In this study, the beliefs and practices of pharmacists with regards to weight management were contrasted by significant knowledge gaps in this domain. Furthermore, despite the fact that the majority of pharmacists in this study were involved in dispensing weight loss products, a sizeable proportion answered incorrectly the questions related to side effects and interactions of these products. Such knowledge gaps were also identified in previous studies, whereby pharmacists indicated the need for trainings in weight loss consultations, overweight and obesity diagnosis and uses of weight loss products including side effects and interactions with other drugs [ 38 , 39 ].
An important factor was found to be associated with better knowledge, was receiving formal education in weight management. In Lebanon, although the academic curricula of pharmacy education have been evolving to match the shift in pharmacy profession from solely dispensing medicine towards a more patient centered delivery of healthcare services, more focus on weight management services is still needed. In fact, many authorities in the field of pharmacy education, including the International Pharmaceutical Federation FIP , and the Accreditation Council for Pharmacy Education ACPE , called for reforms in pharmacy education to include courses on nutrition and lifestyle counselling.
The implementation of these reforms was shown to improve knowledge about many aspects of weight management [ 52 , 53 , 54 ].
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Related to pharmacy education, the results of this study showed that attaining a Masters or PhD of pharmacy was found to positively influence knowledge of weight management. This finding further underscored the role of formal education in enhancing the foundational knowledge in health and wellness. Another factor found to be associated with knowledge was obtaining the degree of pharmacy from a university inside Lebanon.
A potential explanation of this association is that pharmacists studying in the country may be more literate in the health and social constructs of the society than those who studied abroad. Examining the barriers that pharmacists faced in providing weight management services was essential to provide a more comprehensive situation analysis. The majority of these barriers were also cited in previous studies [ 10 , 15 , 17 , 38 ].
A recent study showed that the pharmacy profession in Lebanon has been facing multiple challenges relating to the practicing of the profession and the protection of the professional status of pharmacists. More specifically pharmacists in Lebanon were found to be dissatisfied with multiple issues including the distribution of pharmacies, drug prices, profit margin, low income, workload, policies governing the profession, prescribing ethics, sale of counterfeit drugs and political intervention [ 55 ]. Regarding space limitations, it is argued that the physical space in the majority of pharmacies is designed to support the drug dispensing role of the pharmacist with little room for counseling.
For the latter, space is needed not only to provide the physical setting but also to ensure confidentiality of personal information often shared during weight management counseling. In fact, this decree specified that a minimum of 32 m 2 is required to register a pharmacy which should be divided into four sectionsreception of customers, 2-department of medicine cabinets, 3-laboratory dedicated to the preparation of prescriptions, 4 -warehouse of goods and medicines [ 57 ]. A few studies attempted at altering the lay out of the pharmacy placing the pharmacist in front of the counter, rather than behind.
The results of these studies showed promising results in allowing a more prominent counseling role of the pharmacist [ 58 , 59 ]. This is the first study to examine the role of pharmacists in weight management in Lebanon. The strengths of this study included the recruitment of a nationally representative sample of community pharmacies.
The high response rate further enhances the external validity of the study findings. Despite this high response rate, 42 pharmacists who were approached did not agree to participate in this study. Therefore, a non-respondent bias could have affected our results.
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In addition, by addressing various aspects such as beliefs, practices, knowledge and barriers, the study provided a comprehensive assessment allowing for the development of evidence based interventions to enhance the role of pharmacists in weight management. The data collection was conducted using an interview-based survey technique, therefore limiting reporting errors and decreasing missing answers.
It is important to note, however, that the results of the study ought to be considered in light of a few limitations. First, the cross sectional design of the survey prevented any inference about causality. The direct association observed between the frequency of queries regarding weight management and knowledge could be an example of reverse causality precipitated by the design of the survey.
Second, although field workers were extensively trained on maintaining a neutral attitude and on non-judgmental reaction, the possibility of a social desirability bias could not be ruled out and the results of the study could have been skewed in a manner to satisfy the person administering the questionnaire. That said, it is important to note that despite this potential bias, certain mal practices were observed at high rates.
Alternative methods to conducting the survey, such as mailing or emailing the questionnaires, were not possible in the context of the study, given that not all pharmacists possess a mailing address or have access to emails. The results of this study showed that community pharmacists in Lebanon have a general positive belief regarding their role in weight management and are engaged in counseling for weight loss and dispensing weight loss products.
In addition, the study findings highlighted important gaps in current practices of the pharmacists such as failing to report side effects of drugs as well as in their knowledge, specifically with regards to side effects of certain products and their interaction with other medications. In addition, time, space, staff, remuneration, and relevant equipment were all common barriers to providing weight management services among community pharmacists in Lebanon.
In conclusion, the findings of the study provided important insights on the beliefs, practices and knowledge of community pharmacists in weight management in Lebanon. Concerted efforts of multiple stakeholders including the Ministry of Public Health, Ministry of Education together with the OPL, are needed to promote the active role of community pharmacists in order to better address the escalating rates of obesity in the country. The findings of this study could be used to inform the development and provision of future evidence based community pharmacists led weight management service nationally and internationally.
The survey questionnaire is included as Additional file. The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. World Health Organization.
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