.35% of the pharmacists check whether a particular supplement taken by the consumer interacts with his/her prescription medicines. However, more than half of the respondents (59.8%) recommended supplements to consumers with confidence about their effectiveness and only 39.22% could refer to valid web pages and scientific references relevant to VS. As seen in Figure 4, the reliability of 0.624, 0.721, 0. 576, and 0.609 indicates an acceptable reliability. Internal consistency of questions related to knowledge, attitude, and practice is measured according to Cronbach’s alpha.

Table 3

Attitudes of the community pharmacists with respect to dispensing and counseling about vitamin supplements (n = 102)

Statement	Agree	Disagree	Neutral
Vitamin supplements have a positive impact on public health	94 (92.16%)	1 (0.98%)	7 (6.86%)
Pharmacists should be knowledgeable about vitamin supplements, and consulting in this field is part of pharmacists’ duties	95 (93.14%)	3 (2.94%)	4 (3.92%)
Vitamin supplement should be dispensed according to the nutritionists’ or physicians’ prescription	79 (77.45%)	8 (7.84%)	15 (14.71%)
Vitamin supplements are considered as an important source of profit for pharmacies	81 (79.41%)	6 (5.88%)	15 (14.71%)
Price is an important factor in recommending supplements to customers	95 (93.14%)	4 (3.92%)	3 (2.94%)
Customers usually are influenced by pharmacist’s comments about vitamin supplements	60 (58.82%)	8 (7.84%)	34 (33.33%)
Mean score (SD)	80.11% (13.7)

Figure 3

Counseling behaviors of community pharmacists with respect to vitamin supplements (n = 102)

Figure 4

Reliability analysis of the questionnaire

Discussion

To the best of our knowledge, this is the first study that assesses knowledge, attitudes, and professional practices of community pharmacists toward vitamins as DS in Saudi Arabia. In fact, there is even no previously published research that assesses the practice of the community pharmacists in Saudi Arabia toward DSs. All the surveyed community pharmacists are male because female pharmacists are not allowed to work in community pharmacies according to the country regulations. Nearly half of the pharmacists working in community pharmacies are less than 30 years of age, have 6.1 years as mean years of experience in pharmacy practice, and have bachelor’s degree. These findings are consistent with the previous outcomes in surveys conducted in community pharmacies in Saudi Arabia.[26] Most of the surveyed community pharmacists in Al-Khobar Region perceived themselves to have adequate information about VS. Respondents considered themselves most knowledgeable about dosage and administration of VS. However, nearly half of the respondents believed to have a lack of knowledge in areas dealing with efficiency, effectiveness, and adverse effects of the VSs. Similar percentage declared to have insufficient information about potential vitamin–drug interactions, indications, and contraindications in special population such as pregnancy, breastfeeding, hypertension, and kidney disease. Results of objective knowledge assessment concerning signs of vitamin deficiency, vitamin overdose, and RDA of some selected vitamins show that mean score of all respondents was rated as good. However, a lack of awareness of the updated researches concerning vitamin effects on cancer and of the negative effect of some lifestyle on vitamin depletion was observed. In addition, less than half of the study participants were cognizant of those few VSs that may contain unlabeled toxic ingredients. Similar findings to this research were observed from pharmacists in Jordan whose present state of knowledge about vitamins was assessed as less than best in meeting the patient hassles for this area of health care.[11] Furthermore, these results were also confirmed by a systematic review,[16] who acknowledged that community pharmacists in US and Canada do not recognize their knowledge of DSs to be suitable, particularly, regarding side effects/adverse events, interactions, therapeutic uses, dosing as well as methods to acknowledge these and further concerns concomitant with common DSs with the patients.[1] Most of the surveyed pharmacists in this research had positive attitude in providing VS counseling as a regular part of their practice. The same positive trends in the attitudes toward VS were noted among the Jordanian pharmacists[11] who also agreed that counseling on VS is part of their role in pharmaceutical care. The preceding interpretations were reliable with the outcomes of other studies dealing with the attitudes of community pharmacists about herbal medicine in Saudi Arabia and Kuwait.[11] In accordance with this result, a similar pattern of practice toward VS counseling was also reported by another researcher in Jordan.[27] Similarly, many studies confirmed that pharmacists reported recommending DS to patients.[12527] In contrast, other studies have indicated insufficient counseling by the pharmacists on the proper use of DS because of unavailability of scientific evidence for their efficacy and safety and inadequate knowledge to recommend patients appropriately.[1928]

Alternative finding from this study was that only less than half of the respondents could refer to valid web pages and scientific references relevant to VS when needed. Finding of current study was stable in comparison to that of other studies where respondents reported that the most common barriers that limit discussing the use of dietary supplements, vitamin supplements, and herbal medicine with their patients were unavailability of reliable resources, absence of quality information, and/or lack to retrieve it.[11123]

Finally, though pharmacists in our community showed positive beliefs in the usefulness of vitamins and their role in pharmacy practice, further research is required to comprehensively appraise their knowledge, attitudes, and magnitude of awareness about other forms of dietary products, by which they may exhibit a wide role in counseling the community.

Conclusion

The study revealed a positive attitude among the community pharmacists in Al-Khobar Region on their role in counseling patients about the safe consumption of vitamins as DS. However, their level of knowledge about VSs needs to be improved to meet consumer’s needs in the pharmaceutical. Consequently, concerned bodies must provide pharmacists continuous education programs and access to training apart from revising and enriching their curriculum to incorporate relevant topics to qualify pharmacists to provide ultimate pharmaceutical care services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.