Community pharmacists' knowledge, attitudes, and practices regarding counselling on vitamins and dietary supplements in Malaysia: A study on complementary medicines

Background The utilization of vitamins and dietary supplements (DSs) among consumers in Malaysia has seen a notable increase. However, there is limited research available on how pharmacists in Eastern countries manage the provision of these products. Objective This study aims to assess the knowledge, attitudes, and practices of community pharmacists in Malaysia regarding the provision of counselling services on vitamins and DSs. The findings will inform education strategies in this area. Methods A cross-sectional quantitative study was conducted from February to April 2022 using a validated online-based questionnaire. The survey was distributed to community pharmacists across Malaysia through social media channels. t-test and ANOVA test were used for data analysis. Results Among the 260 participants, 73.5% were categorized as having average product knowledge. Key concerns included a lack of knowledge about the indications of new products and when to discontinue their use. Regarding dosing in specific patient groups, 33.5% of pharmacists only occasionally consulted references and primarily relied on product labels. Furthermore, 29% of pharmacists believed it was unnecessary to refer patients to doctors when they experienced ongoing symptoms while taking vitamins or DSs. Interestingly, 44.6% of pharmacists believed there was a correlation between the efficacy of vitamins and their price, often recommending more expensive brands despite similar content. Conclusion There is an opportunity to enhance the knowledge of pharmacists in Malaysia regarding vitamins and DSs. Education interventions should focus on areas such as dosing for specific patient groups, when to discontinue products, understanding new products, evidence-based efficacy of products for specific conditions, and providing a framework for appropriate referral to support pharmacists in their practice.


Introduction
Complementary and Alternative Medicines (CAMs) encompass a wide range of medical practices, products, and therapies that are not typically considered part of conventional (allopathic) medicine. 1Some studies have found that certain CAM practices can have synergistic effects when used with allopathic medicines, potentially enhancing the therapeutic outcome.For example, mindfulness meditation might improve the efficacy of antidepressant medications for some patients by reducing stress and promoting better adherence to medication regimes.In contrast, there is also evidence that some CAM practices can interact with allopathic medicines, sometimes in harmful ways.2][3] Vitamins and dietary supplements (DSs), often incorporated within the framework of Complementary and Alternative Medicines (CAMs), command an essential role in the public health domain.These products are specifically designed to complement the diet and to serve as adjuncts in the prophylaxis and treatment of various health conditions.They are known to bolster the immune system and enhance metabolic functions. 4dditionally, they are utilized in the mitigation of risks associated with chronic diseases, contributing significantly to preventive healthcare measures. 5Available primarily through community pharmacies, these supplements necessitate informed counselling from pharmacists, who act as a critical interface between the products and the end consumers. 6he capability of pharmacists to offer comprehensive advice on DSs is impeded by gaps in their professional education and training.8][9] This issue is critical, as the contemporary healthcare landscape requires pharmacists to be well-versed in the interactions and contraindications of DSs, given the trend of consumer-led self-prescription. 8mpirical evidence from Iran has highlighted the inconsistency of pharmacists in providing vital information about DSs, suggesting a global need for improved educational resources and training. 10,11In the Malaysian context, the interplay between traditional health practices and modern medicine accentuates the need for pharmacists to be adept in guiding DS use.The country's regulatory environment for medicines is well-established, yet there remains a dearth of research exploring the role of community pharmacists in the realm of DSs. 8 This situation is compounded by the cultural diversity within Malaysia, which influences health behaviors and practices, making the role of pharmacists even more complex and integral. 12Furthermore, the pattern of DS consumption in Malaysia indicates a high prevalence of use, which warrants targeted educational initiatives to ensure appropriate and safe use by the public. 13,146][17][18][19] This study is designed to investigate the knowledge, attitudes, and practices of pharmacists in Malaysia surrounding vitamins and DSs.It seeks to uncover educational gaps, propose enhancements to pharmacists' roles in DS advisement, and ultimately influence public health education to promote the safe use of DSs.The aspiration is to elevate the standard of DS advisement provided by pharmacists, which is expected to lead to improved health outcomes through more informed DS use by the Malaysian public.

Study design and study population
A cross-sectional quantitative study was conducted using an online questionnaire.The study sample size was determined based on the population of community pharmacists in Malaysia, aiming for a representative sample.Participants were recruited on social media using snowball sampling.This technique was adapted for the online environment to reach the widespread community of pharmacists in Malaysia effectively.The process began with the identification of key contacts within the pharmacist community who were recognized as nodes of professional networks..This technique was chosen due to the practical constraints of reaching a dispersed professional population and to utilize professional networks to ensure a broad reach.Online questionnaires were distributed using SurveyMonkey® to pharmacists in Malaysia who spoke English and who were Provisionally registered pharmacists (PRP), Fully registered pharmacists (FRP), or pharmacy assistants with a diploma in pharmacy, reflecting the composition of the community pharmacy workforce in Malaysia.

Survey instrument
Questionnaire items in this study were adapted from a few validated studies that assessed similar content [6, 10, 12, 13, 14].The questionnaire, comprising 63 questions across four sections-demographics, knowledge, attitudes, and practice-was written in English and validated to ensure its reliability and applicability in the Malaysian context.Knowledge questions, designed as multiple-choice items, focused on common products sold in Malaysia.Attitude and practice questions utilized a five-point Likert scale to gauge the opinions and behaviors of community pharmacists.
To confirm the questionnaire's face and content validity, we conducted structured interviews with a representative panel of Malaysian community pharmacists.This panel evaluated the questions for relevance, clarity, and appropriateness, resulting in iterative modifications until consensus on content was achieved.
Furthermore, we employed a pilot study involving a separate cohort of pharmacists to test the questionnaire's reliability.Statistical analysis of the pilot study data yielded a Cronbach's alpha of 0.82 for the knowledge section, 0.89 for attitudes, and 0.85 for practice, indicating a high level of internal consistency for each domain.These values surpass the commonly accepted threshold of 0.70 for Cronbach's alpha, demonstrating the instrument's reliability.
In addition to face and content validity, we also ensured construct validity through exploratory factor analysis, which confirmed the questionnaire's ability to measure the constructs it was intended to.The factor loadings for all items were above the acceptable threshold of 0.50, providing further evidence of the instrument's construct validity.
The rigorous validation process we employed not only strengthens the reliability and validity of our questionnaire but also reinforces the credibility of the data collected, allowing for confident interpretation of the study results.

Data collection
The participants were recruited using social media, including Facebook, WhatsApp, Instagram, and Telegram, within a three-month period from 8 February 2022 to 30 April 2022.A sample size was calculated using the Raosoft calculator, reflecting the population of community pharmacists in Malaysia to be the required sample size of 385.Besides, an official invitation was sent to the headquarters of chain pharmacies in Malaysia to disseminate the survey link among their community pharmacists as well as Malaysian community pharmacy groups in social media.Before filling out the surveys, participants were required to sign a formal consent form agreeing to participate in the study.To enhance the response rate and the representativeness of the sample, participants received weekly reminders to complete the survey.Participants were also asked to forward the online questionnaire to colleagues to complete.

Data analysis
Normality of variables was analysed and accepted with the Kolmogorov-Smirnov test at first.The hypotheses being tested through the t-test and ANOVA were focused on determining if there were statistically significant differences in the knowledge, attitudes, and practices (the dependent variables) between different groups of pharmacists categorized by their registration status and work experience (the independent variables).Independent t-test and ANOVA were used for inferential statistical analysis.1][22][23] The cut-off points for the classifications of knowledge, attitude, and practice categories were derived from percentile ranks based on descriptive statistics, ensuring a data-driven categorization.For the knowledge section consisting of 13 questions, one point was given for every correct response and zero for every inappropriate response.Participants' scores were then categorized: 0 to 5 as poor knowledge, 6 to 9 as average knowledge, and 10 to 13 as good knowledge.For the attitudes section consisting of 16 questions, one point was given for every appropriate response (strongly agree or agree for a positive statement and strongly disagree or disagree for a negative statement) and zero for every inappropriate or uncertain response. 20he final total score of attitude was classed, with a score of > 8 considered reflecting a positive attitude.For the practice section which consisted of 20 questions, one point was given for every appropriate response (never or rarely for a negative statement and often and always for a positive statement) and zero for every inappropriate or uncertain response.The final total score was classed, with the cut-off value of > 10 considered to reflect good practice towards vitamins and DS. 23Additionally, the distribution of the categories will be reported in the results section to provide a comprehensive overview of the data collected.

Sociodemographic
Out of the 438 participants who were invited to participate in this survey, 260 participants (response rate = 59.36%) agreed to participate and completed the questionnaire.The majority of the participants were young adults with the mean age of 29.15 ± 5.849 years (Table 1).Most of them were female (61.2%) and majority of them were Chinese (73.1%).Majority of the participants had the highest qualification of Bachelor in pharmacy (87.3%) and approximately three quarters of the participants were fully registered pharmacists (FRP), with more than two-thirds of the participants graduating from private universities.Furthermore, 85.0% of the participants were full time pharmacists while 39 (15.0%) are part time or locum pharmacists, with 70.4% of them working in a chain pharmacy.Among the 260 participants, more than half of the participant pharmacists were working for 36 to 48 h weekly, with the majority (48.1%) having one to five years of working experience in the community setting.Approximately 51% of the participant pharmacists had frequent direct interactions with patients as shown in Table 1.

Knowledge
The majority of participants have average knowledge to counsel patients about vitamins and DSs (73.5%), while 21.2% have good knowledge and 5.4% have poor knowledge about vitamins and DSs (Table 2).When considering specific knowledge on common products, most of the pharmacists (83.2%) had a good understanding of the clinically proven benefits of common supplements including milk thistle, saw palmetto, ginkgo biloba, rooibos tea; however, most pharmacists were not familiar with indications of Eurycoma longifolia including treating minor illness, improving muscle strength and physical activities and reducing blood sugar level.More than half of the participants (52%) were also unaware that St John's wort should be stopped at least two weeks before scheduled surgery as it can lead to serious heart complications.Moreover, participants (24%) were also unsure about the dosage required for Labisia pumila, which is a popular herb used among females locally (Table 2).

Attitudes
Table 3 shows the results of participants" overall attitude towards vitamins and DSs.Based on the participants' responses, about 80% of them agreed that supplements can bring a positive impact on public health, and are a major source of profit for community pharmacies.Nearly all participants (91.2%) believe pharmacists play an important role in advising patients regarding the use of DS, by helping patient in decision-making (34.3%) and providing appropriate counselling (91.2%).Most participants agreed you should frequently follow-up a patient after selling them a vitamin or DSs (60.8%), whereas 13.1% stated it was unnecessary to have frequent follow-ups with patients after their purchase.Nearly all the participants (91.2%) declared that they respected the choice of patient when choosing a vitamin and DSs, and 46.9% of the participants understood the desire for patients to take supplements to optimise their health.Some pharmacists (35%) even believe that it is safer for patients to take vitamins and DSs compared to taking conventional medications and around 32% of them claim that vitamins and DSs can replace certain medications such as cholesterollowering medications.
Approximately 44.6% of the pharmacists believed that there is a correlation between the efficacy and the price of vitamins and supplements, and around 35.4% (23.5% + 11.9%) of them preferred recommending more expensive brands despite having similar content as other brands.

Practice
Table 4 reports current practice of pharmacists and their provision of sales of vitamins and DSs.More than half of the participants (mean = 4.37/5) would always refer the patients and consumers to visit a doctor if their symptoms persist despite regular consumption of supplements, yet there are around 29% of the pharmacists who do not always refer the patients to the doctor.Many pharmacists also declared that they often or always educate patients and consumers about dosage and administration of vitamins and DSs (118, 45.4% and 109, 41.9% respectively).A gap in practice was seen (mean 3.58) in regards to consulting references for recommended doses for specific patient groups (e.g.pregnant women, renal patients) and 38 (10.8%) of the participants indicated that they rarely check the dose against a reference and usually go by the standard dose on the packaging.

Sociodemographic factors and its impact on knowledge and attitudes
Table 5 explores whether sociodemographic factors of the participants had any impact on knowledge and attitudes.Pharmacists working in the chain pharmacies were shown to have a higher knowledge mean score compared to those working in independent pharmacies (p < 0.05).Pharmacists of Chinese ethnicity have a higher knowledge mean score (8.64) compared to other ethnicities.There is also a statistically significant difference between whether pharmacists had roles that predominately involved direct interaction with patients and knowledge mean score (p < 0.05).
Furthermore, there is no significant difference between residence setting, employment contract status, and work setting in terms of attitude score.Participants who graduated from private universities (9.93) having a better attitude towards providing counselling service to patients about vitamins and DS compared to those who graduated in a public university.(p < 0.05) (9.11).Female pharmacists also have a better score compared to male pharmacists (p = 0.012).There is also a significant difference between attitudes of pharmacists who directly interact with patients compared to those who don't (p = 0.0.03).

Discussion
Vitamins and DSs are used by an average of 20-30% of the population in developed countries. 24In Malaysia, 28.1% of the country's total adult population uses vitamin and mineral supplements. 25Compared to five years ago, customers expect more information about complementary medicines from their pharmacists. 9This study shows gaps in the  The study has also shown pharmacists in Malaysia aren't providing enough information on these products, and potentially not matching the growing expectations of the public.Further research should see whether the consumers in Malaysia are satisfied with the amount of information provided by the pharmacist to make an informed decision about the purchase, and whether they feel confident the dosing and safety information provided is sufficient.Malaysian pharmacists generally have a positive attitude towards the provision of vitamins and dietary supplements (DSs).They acknowledge their role in ensuring safe use of these products.This aligns with findings from other studies, which report pharmacists' enthusiasm in advising on vitamins and DSs as part of their professional responsibilities. 11,26,27The favorable perspective is likely influenced by a common belief among Malaysians in the benefits of vitamins and DSs.Many Malaysians trust that these products can enhance general health.Additionally, some pharmacists perceive these supplements as safer alternatives to conventional medicines.In our study, 35% of participants expressed that it is safer for patients to use vitamins and DSs rather than conventional medicines.Moreover, about 32% believe that these products could substitute for certain medications, such as those used to lower cholesterol.Despite this, pharmacists tend to be skeptical about selling vitamins and DSs without solid scientific proof of their efficacy and safety.They show a negative attitude in such cases, as reflected in the literature. 8,28s there was a positive attitude shown from these participants, this could suggest educational interventions should be well-received by Malaysian pharmacists if they are accessible and help them with the supply of these products.More than half of the pharmacistss (80%) in this study recommended selling vitamins and DSs in pharmacies because it is seen as a major source of profit in community pharmacies.Furthermore, only more than half of the pharmacists had undergone formal education and training on vitamins and DSs.A systematic review conducted in Malaysia discussed that post-graduate pharmacists urged that an increasing DSs training should be increased to gain a comprehensive understanding of these products and to provide better counselling to inquiring patients. 29If there is a lack of evidence-based training, pharmacists have been shown to turn to media sources, including product advertisements to learn about the products. 302][33] Studies have also reported that pharmacists are generally less likely to educate patients about vitamins and herbal supplements. 21,34Future studies could integrate training on vitamins and DSs as part of renewal of registration which has shown to be successful in Singapore. 35n area of education that needs to be address is providing a framework for referral to support pharmacists when recommending vitamins and DSs.Some studies have found pharmacist will refer to doctor if the patient's symptoms persist despite regular consumption of supplements 36,37 but not all our participants in our study encourage referral when needed, with 29% of pharmacists perceiving it to be unnecessary to refer to the doctor when patients have ongoing symptoms whilst taking vitamins or DSs.Concerns were also raised regarding the dosing for specific patient groups, including pregnant and patients with noncommunicable disease groups.Many pharmacists, accounting for 33.5%, reported that they consult their reference materials only occasionally and typically rely on the product label for dosing information.This practice may be due to the inconvenience of making a proper referral or the belief that referrals are only necessary when the patient's condition becomes severe. 32Another gap was that results showed that community pharmacists were not consulting their references for dosing for specific patient groups and just counselling on the standard directions on the packaging.This could be due to limited reliable references, time constraints, and excessive workload, resulting in an insufficient allocation of time to patients. 21,38To better support pharmacists, there could be education on common patient groups and what to watch out for dosing, or a guide to where to best look for this information or online module or app, that provides the safest dose to give and to emphasis what toxicity signs to look out for in these patient groups.
When considering participant demographic factors, this study suggests that working at a chain pharmacy compared to an independent pharmacy, as well as having a more patient facing role, can significantly impact on the level of knowledge.This is consistent with a study conducted in China, where pharmacists at chain pharmacies had a better knowledge and attitudes towards pharmaceutical care and were able to practise more advanced pharmaceutical care than pharmacists at independent pharmacies. 39This could be because chain pharmacies tend to have more frequent product training and courses for their staff as compared to independent pharmacies, which can then affect their level of knowledge and quality of professional advice given to the patients.Moreover, community pharmacists who work in chain pharmacies provide more frequent one-on-one consultations for patients and deal with more sales of vitamins and DSs than independent pharmacies. 40his is the first study of its kind in Malaysia and will help inform policies that will help regulate these sales as these are popular products used by many Eastern countries.Further research could expand to other eastern countries to see what other facilitators and barriers to better provision of sales of CAMs exist.This study has some limitations; it has a modest sample size but has managed to capture a wide catchment of Malaysia and still provides a snapshot of the need for improvement in our services.The number of community pharmacists in Malaysia is estimated to be 2780 according to the Malaysian Pharmacist Society 41 ; the participants in the study (n = 260) is approximately represents 10% of the population of pharmacists.The answers in this survey is selfreported and may not match to what these pharmacists actually do in real life and should be follow up by and observational study or mystery shopper or simulated patient study.It is a first step at investigating the main concerns and how training can be targeted.
Since COVID-19, the sales of vitamins and DSs, especially "immune boosting" supplements such as vitamin C, multivitamin, vitamin D, probiotics, selenium, zinc etc. increased significantly. 31It has been noted that the knowledge of community pharmacists selling vitamins and DSs is not increasing to match the increasing sales.Malaysian consumers also heavily rely on their pharmacist to provide accurate advice for these products. 42As vitamins and supplements are available online and in supermarkets, and with the surge of false advertisements of products to cure or prevent disease especially COVID-19 raised major concern in Canada, China, and the United States.[24].Regulatory oversight and public education are vital for safe provision of these products and a pharmacist is in the best position to provide these services.Pharmacists should put extra effort in understanding the dosage, indications, drug-herb interactions, and when to stop herb products in

Limitation
This study has several limitations that should be acknowledged.Firstly, while efforts were made to achieve a representative sample of community pharmacists in Malaysia, the calculated sample size may have influenced result precision.Secondly, although rigorous validation procedures were employed for the survey questionnaire, self-reported data collection methods may introduce biases.Additionally, the recruitment approach via social media and snowball sampling may have led to self-selection bias.The cross-sectional design limits the study to a single point in time, hindering the assessment of temporal changes.Furthermore, the study's findings may not be entirely generalizable to regions with different healthcare systems and practices.

Conclusion
Our study has shown that while the majority of Malaysian pharmacists have an adequate understanding of vitamins and dietary supplements (DSs), there are knowledge gaps, particularly with less common products and dosing for specific patient groups.Attitudinally, pharmacists value their role in public health and patient counselling, yet some lack engagement in follow-up care.Practically, a notable portion does not always refer patients to doctors when needed and often defaults to label instructions for dosing.
These findings underscore the need for targeted educational interventions to deepen pharmacists' knowledge and refine their practices.By focusing on dosing, product cessation guidelines, and the efficacy of DSs, we can enhance the safe use of supplements and strengthen the referral process.This approach promises to elevate the standard of patient care provided by pharmacists in Malaysia.

Table 2
Summary of product knowledge questions (correct answers are flagged).

statement best describes the evidence for St. John Wort's effects? (choose all that apply
) -St John wort can be taken concurrently for people with sleeping disorders who are taking sleeping pills at the same time 154 (16.9) -St John wort is used for mild to moderate depression, menopausal symptoms, and somatic symptom disorder* 203 (78.1)

Table 2
(continued ) # participants were allowed to choose more than one options.* Correct Answer.

Table 3
Attitudes towards provision of sales of vitamins and DSs (N-260).

Table 4
Practice of participant pharmacists in regards to provision of sales of vitamins and DSs.

Table 5
Analysis of difference between knowledge and attitude score with participants demographic characteristics.circumstances for patient safety.There is a need for pharmacists to constantly update themselves about the newly available vitamins and DSs in the market, and update themselves.Consumers in Malaysia have a desire to use vitamins and DSs and its important future research investigates education interventions targeting dose in specific patient groups and when to stop products, new products, evidence-based efficacy of products for specific conditions, and provide a framework for appropriate referral to support pharmacists.