Design and Implementation of an Elective on the Ethnopharmacology of Appalachia for the PharmD Curriculum

Rebecca S. Linger, PhD

Am J Pharm Educ. 2017;81(10):6100

Abstract and Introduction

Abstract

Objective. To create and implement a class in ethnopharmacology that would educate student pharmacists on folk medicine, including home remedies and native plants that are used as alternative medicinal sources; active components of medicinal plants including toxicity issues and the mechanism of action of beneficial compounds, such as catechins and other flavonoids; and nutraceuticals and poisonous plants.

Methods. In this three-credit hour class, herbal remedies are investigated from the standpoints of medical efficacy, potential toxicities and drug interactions with prescribed medications. Class discussions are conducted on the usefulness of remedies, the attitudes of practitioners toward traditional remedy use and the risks of relying on herbal preparations. Each student prepares a 15-minute presentation on a disease state, which covers modern pharmaceuticals and herbal or folk remedy alternatives used in that disease. Special emphasis is given to drug-herb interactions.

Results. The class has gained popularity among students and consistently fills within the first hour of computerized registration. Students agree that being educated in the benefits and potential toxicities of herbal products will better prepare them to counsel their patients who use these remedies. The elective has been offered 10 times since 2007. Anecdotal comments from our alumni indicate that they have found the information to be very useful in their practice environments.

Conclusion. Providing our students with a greater understanding of herbal remedies is essential to prepare them for practice. By including both the uses and potential toxicities, the student pharmacist is able to counsel her patients from a standpoint of expertise on these self-administered remedies.

Introduction

The popularity of herbal medicine and alternative remedies remains strong within the United States. The National Center for Health Statistics has conducted the National Health Interview Survey (NHIS) on complementary and alternative medicines nationwide since 1997. This survey, conducted every five years, asks adults living in the United States about their use of herbal preparations and dietary supplements. In 2012, the NHIS reported that 53.6 million Americans utilized herbal remedies and dietary supplements.^[1] The sale of botanical dietary supplements was estimated at $11.5 billion in 2012.^[2] A population-based survey of 2,982 respondents conducted by Emory University in 2004 indicated that while 20% of the population used medicinal herbs, over 33% admitted to daily use.^[3] People who use dietary supplements report feeling an increase in general well-being and energy and feel that the supplements will help them fight or prevent various diseases.^[4] As our nation continues its pursuit of healthier lifestyles, we can expect the use of herbal supplements to continue to rise. Thus, the education of our student pharmacists in the uses of herbal supplements is of utmost importance.

In a 1998 report on complementary and alternative medicine (CAM) education in U.S. pharmacy schools, Rowell and Kroll indicated that 60% of schools responding presented herbal medicine in their curriculum, either in standalone classes or as part of the core curriculum.^[5] The guidelines they developed for CAM coursework for pharmacy schools stress the critical evaluation of the efficacy of the herbal remedies discussed. In 2003, Shields and colleagues found that 63% of schools responding had a specific course in natural products within their curriculum, with the majority of these classes offered as electives.^[6] In 2013, Noureldin and colleagues reported that while the majority of students surveyed had a positive opinion of CAM, students who had "personal experience, pharmacy education and family background" with CAM had a more favorable attitude toward its use.^[7]

The importance of educating student pharmacists in the use and risks of herbal remedies cannot be overstated. The study of commercially available herbal supplements and an understanding of the lax regulatory oversight in their production are essential. The Dietary Supplement Health and Education Act of 1994 was established to help regulate products to be used for nutritional supplementation, but does not require certification or registration of active ingredients or potencies.^[8] Consequently, some commercially available nutritional supplements may contain insufficient quantities of active ingredients for efficacy, or competing brands may have significantly different concentrations of active ingredient leading to overdose or significant drug-herb interactions in the patient who is unaware that the concentration has increased from one brand to the next.

Given the large market for herbal supplements, it is interesting to note that many of the herbal remedies used today in Appalachia utilize foraged plants. The remedies have been passed down through oral tradition from ancestors who settled this area in the late 18th and early 19th century. For the uninitiated, descriptions of these remedies can be found in publications, such as almanacs, family medicine books and herbal texts, many of which date back to the homesteading period. Self-treatment with "tried and true" family remedies is part of the Appalachian spirit of self-reliance, which also includes the reluctance to seek outside medical attention.^[9] Although many Appalachians will admit to a lack of medical knowledge, their faith in family remedies will foment their reliance on self-treatment. Economic issues also influence their choices; many families do not have adequate health insurance, or medical personnel and facilities may be too far away.^[10] Pharmacy education in these rural areas should take these factors into account and include discussions of alternative remedies and practices of the local population.

According to Standard 12 of the "Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree" (Accreditation Council for Pharmacy Education 2016),^[11] "the didactic portion of the pre-APPE curriculum includes rigorous instruction in all sciences that define the profession" including "evidence-based evaluation of the therapeutic value, safety, and regulation of pharmacologically active natural products and dietary supplements. Cultural practices commonly selected by practitioners and/or patients for use in the promotion of health and wellness, and their potential impact on pharmacotherapy" (Appendix 1 of Standards 2016). Patient-centered care must consider the health-literacy of the patient as well as any cultural issues that might need to be addressed. Student pharmacists need to understand the cultural background of their patients and be able to describe prescribed therapies and potential interactions in terms that can be understood by the patient. In this course, we expose the students to the folk lexicon of Appalachian residents, such as "risings" for hives or boils, "piles" for hemorrhoids, dropsy for edema.^[12] This sensitivity to the patient is also prescribed by the Center for the Advancement of Pharmaceutical Education (CAPE) 2013 Educational Outcomes, which describes within Domain 3 the need to advocate for the patients' best interests in a way that engages cultural sensitivity.^[13]

This article describes the design and implementation of a class in ethnopharmacology. The University of Charleston resides in the heart of Appalachia. Approximately 70% of the students come from counties considered part of Appalachia by the Appalachian Regional Commission. Focusing on herbal supplement and folk medicine use following the traditions of Appalachia, this class adequately trains students to counsel their patients in a more culturally sensitive manner.

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Next Section

Abstract and Introduction
Methods
Results
Discussion
Conclusion
References

Table 1. Lecture Topics
Introduction to Ethnopharmacology (1 hr)
Herbal Preparations (3 hrs)
Abandoned Theories of Illness (2 hrs)
Alternative Medicine (2 hrs)
Our Family Remedies (2 hrs)
Poisonous Plants (2 hrs)
Some Commonly Used Herbal Remedies (4 hrs)
Patent Medicines (1 hr)
Flavonoids and Nutraceuticals (1hr)
Herb-Drug Interactions (2 hrs)
Ethnobotanical Uses of Appalachian Plants (2 hrs)
Compounding Lab: Beeswax/Almond Oil Hand Cream, Tea Tree Oil, Witch Hazel Insect Repellent (3 hrs)

Table 2. Performance of Students Per Year on Individual Course Assessments
Year	Exams	Paper	Presentation	Final
2007	97	91	93	93
2008	96	90	94	93
2009	95	^a	93	95
2010	95	^a	95	96
2011	91	^a	83	90
2012	93	^a	94	94
2013	93	^a	94	94
2014	91	72	94	89
2015	88	70	90	87
2016	92	88	92	92

^aNo paper was assigned
Mean scores are presented as percentage of total points

Table 3. Student Course Evaluation Scores (5 = Excellent)
Year	Score	Respondents	Enrollees
2007	4.8	20	20
2008	4.7	15	20
2009	4.7	22	31
2010	4.9	25	26
2011	3.5	7	28
2012	4.7	25	30
2013	4.9	11	39
2014^a
2015	4.2	19	19
2016	4.8	21	25

^aNo class evaluations were made during this period

Table 4. Selected Student Comments as Part of the Course Evaluation
The open discussions in class are helpful in allowing the students to connect with the material as opposed to just memorizing it. Out of all the classes taken this semester, this single class is most applicable in regard to the myths and facts of home remedies and herbal therapy.
The information from this class leaked into a few other courses this semester. I am glad I chose this elective because it helped me with my other courses.
I feel like [this course] is really helpful in the practice of pharmacy, especially for me because I plan to practice in West Virginia. I actually had a patient come in to my pharmacy and ask a question about homeopathic remedies for gout. Someone had told him to use cherries. I was able to apply my knowledge of the class to my actual pharmacy practice
This class was amazing; I loved learning about how natural remedies and synthetic remedies can either work or hinder each other in treating a patient. The labs were fun and informational. The stories told by the professor only enhanced the fun I had in this class.
Great class overall, would recommend to others. Quite interesting. I thought the course was extremely informative and interesting. Considering that I grew up roaming the hills and being outdoors quite a bit, and having the ability to learn about some of the medicinal properties of the plants was very interesting.

Appendix 1. Student Oral Presentation Scoring Rubric ^a
Score	4	3	2	1
Non-Verbal Skills
Eye Contact	Holds attention of entire audience with the use of direct eye contact, seldom looking at notes.	Consistent use of direct eye contact with audience, but still returns to notes.	Displayed minimal eye contact with audience, while reading mostly from the notes.	No eye contact with audience, as entire report is read from notes.
Body Language	Movements seem fluid and help the audience visualize.	Made movements or gestures that enhance articulation.	Very little movement or descriptive gestures.	No movement or descriptive gestures.
Poise	Student is relaxed and self-confident.	Makes minor mistakes, but quickly recovers. Appears calm.	Displays mild tension; has trouble recovering from mistakes.	Nervousness is obvious; has trouble recovering from mistakes.
Verbal Skills
Enthusiasm	Strong, positive attitude during entire presentation.	Occasionally shows positive attitude.	Shows some negativity toward topic presented.	Shows absolutely no interest in topic presented.
Elocution	Student uses a clear voice and correct, precise pronunciation of terms so that all audience members can hear presentation.	Student's voice is clear. Student pronounces most words correctly. Most audience members can hear presentation.	Student's voice is low. Student incorrectly pronounces terms.	Audience members have difficulty hearing presentation.
Content
Subject Knowledge	Student demonstrates knowledge by answering all class questions with explanations and elaboration.	Student is at ease with expected answers to all questions, without elaboration.	Student is uncomfortable with information and is able to answer only rudimentary questions.	Student does not have grasp of information; student cannot answer questions about subject.
Organization	Student presents information in logical, interesting sequence. Introduction, Development of Material and Conclusion included.	Student presents information in logical sequence which audience can follow. Introduction, Development of Material and Conclusion included.	Audience has difficulty following presentation. Introduction, Development or Conclusion is missing.	Audience cannot understand presentation because there is no sequence of information.
Mechanics	Presentation has no misspellings or grammatical errors.	Presentation has no more than two misspellings or grammatical errors.	Presentation has three misspellings and/or grammatical errors.	Presentation has four or more spelling and/or grammatical errors.
PowerPoint Presentation
Text	All slides present one idea and a few supporting facts.	Most slides present one idea and a few supporting facts.	Most slides present one idea but too many words.	Most slides present multiple ideas and/or too many words.
Font	Font on all slides is large enough to be read at a distance.	Font on most slides is large enough to be read at a distance.	Fond on most slides is too small to be read at a distance.	Font on all slides is too small to be read at a distance.
Contrast	There is good contrast between the font and background on all slides.	There is good contrast between the font and background on most slides.	The lack of contrast between the font and background makes the text difficult to read.	The lack of contrast between the font and the background makes the text impossible to read.
Images and Layout	All slides contain one powerful, high-quality image per slide which helps the audience understand the content. Layout is visually pleasing.	Most slides include one powerful, high-quality image per slide which enhances the content. Layout uses most space appropriately.	Most images are clip art or images are too large/small or poor quality. Layout shows some structure.	Images are distracting decorations that create a busy feeling and detract from the content. Layout is cluttered and confusing.
Presentation Style	Student uses text on slides as prompts for original narration.	Student reads text on slides and elaborates comfortably.	Student reads text on slides, adding few comments.	Student just reads text on slides.

^aAdapted from NCTE/IRA "Read Write Think" www.readwritethink.org

Appendix 2. Term Paper Scoring Rubric ^a
Score	4	3	2	1
Focus & Details	There is one clear, well-focused topic. Main ideas are clear and are well supported by detailed and accurate information.	There is one clear, well-focused topic. Main ideas are clear but are not well supported by detailed information.	There is one topic. Main ideas are somewhat clear.	The topic and main ideas are not clear.
Organization	The introduction is inviting, states the main topic, and provides an overview of the paper. Information is relevant and presented in a logical order. The conclusion is strong.	The introduction states the main topic and provides an overview of the paper. A conclusion is included.	The introduction states the main topic. A conclusion is included.	There is no clear introduction, structure, or conclusion.
Voice	The author's purpose of writing is very clear and there is strong evidence of attention to audience. The author's extensive knowledge and/or experience with the topic is/are evident.	The author's purpose of writing is somewhat clear, and there is some evidence of attention to audience. The author's knowledge and/or experience with the topic is/are evident.	The author's purpose of writing is somewhat clear, and there is evidence of attention to audience. The author's knowledge and/or experience with the topic is/are limited.	The author's purpose of writing is unclear.
Word Choice	The author uses vivid words and phrases. The choice and placement of words seems accurate, natural, and not forced.	The author uses vivid words and phrases. The choice and placement of words is inaccurate at times and/or seems overdone.	The author uses words that communicate clearly, but the writing lacks variety.	The writer uses a limited vocabulary. Jargon or clichés may be present and detract from the meaning.
Sentence Structure, Grammar, Mechanics & Spelling	All sentences are well constructed and have varied structure and length. The author makes no errors in grammar, mechanics, and/or spelling.	Most sentences are well constructed and have varied structure and length. The author makes a few errors in grammar, mechanics, and/or spelling, but they do not interfere with understanding.	Most sentences are well constructed, but they have a similar structure and/or length. The author makes several errors in grammar, mechanics, and/or spelling that interfere with understanding.	Sentences sound awkward, are distractingly repetitive, or are difficult to understand. The author makes numerous errors in grammar, mechanics, and/or spelling that interfere with understanding.