Implementation of the Traditional Medicine Policy 2014–2023 of the World Health Organization (WHO) in “promoting the safe and effective use of Traditional and Complementary Medicine (T&CM) through the regulation, research and integration of T&CM products, practices and practitioners into the health systems as appropriate” continues to unfold across the world (The World Health Organisation, 2014). The terms used when referring to T&CM products vary across regions depending on the regulatory frameworks for medicines and food. The terms “traditional medicine” and “health supplements” are used in China and parts of South and Southeast Asia, the term “complementary medicines” (CMs) is used in Australia, and the term “dietary supplement” is used in the United States (US) (The World Health Organisation, 2019). For this study, the term T&CM products will be employed to refer to products containing vitamins, minerals, herbs, essential oils, and homeopathic and flower essence preparations, regardless of the regulatory status within a country. Throughout the world, pharmacists encounter T&CM product use in their day-to-day practice through direct provision of products or indirectly while caring for patients who use them. This aligns with the WHO statement related to the mission of pharmacy practice: “to provide medications and other healthcare products and services, and to help people and society to make the best use of them” (The World Health Organization, 2011).

An estimated 80% of the world population use T&CM products as part of their healthcare (The World Health Organisation, 2014). Such prevalent use is associated with risks and benefits and has implications for public health. As T&CM products are generally considered low risk by most regulators, they are directly marketed to consumers and predominantly self-selected in retail outlets, including pharmacies. Pharmacists’ contribution to public health through the professional stewardship of prescription and over-the-counter medicine use is well established. However, there are currently no data comparing the practicalities and formal processes required to engage pharmacists in caring for people who use T&CM products. Over the last 20 years, there have been deliberations about advancing and formalizing pharmacists’ professional responsibilities in promoting the safe and appropriate use of T&CM products (The World Health Organisation, 2019). These discussions have resulted in messaging by professional organizations recommending pharmacists adopt professional practice behaviors associated with T&CM products. The evidence suggests that pharmacists acknowledge that incorporating stewardship of T&CM product use into pharmaceutical services is needed and of value (Ung et al., 2017a; Harnett et al., 2019; Yao et al., 2020). However, the evidence suggests that pharmacists are not proactively engaging with the public about their T&CM product use and overall are underperforming in this area (Lee et al., 2021). These concerning observations have been reported in countries with a high prevalence of T&CM product use: the United States (Harnett et al., 2019), Australia (Lee et al., 2021), China (Yao et al., 2020), and some other countries (Ung et al., 2017b).

A recent review involving data analysis from 30 countries, exploring the interface between T&CM product use and the pharmacist role, reported that research advocating and strategizing change in this area has grown in the last 5 years (Ung et al., 2017b). Moving beyond soft recommendations for professional practice behaviors associated with T&CM products to establishing professional standards is considered important (Harnett et al., 2019). Therefore, there is a need to listen to the pharmacy professions to determine an agreed set of reasonable professional practice responsibilities and the competencies required to fulfill them. Competency standards are foundational in informing the development of pharmacists’ education and associated learning outcomes, thus equipping pharmacists to meet such professional practice requirements.

The need for pharmacists to step up their role with regard to T&CM products as an extension of their professional duties has been repeatedly discussed. More recently, a bioethical framework has been proposed to guide pharmacists’ responsibilities associated with the sale of T&CM products (Popattia and La Caze, 2021). This framework concurs that there is a need for standardizing a set of professional practice responsibilities that center around pharmacists providing evidence-based information and consultations when purchasing products (Popattia and La Caze, 2021). Meanwhile, public health needs remain wanted with obvious gaps between these recommendations and the T&CM pharmaceutical care being delivered (Lee et al., 2021; Ng et al., 2021). This disconnection is indirectly supported by the fact that in most countries, the legal and regulatory frameworks associated with T&CM are not clearly defined (Ung et al., 2017a).

Given the nuances, cultural context, history of traditional medicines use, and the political and commercial interests associated with complementary medicines, any changes to legal frameworks and associated practice standards of a profession associated with T&CM products are complex. Therefore, both the voices of pharmacists and the public should be present in conversations about professional practice responsibilities and any legal requirements that may ensue. Meeting public health needs in day-to-day practices requires considering the diverse communities that use T&CM products and how these products are integrated (or not) into different healthcare systems and into pharmacist education across the world. Other relevant stakeholders in these conversations include pharmacy educators, professional pharmacist organizations, universities, the government, and pharmacy business owners (Ung et al., 2018). This requires a considered effort from pharmacists and their representative organizations toward such a consensus that translates the last two decades of research into implementable global practice behaviors that support public health and safety.

The first step toward greater standardization, development, and implementation of practice standards and ultimately guidelines is to garner up-to-date information regarding pharmacists’ beliefs about T&CM-related responsibilities, education, and their current practice behaviors from various locations around the world that vary by income status and health and education systems. Identifying areas of agreement and potential discrepancies across these countries will assist in developing a set of realistic professional practice responsibilities informed by real-world practice. These can be used to inform the development of education, competency, and practice standards.

The overarching aim of this cross-country study was to identify an agreed set of professional pharmacy practice responsibilities that support pharmacists’ contribution to ensuring the quality and safe use of T&CM products and promote public health. The objectives were 1) to develop, pilot, and disseminate a cross-country e-survey through a cross-country collaboration with professional associations and representative organizations and 2) to provide a cross-country perspective of pharmacists’ opinions about their professional practice responsibilities associated with T&CM products and, importantly, the steps and support required to formalize a professional practice role. The findings of this study will be used to inform the next research stage in developing a consensus on professional pharmacy practice responsibilities associated with T&CM products.

In this study, a set of professional practice responsibilities and actions that would enable pharmacists’ contribution to ensuring the quality and safe use of T&CM products were proposed to pharmacists across nine countries. This is the first study to examine the pharmacist’s role in T&CM products across a range of countries during a single 12-month period (2022). The data obtained from 2,341 pharmacists provide a contemporary, multi-country representation and indicate an overall agreement on broadening the scope of professional practice to assume responsibilities associated with T&CM products. Together with previous research conducted over the last 5 years in Australia (Ung et al., 2018; Popattia and La Caze, 2021), China (Yao et al., 2020), and the United States (Harnett et al., 2019) that examined pharmacists’ views about their role and T&CM products, there are strong signals that formalizing and supporting pharmacists to enact such responsibilities in the real-world setting are palpable and needed. Therefore, concerned stakeholders, especially public health authorities and educational bodies, are expected to develop effective interventions to promote the professional role of pharmacists in ensuring the safe and proper use of T&CM products (Hijazi et al., 2021).

Consistent agreement across countries about the need for education and training, development of competency standards, establishment of accreditation of pharmacists’ services, and greater regulation of T&CM products and services provided by pharmacists should be considered a priority. Successful development of education, accreditation standards, and advancing quality assurance and regulatory frameworks would have positive implications for ensuring the appropriate and safe use of T&CM products by the public. The main advantage of a cross-country joint effort is that the attention to pharmacists’ role in T&CM products is universal, and the study findings allow some common ground for further discussion about pharmacists’ practice at an international level, which is a key determinant of making progress in a collaborative manner. Other advantages are that the study findings may draw further attention from other countries, their engagement in this topic, and international harmonization of the actions recommended. The responsibilities outlined here can contribute to establishing a common goal and developing a set of well-orchestrated actions that need to be undertaken by various stakeholders, whether pharmacists themselves, professional organizations, universities, government, consumer groups, or regulatory bodies (Ung et al., 2018).

Discussions about broadening pharmacists’ professional role in ensuring the safe and appropriate use of T&CM products have been described in detail twice over the last decade, and strategies required to accomplish this goal have been proposed (Ung et al., 2017b). A strategic model was proposed by Ung et al. (2018), and in 2020, an implementation science framework was recommended as an approach to navigating the multiple stakeholders and factors that influence pharmacists in successfully adopting responsibilities (Harnett et al., 2020). Despite the strategies proposed, including developments in education, day-to-day practice behaviors did not reflect that pharmacists are educated or proficient in inquiring or responding to T&CM use (Lee et al., 2021). The many challenges reported in the literature reflect that pharmacists remain under-resourced through a lack of education and training, access to reliable, reputable information, being time-poor, and concerns about the quality of T&CM products (Ung et al., 2017b). Such barriers often lead to inappropriate awareness of and recommendations for the use of T&CM products (Jalil et al., 2022), and, should they remain, will further stall the necessary developments in the provision of quality advice and products that support appropriate and safe use of T&CM products (Ung et al., 2017a).

An important consideration moving forward is that although 83% of the pharmacists surveyed in this study agreed that T&CM product use should be included in their scope of professional practice, the types of T&CM products for inclusion in their practice varied between countries. This is also not surprising considering the way different T&CM products are incorporated into health systems, as reflected in Supplementary File S1 by the nine studies included in this study. They may be part of traditional health-seeking behavior, such as in China (Li et al., 2017) and Cabo Verde (de Pina Araujo et al., 2022), whereby traditional medicine is highly integrated into the overall healthcare system, or as a complementary approach as seen in Portugal (Tavares, 2015) and Saudi Arabia (Khalil et al., 2018). Interestingly, of the five categories of T&CM products, there was a high level of agreement that herbal products should be included in pharmacists’ scope of professional practice regardless of the country and the level of integration into the healthcare system. However, there were substantial variations in agreement on the inclusion of T&CM products containing vitamins/minerals, non-vitamin/mineral nutrition ingredients, and pro- and pre-biotics into professional practice. This disparity may relate to these products sitting within the discipline of nutrition and dietetics rather than pharmaceuticals. Recent reports have indicated that pharmacists in Western countries are also keen on knowledge about nutrition (diet- and or nutrition-related supplements) (Carter et al., 2022a; Carter et al., 2022b).

Furthermore, although Australia, New Zealand, and the United States did not participate in this survey, it is interesting to note that previous research has reported that vitamin, mineral, and nutritional supplements account for the majority of T&CM products used in those countries (Harnett et al., 2023). The inclusion of homeopathic products was least supported, and the opinions were mostly diverse, which partly reflected the pharmacists’ acceptability and confidence in such products considering the current availability (or lack of) of clear evidence of homeopathy efficacy over placebo. These inherent nuances between the East and West and the types of T&CM used within the respective cultural settings should be considered when developing an international consensus. The need to reflect the diverse needs of the communities that pharmacists serve while maintaining an evidence-based approach to providing information and care is significant.

Providing evidence-based information about the safe use of medicine is central to good patient-centered care (Sackett et al., 1996). The Hippocratic Oath of “above all do no harm” shared among health professionals revealed itself strongly in relation to pharmacists’ level of agreement on T&CM responsibilities associated with safety. This is unsurprising, given that one of the central roles of the pharmacist is the custodian of drug safety. In particular, informing consumers about the potential risks associated with the use of T&CM products (Responsibility 7), providing advice about the effectiveness of T&CM products based on scientific sources, helping consumers in making informed decisions (Responsibilities 8, 9, and 10), providing guidance on managing adverse events associated with T&CM products (Responsibility 12), and reporting any suspected adverse events to the regulatory authority (Responsibility 13) received high levels of agreement. Pharmacists in this study indicated a willingness to work more closely and train other pharmacy staff (Responsibility 17) and communicate with other healthcare professionals (Responsibility 18). By taking a more holistic and patient-centered approach, pharmacists can, as a leading role in the multi-disciplinary healthcare team, help drive an improvement in the safe and appropriate use of T&CM products, which is an area often overlooked by others (Nguyen et al., 2019).

From a pragmatic point of view, these are well-established responsibilities practiced by pharmacists all over the world every day in relation to pharmaceutical drugs. Extending these responsibilities to T&CM products would appear at face value to be sensible. However, despite the encouraging levels of agreement with the responsibilities proposed to the pharmacists in this study, without adequate education and training in the relevant areas related to safety, as learned from other areas in advancing pharmacists’ practice, such recommendations of responsibilities become unrealistic and idealistic expectations (Forsyth and Rushworth, 2021). This concern is supported by the fact that nearly 70% of pharmacists surveyed in this study indicated that T&CM products were common in their community; however, only one-third found that undergraduate pharmacy education in T&CM was comprehensive enough to support their professional practice. This aligns with a strong agreement with the proposition of a need for training and education for both pharmacy students (Action 4) and continuing professional development (Action 5). The infamous words of Nelson Mandela, “Education is the most powerful weapon to change the world” (Mandela, 1990), are likely very relevant here. Very little can change in this area without the educational institutions involved in the training of pharmacists and the professional associations involved in governing professional development investing time and resources in the development of high-quality non-bias T&CM education. To this end, the current qualification system for pharmacists, as seen in the participating countries, offers multiple opportunities to introduce education and training interventions. As shown in Supplementary File S1, it is common that the minimum education requirements in the form of a university degree before registration as a pharmacist and the requirements for continuing education as a criterion for registration renewal are in place. Therefore, introducing and integrating T&CM-related education and training before and after registration should be considered a priority of actions to facilitate the improvement of pharmacists’ professional practice in the area of T&CM.

Adding another layer to the complexities for pharmacists adopting responsibilities and central to this argument is the need to access effective and safe T&CM products of known quality (Barnes, 2019). This was echoed by the pharmacists in this study, who supported the need for regulatory standards of T&CM products to better safeguard the quality, safety, and efficacy (Action 11) and how the labeling and advertising of T&CM products should be overseen more rigorously (Action 12). Another quality aspect is product-specific evidence, which is currently lacking (Barnes, 2019), with variations in the herbal constituents present between batches and brands yet using generic evidence for therapeutic claims (Cohen and Hunter, 2017). Not surprisingly, pharmacists are also seeking non-biased high-quality research to develop scientific evidence about the efficacy and safety of T&CM products (Action 9), which was also considered highly important by the broader scientific community (Gagnier et al., 2006). Confounding the need for greater regulation of T&CM products and services is the right of consumers to make decisions about their health and access the products and health services they prefer as part of broader cultural and personal beliefs and preferences (Ung et al., 2017b). Over-interference by regulators and healthcare professionals may be counterproductive and act as a deterrent to consumers seeking professional advice to maintain their right to patient autonomy (Popattia and La Caze, 2021). For reinforcement of the knowledge base about T&CM products, it is equally important for regulatory authorities to prioritize pharmacovigilance of T&CM products (also referred to as phytovigilance) and for pharmacists to report any suspected adverse reactions (Memişoğlu and Otlatıcı, 2022).

A set of professional practice responsibilities and stakeholder-enabling actions related to the provision of T&CM products have been proposed to pharmacists across nine countries and received varying degrees of agreement. The variations in agreements are likely associated with variations in the healthcare systems they practice and the professional education they receive. The results of this study serve as a foundation for developing T&CM product guidelines for discussions by the pharmacy profession and related stakeholders to develop guidelines. Should these professional responsibilities be enabled and actioned, there are broad-reaching and positive implications for public health and safety.