Community Pharmacists role in obesity treatment in Kuwait: a cross-sectional study

Obesity and overweight represent a rapidly growing public health challenge worldwide. World Health Organization (WHO) estimates that 1.5 billion adults and about 43 million children under 5 years old were overweight in 2010. In general, greater than one in ten of the world’s adult individuals are obese [1]. Obesity and overweight are the fifth leading risk for worldwide deaths [1]. Obesity is a risk factor for development of various diseases including coronary heart disease, dyslipidaemia, hypertension, stroke, some forms of cancer, type 2 diabetes mellitus, gallbladder disease, osteoarthritis and gout, and pulmonary diseases, including sleep apnoea [2].

In Kuwait, obesity is a growing health concern; several studies have shown the high prevalence of overweight and obesity among the population. In 2010, about 80% of women were overweight or obese, and childhood obesity continues to increase as well [3‐6]. The most common factors contributing to overweight and obesity are overeating unhealthy high-fat foods and sedentary lifestyles [6]. Thus, there is an urgent need for the implementation of effective preventive measures for controlling the prevalence of obesity including public education about lifestyle modifications.

Barriers to the assessment and management of obesity by physicians include inadequate training, lack of time, lack of reimbursement, lack of access to dietician and uncertainty in relation to the efficacy of weight loss interventions [7]. Furthermore, the provision of diet sheets and referral to a dietician or a psychotherapist by physicians was found to be unsatisfactory by the obese patients [8]. In 1989, the definition of health promotion was expanded to emphasise the importance of cooperation between different stakeholders to enhance awareness, change behaviour and create environments that support good health practices [9]. Among them, community pharmacists have a valuable role in promoting and maintaining public health as one of the most accessible health care providers. Pharmacists have already started working with other health care professionals in the USA to maintain and promote public health [10]. A study conducted across Europe shows that 64% out of a total of over 6,000 people in six countries supported the further development of community pharmacies as alternatives to physicians' clinics, so that they can have more choice in receiving advice and treatment for common conditions. The greatest support for extending pharmacy based health care was in the United Kingdom (UK) and Poland [11].

Health promotion plans focus on community based interventions and partnerships to maintain wellness and to help modify individual behaviours such as unhealthy lifestyles [12]. In the UK and Australia, community pharmacies are recognised as the most accessible healthcare settings due to the high volume of the population that use their services [13]. Given the numerous comorbidities characteristically exist with obesity, obese patients often interact with their community pharmacists to obtain prescription drugs and/or over-the-counter (OTC) products for these diseases. In fact, pharmacist is the most accessible health care professional in the community who can help patients in the management of overweight and obesity by assisting in the selection of weight loss agents, offer appropriate counseling on nutritional and lifestyle modifications, and monitoring to ensure safe and effective pharmacotherapy outcomes [14‐17]. A systematic review of community pharmacy-based weight management interventions reported the findings of 10 relevant studies conducted in the USA, the UK, Switzerland, Spain and Denmark [18]. In England, pharmacist-led weight management program has achieved significant results, and its success was one of the major driving forces behind the Department of Health’s recommendation that community pharmacists should be involved in weight management services [19].

Pharmacy associations, such as the American Society of Health-System Pharmacists encourages pharmacists to work with obese clients to reinforce lifestyle modifications and provide education and encouragement [20]. A number of the pharmacy profession roles were identified in a clinical guideline on the prevention and management of obesity published by the National Institute for Health and Clinical Excellence [21]. In developed countries, community pharmacists have been identified as health advisors and highly credible source of health information to the general public through their counseling activities, including helping clients achieve and maintain a healthy weight [18, 19, 22‐26].

In a country like Kuwait, where overweight and obesity are prevalent, the contribution of all health care professionals including pharmacists in fighting this epidemic is crucial. Most studies on the pharmacists’ role in obesity counseling have been conducted in developed countries, and there is a lack of information on this role in the Middle East region including Kuwait. Therefore, the present study was designed to describe the self-reported practice of community pharmacists in relation to counseling patients with obesity, identify the practice barriers to obesity counseling as well as strategies to overcome barriers to counseling.

A descriptive, cross-sectional survey was conducted in Kuwait. Kuwait is a Middle Eastern country with an area of 17.820 square kilometres and an estimated population 3.328.136 people (2007 estimate). The study population included full-licensed pharmacists working at community pharmacies in Kuwait. The ethical clearance for this study was obtained from the "Human Ethical Committee, Health Sciences Center, Kuwait University".

The sample size was determined using Java Applets for Power and Sample Size [27]. It was calculated that a sample size of 186 pharmacists would be required to determine a 20% difference in proportion between two groups (e.g., male vs. female) with an 80% power and a 5% significance level. The community pharmacies’ lists at different governorates were obtained from the Ministry of Health (current at the time of the study) for sample selection, due to the lack of lists with the names and addresses of community pharmacists in Kuwait. A larger sample of 220 community pharmacies (out of a total of 287) was selected to adjust for possible nonresponse, using stratified and systematic random sampling according to the methodology described by World Health Organization [28]. The stratification was at the level of the five governorates of Kuwait (Capital, Al-Ahmadi, Al-Farwaniyah, Hawalli and Al-Jahra). A pharmacy employing more than one registered pharmacist, only one was included.

The basis of developing the study questionnaire was obtained from validated surveys that investigated community pharmacists’ counseling on obesity management and barriers to obesity counseling in the USA [29, 30]. The original surveys remained unchanged except for few items that were not applicable to pharmacists in Kuwait. The questionnaire contained both closed and open-ended questions. It was pretested for content, design, readability, and comprehension on 15 community pharmacists and modifications were made as necessary so that the questionnaire was simple to answer, yet gave accurate data. Demographic and other characteristics data collected included gender, age, basic and postgraduate qualifications, years practiced as a pharmacist and location of the pharmacy. Pharmacists were asked about how often they counseled patients regarding four aspects of obesity management: diet and exercise, prescribed antiobesity medications, diet foods, and nonprescription products and dietary supplements for weight loss. Responses were measured on a 5-point Likert scale (never [1], rarely [2], sometimes [3], most of the time [4], always [5]). Pharmacists' comfort level with counseling about the four aspects of obesity management was measured by a 5-point Likert scale (extremely uncomfortable [1], uncomfortable [2], neither comfortable nor uncomfortable [3], comfortable [4] extremely comfortable [5]). A 5-point Likert scale (extremely ineffective [1], ineffective [2], neither effective nor ineffective [3], effective [4], extremely effective [5]) was used to measure the respondents’ perceived effectiveness of the four aspects of obesity management. The extent to which pharmacists perceived confident in achieving positive outcomes as a result of counseling obese patients was measured by listing seven obesity management related items and asking respondents to indicate on a 5-point scale (extremely unconfident [1], unconfident [2], neither confident nor unconfident [3], confident [4], extremely confident [5]). The barriers that can limit pharmacists’ participation in counseling obese patients was measured by listing ten barriers, and asking respondents to indicate yes or no on each barrier. A 4-point Likert scale (not at all [1]; not very much [2]; to some extent [3]; to a great extent [4]) was used to measure the opinions of the respondents in relation to eight strategies that can help to overcome the barriers.

On approaching a pharmacy, four data collectors (pharmacists) briefly explained the purpose of the study to the community pharmacist on duty (face-to face). Pharmacists were free to refuse to participate in the survey. Those who agreed to take part in the study were given the questionnaires and then were collected from them anonymously after being completed within 1–2 weeks. They were assured for confidentiality and gave written consent to participate in the study. Incentives were not offered for completion of the questionnaire.

Overall mean responses of counseling obese patients by pharmacists were positively correlated with their perceived comfort with counseling and perceived effectiveness of obesity management aspects. Similarities as well as differences in beliefs and practices were identified between pharmacists in Kuwait and those in developed countries. Due to the high prevalence of overweight and obesity among the population in Kuwait, there is a greater need for pharmacist involvement in helping to tackle this problem, than in many other developed countries where it is already happening.

The involvement of the respondents in obesity counseling, in addition to their declaration of the perceived barriers and strategies to overcome them would certainly be an advantage to the provision of weight management services in community pharmacies of Kuwait. Furthermore, pharmacists who effectively perform obesity counseling need to be identified so that they may act as a role model for others.