A principal aim of this study was to develop and pilot a nutrition education intervention for pre-registration pharmacists. This also involved a preliminary mapping of attitudes and practices towards diet-related health promotion and disease prevention. Assessment of AP for community pharmacists confirmed a widespread feeling of inadequacy in relation to nutrition education. Furthermore, qualitative responses suggested that pharmacists considered health promotion and disease prevention activities to be within their professional role but recognised that they had an insufficient level of education. Based on findings from the AP questionnaire of community pharmacists, a pilot education session was developed, modelled on a previously successful programme for medical students [20
]. The pharmacy pilot education session demonstrated a post-training improvement in knowledge. Embedded learning could not be conclusively demonstrated, although KAP remained higher than baseline at three months post-training.
4.1. Phase 1: Needs Assessment
The respondents exhibited a very positive attitudinal score towards nutrition and public health. This is encouraging given the expanding role of the pharmacy under national direction, as documented in Transforming Your Care [23
], a Vision for pharmacy in the new NHS [24
] and increased participation in community health screening [5
]. However, concurrent with Ray et al. [20
], confidence in ability appears to be a strong predictor of a higher practice score, i.e., engaging in health promotion activities with patients [11
] achieved a statistically significant improvement in scores of self-efficacy following nutrition training, with students possessing an improved ability to communicate confidently with classmates. Just over one-fifth (21%) of this sample of pharmacists felt confident in providing dietary advice to a diabetic patient compared to 72% when presented with an overweight patient. This vast difference in confidence could be attributed to the training provided to pharmacists in preparation for the launch of OTC orlistat (Alli) in 2009.
One community pharmacist recognised this and commented, “When orlistat first became available OTC we were promoting heavily in pharmacy and giving excellent nutritional information along with the product … such as tips on healthy eating, recipe and meal ideas and advice on exercise”.
A study by Weidmann et al. [25
] reported that 92% of pharmacists felt confident in their ability to supply the product and over two-thirds believed it provided a good opportunity to extend their role as a healthcare professional. As a result, pharmacists may be receptive to health promotion training, which could improve their confidence and competence in primary and early secondary prevention.
One example of disease prevention identified by the current study was recommending OTC oral nutritional supplements (ONS), particularly to older people and patients recuperating from an illness. Requests for the supply of these products could act as a timely opportunity for pharmacists to objectively assess the patient’s nutritional status using the ‘Malnutrition Universal Screening Tool’ (MUST) [26
]. Patients classified as at risk of malnutrition have been shown to benefit more from a nutritional intervention than those rated as malnourished [27
]. The majority (83%) of pharmacists have never heard of MUST. With appropriate training, the use of this screening tool could lead to more appropriate advice, such as food fortification or a timely referral to the GP or registered dietitian [28
]. Additionally, the recent launch of MUST self-assessment is likely to result in more individuals seeking help and advice from their pharmacist in this area of practice [29
The current study of community pharmacists has also highlighted concerns in relation to the use and supply of prescribed ONS. Qualitative responses implied that pharmacists are unhappy with the way malnutrition is managed in the community and have alluded to key areas where they think improvements can be made: compliance and follow-up. These two matters are the absolute core of ‘The pathway for using ONS in the management of malnutrition’ [30
] and it appears pharmacists are observing obvious inadequacies with individual community pharmacists, reporting that they “don’t feel able to comment or advise” due to “inadequate training on these products”. Again, with appropriate training, pharmacists could reassess the need for prescribed ONS and discontinue treatment that is no longer required. Furthermore, patients with signs of poor compliance, returning unused supplements or complaining of the taste or texture, could be identified by pharmacists and the issues rectified (e.g., allow patient to taste other similar supplements) or refer patients back to the dietitian much earlier than the scheduled review.
The current study demonstrated that the elderly, pregnant women and children were the patient groups most likely to seek advice about vitamin supplements. This shows the broad spectrum of ‘healthy’ people pharmacists come into contact with on a daily basis, thereby providing a platform for increasing awareness and personalising the importance of good nutrition and lifestyle practices for the prevention of disease [31
]. The responding community pharmacists listed the supplements that were most frequently observed in practice, including vitamin D, calcium and multivitamins. Of note, folic acid supplements were not listed as a vitamin the respondents would regularly recommend, despite highlighting pregnant women as a key population group. This is of topical interest due to the recent National Diet and Nutrition Survey 2015 [32
]. In addition, update and refresher courses as part of lifelong learning may be of particular importance so the latest advice, such as folic acid recommendations, is not omitted.
The request for the sale of specific vitamin and mineral supplements provides opportunities for pharmacists to enquire about dietary intake and why they feel the need to supplement their diet, particularly when the patient has initiated the conversation. Revised Reference Nutrient Intakes in the United Kingdom [33
] of 10 μg/d (400 IU/d) for those aged 4 y and above and for infants and younger children to achieve a safe intake in the range 8.5–10 μg/d (340–400 IU/d) at ages 0 to < 1 y and 10 μg/d (400 IU/d) at ages 1 to < 4 y also have implications for pharmacists.
Pharmacists also voiced concern over their source of nutrition information and find sales representatives’ information ‘biased’ for both ONS and infant nutrition. It appears that pharmacists want to learn from independent experts in the field and feel that “dietitians rarely reach out to educate other professionals and allow charlatan nutritionists to propagate nonsense”. In addition, pharmacists’ desire for interprofessional learning emerged as a core theme and supports the central focus of utilising Integrated Care Partnerships to create a collaborative network of care providers to coordinate local health and social care services [23
]. Although dietitians are not specifically mentioned in this framework, the primary care team could benefit greatly from their expertise to equip primary care with the skills to instigate timely referrals and ensure a consistent dietary message is communicated to patients from all healthcare professionals [34
4.2. Phase 2: Pilot Nutrition Education Intervention
The pilot education sessions demonstrated improvements in KAP scores from baseline. While there was some decrease in these scores between the end of the education session and three months post-training, the KAP was still higher than the baseline. The pilot was carried out with a small sample of pre-registration pharmacy students. The pre-registration year curriculum in Northern Ireland, includes ongoing professional training and information sessions on products such as infant milks as well as nutrition related to specific specialities. The Phase 2 study education sessions focused on key areas highlighted within the responses to Phase 1 questionnaire. These included diets in CVD and diabetes prevention and management, infant feeding, vitamin supplementation and malnutrition. Underpinning principles such as drug‒nutrient interactions were also included.
Previous research into the impact of nutritional training on pharmacists is limited and tends to focus specifically on the academic curriculum rather than the pre-registration year or post-registration. However, the studies that have been undertaken in this area suggest that, regardless of the training medium, improvements in nutritional knowledge and self-efficacy were demonstrated post-training [20
For nutrition education to be effective it must result in embedded learning. This current study did find a sustained improvement from the baseline, but there was a decline in KAP from immediately post-training to three months post-training. This is reflective of similar findings in relation to other healthcare professionals [20
To the authors’ knowledge, this is the first study in the UK to consider nutrition education in pharmacy. A small number of previous international studies offer educational interventions to undergraduate pharmacy students, a population that may not yet fully appreciate how applicable nutrition is to the community pharmacy setting [15
]. Surveys involving health care providers are characterised by low and reduced response rates [37
]. In this target population of busy professionals with varying work schedules and time constraints, an 11% response is comparable to other studies in this field, but the offer of a monetary reward may have improved this further [38
]. The pattern of gender response observed (72% female) is similar to that reported in the literature [11
Numbers of participants for the education session were low, reflecting the nature of this pilot study. One of the primary challenges of providing education sessions to busy professionals is the time commitment involved. While the benefits of face-to-face sessions and the ability to interact with others are clear, the practicality of this form of delivery needs to be considered prior to further roll-out of training. Having nutrition education embedded within the CPD training portfolio offered by the professional body could aid the face-to-face uptake; the provision of online “bite-size” training sessions should be explored and evaluated. The latter mode of delivery of training could be of particular benefit in terms of sustained and embedded learning as individuals could return to these on a regular basis to refresh learning.
An acknowledged limitation of this study is that the participants may have had a predisposed interest in nutrition. For example, some respondents stated, “unless you have a personal interest as I do, (nutrition) problems are not dealt with well” and “I have a keen personal interest in nutrition but few others have”. Despite this, it is also true to say that non-respondents may be, as yet, unaware of the importance nutrition has in their everyday role as Boggs et al. [12
] reported that those pharmacists who felt they needed more training to answer patients’ nutrition-related queries were more likely to be those who had engaged in nutrition courses. Any increase in provision of nutrition education for this critical group could, in turn, create a desire for more information and encourage participation in continued professional development relating to nutrition.
Nutrition is a key aspect for consideration in every medical condition. Consequently, many healthcare professionals should have a foundational knowledge of nutrition to optimize patient care. Incorporation of nutrition education into curricula is a potential way of enhancing interprofessional learning [39