Community pharmacists’ knowledge, confidence, and perceived need for training on fall-risk increasing drugs and fall prevention: a cross-sectional study in Selangor, Malaysia

Abstract

Objectives

Community pharmacists (CPs) can offer fall prevention services to minimize fall risks among older people. To effectively perform fall prevention activities, CPs need sufficient knowledge about fall prevention and fall-risk increasing drugs (FRIDs), as well as the confidence to execute fall prevention activities. This study aims to identify gaps in CPs’ knowledge about fall prevention and FRIDs, as well as assess their confidence in implementing fall prevention activities and perceived-need for training.

Methods

A cross-sectional study using an online questionnaire was undertaken over 4 weeks from 21 June to 19 July 2023, among CPs in the state of Selangor, Malaysia.

Key findings

Overall, 369 attempted the survey (response rate: 99.5%). However, the completion rate was 79.9% (295/369). Most were female (67.8%, 200/295) and aged 25–30 (43%, 127/295). Many CPs were unaware that FRIDs such as antiepileptics, centrally acting antihypertensives, diuretics, and medications for overactive bladder and incontinence could increase fall risks. CPs had limited knowledge of resources for identifying FRIDs, with only 35.6% (105/295) of them aware of the Beers criteria. Furthermore, knowledge gaps were identified among CPs regarding fall prevention activities, particularly concerning the deprescribing of FRIDs. CPs had limited confidence in recommending deprescribing and offering advice to minimize medication-related fall risks. Most CPs believed that they received inadequate training in fall prevention and FRIDs and recognized the importance of such training.

Conclusion

Knowledge and confidence gaps were identified among CPs regarding fall prevention and FRIDs. Enhanced education and training for CPs are essential for effective fall prevention.

Introduction

The role of community pharmacists (CPs) in fall prevention has garnered support and recognition as a means of addressing the increasing prevalence of falls among older people. Notably, the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative developed by the Centers for Disease Control and Prevention (CDC) has integrated CPs into the program, equipping them with tools and resources to identify and prevent falls in the community pharmacy setting [1]. Moreover, in the UK, the National Health Service has incorporated CPs into fall prevention services, particularly in clinical medication reviews, medicine optimization, and bone health [2].

In the community pharmacy setting, CPs are pivotal in providing pharmaceutical care to reduce fall risks among older people [3]. As frontline healthcare providers, CPs serve as the primary point of contact for older people seeking initial treatment or assistance for various health issues. Through patient interactions and thorough assessments, CPs can recognize older people who are at risk of falls and identify potentially inappropriate medications, including fall-risk increasing drugs (FRIDs) [4, 5]. By collaborating with other healthcare providers, CPs can recommend deprescribing when necessary [6], ensuring the appropriate use of medications and mitigating fall risks [7, 8].

Previous research has demonstrated that fall prevention interventions based in community pharmacies led to a decrease in the use of high-risk medications among older people with fall risk [1]. Moreover, the effective management of medications has been shown to reduce falls in older people [9]. In addition to medication management, CPs can also provide fall prevention education including fall prevention strategies, adverse effects of FRIDs, or vitamin D supplementation [10, 11].

CPs require adequate knowledge and confidence to execute fall prevention activities effectively. However, in a qualitative study in the Netherlands, pharmacists were found to have reported knowledge gaps regarding fall prevention and FRIDs [12]. Similarly, a study conducted in Nigeria revealed that over 75% of the surveyed pharmacists had unsatisfactory knowledge about FRIDs and 91% reported no prior training on FRIDs [13], highlighting the necessity for training interventions to address pharmacists’ learning needs. This study aims to identify gaps in CPs’ knowledge regarding fall prevention and FRIDs, as well as their confidence in executing fall prevention activities. In addition, the study seeks to investigate the perceptions of training adequacy among Malaysian CPs.

Methods

Study design

A cross-sectional study using an online questionnaire was undertaken over 4 weeks from 21 June to 19 July 2023, among CPs in the state of Selangor, Malaysia. The study received ethical approval from the Research Ethics Committee of Universiti Teknologi MARA (UiTM), Malaysia (REC/04/2021[UG/MR/247]). The study procedures and findings were documented in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Checklist [14] (Supplementary Appendix S1).

Participants

The study included full-time CPs from community pharmacies in Selangor. Part-time CPs and those solely involved in administrative or wholesaling roles were excluded. From an initial pool of 1592 CPs identified from the Pharmaceutical Services Programme website of the Malaysian Ministry of Health [15], 333 were ineligible, resulting in a final sampling frame of 1259 CPs. Using Raosoft© sample size calculator [16], a recommended sample size of 295 was determined, with a 5% margin of error, a 95% confidence interval, and a 50% response distribution.

Sampling of participants

To accommodate possible incomplete questionnaires and participant decline, the researchers contacted and recruited 25% more CPs than the suggested sample size of 295. Accordingly, 369 CPs were randomly selected from the pool of 1259 CPs. A member of the research team (MSRH) then contacted each selected CP by phone, providing them with a comprehensive explanation of the study, assessing their eligibility, and inviting them to take part in the survey. After initial contact, two declined due to busyness, five were ineligible, and five were unreachable. To compensate, additional 12 CPs were contacted, all of whom were found eligible and agreed to participate in the study, bringing the total to 371 eligible CPs ultimately contacted for participation.

Data collection

CPs who met the study inclusion criteria and willing to participate were given access to the survey link. The online survey’s introduction page included study details, estimated completion time, investigator names, and emphasized voluntary participation, anonymity, and confidentiality. Each participant could only respond once, with no incentives offered. Upon consenting, CPs could proceed to complete the questionnaire.

Survey instrument

The survey instrument (Supplementary Appendix S2) was developed by integrating relevant literature and guidelines, such as the World Guidelines for Falls Prevention and Screening Tool of Older Persons Prescriptions in older adults with high fall risk (STOPPFall) [1, 12, 13, 17, 18]. These resources informed the types of FRIDs, recommended resources for FRID information, and the roles of CPs in fall prevention.

Designed in English, the instrument comprises six sections: (i) Section 1: demographic data of CPs (including information on the estimated frequency with which older people were received at their pharmacy; encountering older people with complaints of dizziness, drowsiness, and hypotension due to medications; and encountering older people with a history of falls); (ii) Section 2: knowledge on medication classes associated with increased fall risks in older people (12 items); (iii) Section 3: knowledge on evidence-based tools to identify FRIDs, such as the Beers criteria and STOPPFall (seven items); (iv) Section 4: knowledge on fall prevention topics (e.g. fall risk assessment and FRID deprescribing) (16 items); (v) Section 5: confidence in performing fall prevention activities (13 items); and (vi) Section 6: CPs’ fall prevention and FRID training history, as well as their perceived need for additional training (10 items).

For Sections 2 and 3, respondents were asked to indicate their knowledge of whether the listed medication classes could increase the risk of falls in older people, and whether the listed resources could provide information about FRIDs by selecting either “Yes” or “No.” For Section 4, participants were required to indicate whether each statement was “True” or “False” or choose “Not Sure” if they are uncertain. Both Sections 5 and 6 employed a Likert-type scale, where responses ranged from 1 for “Strongly disagree” to 5 for “Strongly agree.”

The questionnaire was reviewed by an expert panel of four pharmacy practice researchers and four practicing CPs to confirm its relevance and content validity. Minor adjustments were made based on their feedback. Subsequently, the survey was adapted into an online format using SurveyMonkey and pilot tested with 10 CPs to ensure clarity and technical functionality. No amendments were needed following the pilot test as participants found it clear and feasible. The pilot responses were excluded from the final analysis of the study. Participants took approximately 15 min to complete the survey.

Data analysis

The statistical analysis was performed using IBM SPSS version 28 (IBM, Armonk, NY, USA). Continuous data were reported as mean ± standard deviation, while categorical data were presented as frequency and percentage. Mean FRID classes known by CPs and correct answers on fall prevention activities, as well as mean scores of confidence and perceptions regarding training were calculated. Independent samples t-tests compared these mean values by gender, type of community pharmacy, and years of experience. Statistical significance was set at P < .05.

Results

Out of all the 371 eligible CPs contacted, only two refused to participate in the study, while the remaining agreed, received the online survey link, and attempted the survey (response rate: 99.5%). However, 74 participants did not complete and were subsequently excluded (completion rate: 79.9%). The remaining sample consisted of 295 participants, thus meeting the minimum recommended sample size for the study.

Demographic characteristics

The CPs were mostly female (200/295, 67.8%) and in the 25–30 age group (127/295, 43%). The majority were working in chain pharmacies (195/295, 66.1%). Approximately 40% (125/295) had more than 5 years of experience as a CP. Most had more than 10 older clients per day (189/295, 64.1%). The majority had encountered older people with a history of falls (210/295, 71.2%), as well as those who had experienced dizziness (258/295, 87.5%), drowsiness (244/295, 82.7%), and hypotension (195/295, 66.1%) due to medication use (Table 1).

CPs’ knowledge of medication classes that can potentially increase the risk of falls in older people

Most CPs were aware that benzodiazepines (BZD) and BZD-related drugs (289/295, 98%), opioids (279/295, 94.6%), and sedative antihistamines (271/205, 91.9%) could increase fall risks in older people (Table 2). However, less than 60% were aware that antiepileptics, centrally acting antihypertensives, diuretics, and medications for overactive bladder and incontinence could also increase fall risks in older people. When considering gender, type of community pharmacy, and years of experience in community pharmacy practice, no significant differences were found in the mean number of FRID classes known by the CPs.

CPs’ knowledge of resources that could be used to identify FRIDs

The most recognized resource among the CPs was the Beers criteria (Table 3). However, only 35.6% (105/295) indicated awareness of this tool. Tools such as the STOPPFall, Web-based Meds 75+ Guide, and Fit fOR The Aged were largely unfamiliar to CPs, with 80% and more being unaware of these resources. No significant differences were observed in the mean number of resources known by CPs in relation to gender, type of community pharmacy, and years of experience in community pharmacy practice.

CPs’ knowledge regarding fall prevention activities

Overall, many CPs correctly answered questions related to fall risk assessment, but most were uncertain about the CDC’s STEADI “Three Key Screening Questions.” While many CPs knew that FRIDs can be withdrawn due to certain side effects, only a minority were correct about the deprescribing of FRIDs. Notably, approximately 40% (113/295) held the misconception that daily vitamin D supplementation should be recommended to all older people, even if they are not deficient in the vitamin. Moreover, while most CPs correctly indicated that CPs can refer older people to other healthcare providers for comprehensive fall risk assessment, fewer CPs (166/295, 56.3%) correctly indicated that CPs can refer older people with a low risk of falls to community exercise or fall prevention programs. There were no significant differences in the average number of correct answers among CPs based on gender, type of community pharmacy, or years of experience.

CPs’ confidence in performing fall prevention activities

The majority of CPs generally displayed confidence in assessing postural hypotension in older people (227/295, 76.9%), optimizing medication usage through medication reviews (258/295, 87.5%), educating patients about fall prevention (207/295, 70.2%), as well as in identifying (261/295, 88.5%) and educating older people requiring vitamin D supplementation (273/295, 92.5%) (Table 5). Only 29.5% (87/295) felt confident in recommending FRID deprescribing to doctors.

Compared to those working in independent pharmacies, CPs working in chains had significantly more confidence in recognizing drug-drug interactions that increase the risk of falls (chain: 3.83 ± 0.71 vs. independent: 3.53 ± 0.75; P < .001), recognizing older people who require vitamin D supplementation (chain: 4.15 ± 0.68 vs. independent: 3.91 ± 0.61; P = .003), providing patient education on vitamin D supplementation (chain: 4.22 ± 0.61 vs. independent: 4.04 ± 0.55; P = .016), and referring older people who require other medical support to other healthcare providers (chain: 3.82 ± 0.67 vs. independent: 3.64 ± 0.75; P = .042).

In addition, CPs with more experience (≥6 years) in community pharmacy practice exhibited a higher level of confidence in assessing postural hypotension among older people compared to their counterparts with less experience (≤5 years) (≥6 years: 3.89 ± 0.63 vs. ≤5 years: 3.71 ± 0.79; P = .035). However, they displayed significantly less confidence about providing patient education on fall prevention (≥ 6 years: 3.62 ± 0.75 vs. ≤ 5 years: 3.82 ± 0.74; P = .023).

Perceptions of CPs regarding their training in fall prevention and FRIDs, as well as their perceived need for further training

Most CPs disagreed that they had received adequate training on fall prevention and FRIDs (Table 6). However, most CPs recognized the need for training (281/295, 95.3%). Most CPs expressed interest in attending training programs focused specifically on fall prevention and FRIDs (275/295, 93.2%).

CPs with less experience (≤5 years) in community pharmacy practice had a significantly higher score (1.89 ± 1.032) for having received adequate training on fall prevention during their provisional registered pharmacist (PRP) training compared to those with more experience (≥6 years) (1.66 ± 0.729) (P = .034). Moreover, those with less experience (≤5 years) had a significantly higher score for having received adequate training on FRIDs during their PRP training (1.95 ± 1.042) compared to those with more experience (≥6 years) (1.72 ± 0.768) (P = .036). However, it should be noted that the mean scores for both receiving adequate training on fall prevention and on FRIDs during PRP training were generally low. In addition, chain CPs had a significantly higher score in recognizing that training on fall prevention and FRIDs can assist CPs in minimizing falls among community-dwelling older people (4.55 ± 0.610) compared to independent CPs (4.39 ± 0.690) (P = .037).

Discussion

This study is the first to investigate Malaysian CPs’ knowledge of fall prevention and FRIDs, their confidence in performing fall prevention activities, and their opinions on the sufficiency of their training and the need for further education in these areas. The study highlights knowledge and confidence gaps among Malaysian CPs in fall prevention and FRIDs, despite their frequent interactions with older people with a history of falls or medication adverse effects that could increase fall risks.

A notable strength of this study is its focus on Malaysian CPs and their preparedness to contribute to fall prevention efforts, a topic that has not been extensively explored in the local context. Moreover, the study employed a well-structured survey to evaluate multiple dimensions of CPs’ knowledge, confidence, and training needs. However, several limitations should be acknowledged. The reliance on self-reported data introduces the potential for recall bias and social desirability bias, as participants may have overestimated their knowledge or confidence levels. In addition, the study sample was confined to CPs from a single state in Malaysia, which may limit the generalizability of the findings to the broader CP population. Furthermore, the study did not assess CPs’ actual involvement in fall prevention activities, which would have provided a more comprehensive understanding of their practical capabilities. The sample’s demographic imbalance, particularly the overrepresentation of younger CPs and female participants, may have introduced response bias, further constraining the generalizability of the results.

Our findings aligned with two studies involving pharmacists in the Netherlands and Nigeria, which revealed that pharmacists generally have knowledge gaps in this area and expressed the need for training [12, 13]. This underscores the urgent need to equip CPs with the necessary training and resources for them to effectively contribute to the prevention of falls among older people. In this study, the need for further fall prevention training is supported by evidence of CPs’ perceived lack of adequate training in this area.

The positive impact of fall prevention training on pharmacists’ capabilities and practice in this area have been shown in previous studies [19, 20]. In Australia, such training resulted in an increase in perceived knowledge and confidence among pharmacists, with the proportion of “highly knowledgeable” pharmacists rising from 52% to 97% post-training, and “highly confident” pharmacists increasing from 42% to 91%. Following the training, most participants reported providing fall prevention services, although none were implementing fall prevention activities at baseline [19]. Similarly in the Netherlands, pharmacists underwent online training reported feeling well-prepared to implement fall prevention services and were able to effectively provide fall prevention recommendations, make referrals, and propose prescription modifications to general practitioners [20].

Our study suggests that training for CPs should prioritize comprehensive education on FRID classes, the practical application of evidence-based tools for identifying and managing FRIDs, and deprescribing strategies, as these are the areas where CPs have limited knowledge and confidence. Educating CPs about evidence-based resources such as the Beers criteria and STOPPFall is important because these tools have been specifically developed to support healthcare providers in identifying medications that increase the risk of falls [7, 18] and guiding the appropriate management of these medications.

Deprescribing FRIDs, particularly in combination with interventions addressing other fall risk factors, is an effective intervention to reduce falls risk among older people [22]. However, while CPs in this study demonstrated awareness of the necessity to discontinue FRIDs due to adverse effects, they expressed uncertainty regarding the appropriate deprescribing procedures and lacked confidence in recommending FRID deprescribing to doctors. This underscores the importance of incorporating deprescribing strategies for FRIDs into the training of CPs. In addition, it is worth noting that CPs often perceive deprescribing as a complex process, with uncertainties regarding the potential risks and benefits of drug deprescribing [12], and commonly face difficulties in making professional recommendations about deprescribing [23]. Thus, training initiatives can address these barriers and can empower pharmacists to navigate deprescribing challenges effectively.

In addition, CPs’ lack of confidence in recommending FRID deprescribing to doctors highlights the need for enhanced collaboration and communication between CPs and other healthcare providers, along with improved referral practices. In Australia, the absence of structured referral agreements has been identified as a barrier to pharmacists’ multidisciplinary collaboration, indicating the importance of strengthening referral systems [24]. In the Malaysian context, the main stakeholders in the healthcare system should strive to develop strategies and guidelines to facilitate an enabling environment for CPs to engage in drug deprescribing, particularly FRIDs.

According to the World Guidelines for Falls Prevention, daily vitamin D supplementation is recommended for older people at risk of vitamin D deficiency to prevent falls, but not universally [17]. However, a notable finding in this study is that many CPs mistakenly believed that daily vitamin D supplementation should be universally recommended for all older people, regardless of their vitamin D status. Despite expressing confidence in identifying individuals who require vitamin D supplementation, these CPs may lack knowledge about evidence-based recommendations. This emphasizes the importance of integrating the topic of vitamin D supplementation into the content of fall prevention education and training programs for CPs.

Of note, a considerable percentage of CPs in this study lacked confidence in providing patient education on fall prevention and offering advice on minimizing the risk of FRIDs. Thus, equipping CPs with comprehensive educational materials covering fall prevention strategies, risk factors, and the importance of preventive measures during patient consultations or counseling sessions can ensure important information is communicated adequately [10, 25].

From a research perspective, further research is necessary to explore the factors that influence CPs’ knowledge and confidence in this area, and to evaluate the effectiveness of educational interventions in improving fall prevention knowledge and confidence among CPs. Moreover, exploring the actual involvement of CPs in fall prevention activities could provide insights into how well these professionals translate their knowledge into practice.

Conclusion

This study highlights a knowledge gap among CPs regarding fall prevention and FRIDs, as well as their limited familiarity with available FRID resources. Furthermore, CPs demonstrated limited confidence in certain fall prevention activities, particularly recommending deprescribing of FRIDs to doctors and advising on minimizing the risk of FRIDs. These findings indicate an urgent need for targeted education and training to enhance CPs’ skills and confidence in fall prevention efforts. By addressing these specific educational needs, CPs can better mitigate fall risks among older individuals, thus improving patient safety and care outcomes. The insights from this study not only pertain to Malaysia but also serve as a valuable reference for CPs in other regions seeking to implement similar training interventions to strengthen their roles in fall prevention and older people care.

Supplementary data

Supplementary data are available at International Journal of Pharmacy Practice online.

Author contributions

All authors have significantly contributed to this manuscript. M.S.R.H. and M.S.A.W. were involved in the design of the study and survey questionnaire. M.S.R.H., M.S.A.W., J.A.J., N.S.M.H., and H.H.Z. analysed and interpreted the data. M.S.R.H., M.S.A.W., and J.A.J. led the drafting of the manuscript. M.S.R.H., M.S.A.W., J.A.J., N.S.M.H., H.H.Z., L.C.M., and A.H. contributing to drafting and reviewed the final manuscript.

Conflict of interest

The author(s) declare that there are no conflicts of interest.

Funding

This work was supported by the Community Engagements—Social Research Innovation (CE-SIR) Grant, Universiti Teknologi MARA [600-RMC/CE-SIR 5/3 (011/2023)]. The funding source played no part in the study’s design, execution, data analysis, interpretation, or the decision to submit the results.

Data availability

The data underlying this article will be shared upon reasonable request to the corresponding author. Data were collected specifically for the purpose of the reported study. No access was therefore required.

Ethical approval statement

The study received ethical approval from the Research Ethics Committee of Universiti Teknologi MARA (UiTM), Malaysia (REC/04/2021[UG/MR/247]).

References