Community pharmacy contribution to weight management: identifying opportunities
Professor Janet Krska, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK. E-mail: email@example.com
Objectives The aim of the study was to determine the public's views on weight-management services, including pharmacies as a potential venue, and the extent of current pharmacy involvement in weight management.
Methods Two questionnaires were developed for face-to-face interview in one Primary Care Trust area: one for the general public and one for community pharmacists.
Key findings Interviews were conducted with 177 members of the public, 75% of whom had tried to lose weight. More had used over-the-counter weight-loss products than prescribed medicines. There was greater awareness of commercial weight-management clinics than of NHS-led initiatives. Leisure centres were the preferred locations for weight-management clinics, with dieticians as the preferred staff. Pharmacies and pharmacists were not favoured as sources of advice on weight management. The questionnaire was completed by 49 community pharmacists (75%). All except one dispensed prescriptions for weight loss and 38 supplied over-the-counter weight-loss products. For both, estimated supply frequency increased with increasing deprivation of the pharmacy's location. Eight pharmacies provided a commercial weight-loss programme and more than half had weighing scales.
Conclusions Opportunities exist for extending NHS-led weight-management services from community pharmacies, but further research is required into the public's expectations of services to support an increase in awareness and acceptance.
Obesity is acknowledged as a huge public health issue worldwide, affecting all age groups in both developed and developing countries. In England it has been estimated that obesity is responsible for 30 000 premature deaths per year and reduces life expectancy, on average, by 9 years. Over the last 25 years, the prevalence of obesity in the UK has almost doubled; in England in 2006 24% of adults and 16% of children were obese (body mass index (BMI) greater than 30 kg/m2). The World Health Organization estimates that by 2015 approximately 2.3 billion adults worldwide will be overweight and more than 700 million will be obese.
Reducing obesity, improving diet and increasing physical exercise are priorities for the NHS in England and are included in the Government White Paper Choosing Health Through Pharmacy as one of 10 key priorities for community pharmacy. However, it has been suggested that pharmacists have less interest in public health interventions which do not necessarily involve a medicine and there is relatively little robust evidence to support community pharmacy weight-loss programmes. Despite this, a range of local and national services have recently developed throughout England enabling community pharmacies to contribute to weight management; some are as part of a wider health check whereas others involve only the provision of advice and support. Several schemes involve the use of patient group directions to facilitate the supply of prescription-only medicines as part of a weight-management programme.[8,9]
Community pharmacies are potentially ideal venues for weight-reduction programmes, since they provide access to a health professional without appointment over extended hours and in convenient locations. Many also have private consultation areas or rooms enabling personal issues to be discussed away from the shop floor. However, some studies have suggested that community pharmacy users were not willing to discuss healthy eating with pharmacists, view pharmacists as ‘drugs experts’ rather than experts on health and illness and do not view providing advice on healthy lifestyles as the pharmacist's role. Pharmacists in the USA and Australia have also expressed this view[11,12] and have identified lack of patient expectations as one of several other barriers to providing relevant services to obese patients.
Sefton Primary Care Trust (PCT), part of Greater Merseyside, has extremes of deprivation, with a higher obesity prevalence in less affluent households and a higher proportion of obesity among males than England as a whole. The Trust's obesity strategy, Lose Weight: Gain Life, recognises that all primary care staff, including community pharmacists, frequently encounter people who would benefit from losing weight, although at present the Trust does not support community pharmacy weight-management programmes. Mapping of current service provision is an essential part of needs assessment and an important stage for PCTs in the development of a novel service. Determining the views of the general public at whom a novel service will be targeted is also an essential prerequisite to service development.
A variety of market research methods have been used to obtain the views of the general public towards potential new health-related services, including postal questionnaires, telephone interviews and face-to-face interviews. Mixed methods approaches using all three techniques are common among academic marketing studies. While all can suffer from low response rates, they form an important part of needs assessments for service development. For this study face-to-face interviews carried out in the street were used. This is a standard market research technique which has grown in popularity, being second only to phone surveys in usage. The application of these interviews in the study of issues relating to both pharmacy and public health is increasing.[17–19] They have the advantage over postal questionnaires of rapid data collection and purposive targeting of respondents with desirable demographic characteristics. All market research methods are valuable in that the views of the full spectrum of a population, including so-called hard-to-reach individuals, for example those with a low literacy level, can be obtained. Face-to-face interviews have the additional advantage over postal questionnaires of minimising this latter problem, known to be a major factor within Sefton PCT. Methods which target users of existing health-related services are likely to be less valuable for assessing the views of potential consumers of services.
This study was carried out to determine the views of a sample of the general public in one PCT on their knowledge of and preferences for weight-management services, together with a survey of the extent to which community pharmacies in the same PCT have the opportunity to and currently do provide services supporting weight management.
Approval was obtained from Liverpool John Moores University Research Ethics Committee. Two questionnaires were devised: one for the general public and the other for community pharmacists. Both questionnaires were assessed for face validity by two academic pharmacists with community experience and the community pharmacy liaison officer for Sefton PCT.
Questionnaire for the general public
This questionnaire included mainly closed questions covering basic demographic details, plus respondent estimates of their overall health and diet using a five-point scale from very good to very poor. Respondents were asked whether they had ever considered themselves to be overweight, been informed they were overweight by a health professional or had attempted to lose weight. The remaining questions focused on respondents' actions previously taken to reduce weight, knowledge of weight-management schemes within Sefton PCT and preferences for services. Preferences for weight-loss advice were assessed by providing seven options, including pharmacist, and requesting respondents to identify their first choice and last choice. A similar method was used to assess respondents' preferences for the venue of a weight-management clinic they would be most likely or least likely to attend (four options including pharmacy) and the people they would most and least prefer to be in attendance at such a clinic (five options including pharmacist). These were derived from the venues and personnel likely to provide weight-management clinics within the PCT.
The questionnaire was piloted on a sample of 15 volunteers who incorporated a range of demographic factors, but who were not resident in Sefton, to assess understanding of the questionnaire and time taken to complete it. Piloting resulted in only minor changes to the wording of two questions. Completion time ranged from 5 to 10 min.
The questionnaire was then used to conduct face-to-face interviews by two researchers working together, stationed at seven locations throughout the PCT (shopping centres and high streets), selected to represent areas of socioeconomic diversity, from very high to no deprivation. Researchers specifically avoided standing near pharmacies, in order to ensure that pharmacy users were not specifically recruited. Each location was visited twice at different times of day over a 3-week period to maximise the opportunity to approach a variety of potential respondents. Members of the public passing by were approached and invited to participate in the interviews. An information leaflet was provided explaining the purpose of the survey, but people were free to decline or to refuse the information leaflet. Initially, respondents who agreed to the interview were requested to confirm they were aged 18 years or over and then provide the first half of their home postcode in order to confirm they resided in the PCT, otherwise they were excluded. A quota sampling method was used, which aimed to include a representative sample of the PCT in terms of age and gender. The people approached were not specifically targeted in terms of their outward appearance (underweight, normal weight, overweight or obese). The questionnaire did not ask respondents to provide their current weight.
Community pharmacist questionnaire
This questionnaire was designed to determine the frequency with which community pharmacists encountered people who were trying to lose weight and services offered of relevance to weight management. It was piloted with three practising pharmacists before use and required no changes. Pharmacist respondents were asked to estimate the number of times per week they supplied both over-the-counter (OTC) weight-loss products and prescriptions for weight-loss medicines, using the options none, one to three, four to six, seven to nine, or 10 or more. They were asked to list the weight-loss products they stocked and to indicate the facilities available in the pharmacy which could be useful in supporting weight management, by use of closed questions. This method was used to minimise completion time and maximise response rates; however; open questions were to obtain information about any weight-management services provided. Initially all 66 community pharmacies within Sefton PCT were contacted by telephone to inform them of the study and to arrange a convenient time for a researcher to personally visit those willing to participate. During this visit, all conducted by the same researcher, the questionnaire was completed via a face-to-face interview with the community pharmacist.
The level of deprivation of all pharmacies within the PCT was assessed using Index of Multiple Deprivation (IMD) and the pharmacy postcode. These were categorised as high (IMD 15 or greater), moderate (IMD 9–14) or low (IMD below 9).[20,21] The average estimated frequency of OTC sales and prescriptions was calculated using the frequencies of each option, taking the mid-points where a range was identified and 10 for the highest option.
Data were analysed using SPSS version 14. Associations between responses and demographic variables were tested for statistical significance using Chi-squared tests.
Questionnaire for the general public
In total 177 members of the public completed the face-to-face interview, 69.5% of whom were female. Difficulties were experienced in recording accurately the total number of people approached, many of whom refused to consider being interviewed. However, it was estimated that approximately one in every eight people approached actively considered participating. A high proportion of these, having listened to the standardised introduction and been offered the information leaflet, then agreed to the interview, but we were unable to calculate an actual response rate. Attaining the desired quota sample also proved difficult, since fewer older people and males agreed to be interviewed. Therefore the age distribution of the respondents did not reflect that of the Sefton population: people aged 65 or over were under-represented, whereas younger people were over-represented (Table 1). Fewer respondents viewed their overall health as good or very good compared to health ratings obtained in the 2001 Census for Sefton, while more rated it as fair or poor (Table 2).
Table 1. Age distribution of respondents in the general public in comparison to Sefton population
|65 or over||7.3% (13)||24.2%|
Table 2. Overall health ratings of general public respondents compared to 2001 Census data
|Good/very good||58.7% (104)||67.0%|
|Poor/very poor||9.6% (17)||11.3%|
Just over half of the individuals interviewed considered their overall diet to be good or very good (98; 55.4%), and 57 (32.2%) fair, while 22 (12.4%) stated it to be poor or very poor. More males indicated a poor diet than females (P= 0.03). A substantial proportion (132; 74.5%) of respondents had tried to lose weight, significantly more females (108) than males (24) (P < 0.001), but only 34 (19.2%) had been told by a health professional that they were overweight. Methods used to lose weight varied between the genders, with significantly more males preferring exercise and significantly more females dieting (P < 0.001). Low-calorie diets proved most popular (89), followed by Weight Watchers (49) and the use of Slim Fast products (28). Only four respondents had been prescribed a medicine to support weight loss, but 30 (16.9%) had used an OTC herbal weight-loss product, such as Adios (16) and Zotrim (6). All those using herbal products were female and 10 had purchased these products from a pharmacy. In addition, five individuals stated they had used OTC diuretics or laxatives to induce weight loss. Most respondents indicated frequent short periods of use, although five respondents had used one product continuously for more than 2 months.
Knowledge of weight-management advice and local schemes in Sefton was found to be limited. Although over half the respondents (106; 59.9%) were aware of five-a-day advice (about eating five portions of fruit and vegetables a day), only 53 had heard of Active Kidz (aimed at providing children with knowledge to lead a healthy lifestyle), 23 of Every Step Counts (designed to promote walking), 13 of Active Sefton (a programme of supported physical activity requiring referral by a health professional) and eight of Active Workforce (a health and wellness programme for public-sector employees). There was also limited awareness of weight-management services in Sefton, with most of those who responded positively citing commercial slimming clubs such as Weight Watchers, Slimming World, Rosemary Conley or gyms and leisure centres. Only two respondents mentioned a PCT-operated weight-management clinic.
The most frequently cited locations as first source of advice regarding weight management were gyms (65; 36.7%), followed by weight-management clinics (62; 35.0%) then the general practitioner (GP) (57; 32.2%). Only one person indicated pharmacy as their first choice, while 28 respondents (15.8%) selected pharmacy as their least preferred source of advice. The internet and media were viewed as least preferred advice sources by 51 and 54 respondents, respectively.
By far the most preferred venue for weight-management clinics was a leisure centre, with no differences between males and females in this regard. A dietician was selected by more than half the respondents as the most preferred professional at a weight-management clinic, especially among females (Table 3).
Table 3. Preferences for venue and staffing of weight-management clinics expressed by the general public
|Gym or leisure centre||111 (64.5%)||Dietician||94 (55.3%)|
|GP surgery||33 (19.2%)||Fitness instructor||55 (32.4%)|
|Community centre||25 (14.5%)||Champion slimmer||13 (7.6%)|
|Pharmacy||3 (1.7%)||Nurse||6 (3.5%)|
| || ||Pharmacist||2 (1.2%)|
Participants' views on what such clinics should provide indicated high preferences for advice on diet and exercise (145), regular weigh-ins (137), free gym membership (120) and records of weight changes (102). Over half (94; 53.1%) wanted one-to-one sessions, whereas only 70 (39.5%) wanted group sessions. No clear trends were evident in these preferences by age or gender.
Community pharmacist questionnaire
An overall response rate of 75% (49/66) was obtained, with the remaining 17 pharmacists refusing to complete the questionnaire due to time pressures. Most of the respondents worked for either large multiples (25) or independents (18), with the remainder in smaller chains, while the majority of non-responders (14/17) worked for independents. The distribution of respondents in terms of overall deprivation of the pharmacy location is shown in Table 4.
Table 4. Estimated frequency of pharmacy encounters with people obtaining weight-loss products
|Low||14||58||13 (93)||10 (71)||2.5||2.0|
|Moderate||15||94||15 (100)||13 (87)||2.6||2.5|
|High||20||77||20 (100)||15 (75)||4.6||3.1|
|All pharmacies||49||74||48 (100)||38 (78)||3.4||2.6|
The overall frequency with which pharmacists estimated they dispensed prescriptions for weight-loss products was low, with the majority of respondents (36) indicating only one to three times per week and only 13 indicating higher frequencies. The highest estimated frequency of such prescriptions occurred in pharmacies located in areas of high deprivation (Table 4). Thirteen pharmacists claimed to always provide advice to patients receiving prescriptions for weight-loss medicines, with a further 34 indicating advice was provided only on the first dispensing of such products. OTC weight-loss products were sold with similarly limited frequency and, again, the highest estimated rate of sale in pharmacies stocking these products was in areas of high deprivation (Table 4). The most frequently stocked herbal products aimed at promoting weight loss were Adios (31) and Zotrim (eight), although 21 pharmacies stocked meal-replacement products such as SlimFast. Most pharmacists (29) claimed to always question customers when OTC products were sold.
Most of the respondents stated that their pharmacies had facilities for private consultation (42), 29 had weighing scales, 18 offered height measurement and 17 waist measurement. The majority of pharmacists who did not offer these measurements felt it would be appropriate to do so. However, nine respondents felt it was not relevant to their pharmacy due to lack of space, local need or training. Other services provided of potential relevance to weight-management advice were blood-pressure monitoring, offered by 36 pharmacies and exercise and lifestyle advice (38). Most pharmacists (40) claimed to offer general dietary advice, while eight offered weight-loss clinics. Two pharmacies in the survey offered a package developed by a large multiple pharmacy chain, which includes the supply of orlistat via a patient group direction, while six participated in the Lipotrim programme, which involves no medicines but offers a total food-replacement package instead. Both are aimed at people with a BMI of at least 28–30 kg/m2, depending on co-morbidity.
This study has shown that members of the general public within one PCT in England did not consider pharmacy as their preferred point of contact for advice on weight management and did not appear to want weight-management services from pharmacies. Preferences for weight-management services included location in gyms and leisure centres or GP surgeries and the involvement of a dietician, rather than a nurse or pharmacist. The general public also showed limited awareness of local or national NHS weight-management services or initiatives, with gyms and commercial slimming groups/clubs being identified more frequently as sources of advice on weight management than GPs and pharmacists. Despite the lack of a PCT-led initiative to promote pharmacies as venues for weight-management support, they were providing a variety of services in relation to weight management and clearly could do more. Some pharmacies have facilities for measuring weight, height and waist circumference, but larger numbers stock OTC weight-loss products and demand for these appeared to relate to deprivation. However, the frequency with which pharmacists claimed to provide advice to people presenting prescriptions or question those purchasing OTC products was relatively low, suggesting a lack of pro-active engagement with the public trying to lose weight.
Strengths and weaknesses
The survey population for this study was the general public resident within Sefton PCT, rather than pharmacy users, unlike many previous studies exploring views of pharmacy services. Importantly the questionnaire included pharmacies as only one option for service provision to minimise bias in favour of pharmacies. Although the study sample was not truly representative of the Sefton population in terms of age or general health, it did include a substantial proportion who had tried to lose weight without discussing this with a health professional. This population would therefore be expected to include individuals not being targeted by NHS services, but who would have pertinent views on local weight-management services. The method of data collection selected is likely to have been responsible for the unrepresentative sample, since it required respondents to be present in shopping centres during the day, thus resulting in bias against the employed, males and the elderly. Face-to-face consumer surveys carried out in areas of high pedestrian flow are often considered the best method of collecting attitudinal information from consumers, who are at present those most likely to use community pharmacies for weight management. Standard methods of measuring response rates could not be used because of the nature of the approach used. While the overall response rate could be regarded as low, a high proportion of those who actively considered taking part did so. High response rates and the inclusion of hard-to-reach individuals are some of the benefits of face-to-face interviews in comparison to other methods such as using telephone interviews (random-digit dial surveys).
A high proportion of community pharmacies was included, although independent pharmacies and those in areas of low deprivation were under-represented in the survey and may have provided different services. The frequency of dispensing prescriptions or supplying OTC products for weight loss were based on retrospective estimates and are therefore subject to recall bias. The self-reported nature of all our data means that they should be viewed with caution.
Implications for practice
The recent White Paper Pharmacy in England encourages a much more visible and active role for pharmacists in improving public health and specifically lists measurement of BMI and waist circumference, weight-management clinics and supply of medicines to help reduce weight among a range of activities through which pharmacy can contribute to overall strategies. In addition to providing programmes, pharmacists are also encouraged to increase public awareness of local and national schemes, such as ‘exercise on prescription’. However, as yet there is limited evidence from controlled studies to show that NHS-led weight-management services provided by community pharmacies provide benefit. A recent uncontrolled trial of a weight-management service funded by the Department of Health in England found that 21% of patients recruited lost weight. Studies in other countries have demonstrated benefits of pharmacy weight-management programmes with similar success rates.[25,26] Some of these studies have involved small numbers of participants, which may indicate lack of awareness, as was found here. Other work has also identified that weight management, although considered by the public to be of high priority for improving public health, was not considered an important pharmacy role. Together with our data, these studies suggest that more work is required to develop and evaluate community pharmacy weight-management services and to market them effectively.
When developing and commissioning services, PCTs and other bodies may be unaware of the commercial services currently being provided by pharmacies, such as the Lipotrim programme provided by six pharmacies in this study. The supply of OTC weight-loss products from a large proportion of pharmacies also warrants further investigation. Widespread availability of OTC weight-loss products through community pharmacies was also found in a neighbouring PCT, together with a lack of pharmacy staff knowledge about such products and advice accompanying their sale.[27,28] Pharmacists have received professional guidance outlining the lack of evidence of efficacy of these products and could use the opportunity of requests for these products to emphasise this and instead encourage the use of more effective weight-loss methods. If supply of OTC products is greatest in areas of high deprivation, as our data suggest, this raises concerns that people who may benefit from NHS services may not be receiving appropriate advice regarding the need for more sustainable and efficacious approach to weight management. Conversely, the higher frequency with which customers request these products in areas of high deprivation may have benefits, since the greatest levels of obesity are found in areas of high deprivation.
If community pharmacy advice and support are to be expanded, as suggested by Government, not only is greater evidence of benefit required, but there is a need for an increase in public awareness and acceptance of such services, since at present there appears to be little expectation or desire for weight-management services in pharmacies among the general public we interviewed. The extent to which community pharmacy staff have opportunities for providing advice and support, through ad hoc encounters accompanying prescribed or purchased products or the use of equipment such as weighing scales, should be explored further. More importantly, the views of the general public on accessing weight-management services through pharmacies requires further study.
Conflict of interest
The Author(s) declare(s) that they have no conflicts of interest to disclose.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
We are grateful to the community pharmacists who provided information and to the members of the general public who completed the interviews.