Hijazi et al. BMC Health Services Research
(2020) 20:386
https://doi.org/10.1186/s12913-020-05258-7
RESEARCH ARTICLE
Open Access
Role of community pharmacists in weight
management: results of a national study in
Lebanon
Mohamad Ali Hijazi1, Hibeh Shatila2, Abdalla El-Lakany1, Hiba Al Rifai2, Maha Aboul-Ela1 and Farah Naja2*
Abstract
Background: Ideally situated within the community, pharmacists can be involved in a broad range of health
promotion campaigns including prevention of obesity. Limited evidence is available regarding their involvement in
weight management in Lebanon, a country with escalating prevalence rate of obesity.
Objective: To examine the role of community pharmacists in weight management in Lebanon, specifically
studying their beliefs, current practices, services, and knowledge.
Methods: Using a stratified random sampling approach, a cross sectional national survey of community
pharmacists was conducted (n = 341, response rate 89%). At the pharmacy, and through a face-to-face interview,
pharmacists completed a multi-component questionnaire that addressed, in addition to socio-demographic and
work characteristics, their beliefs, practices, knowledge in relation to weight management. Frequencies and
proportions were used to describe the data. Simple and multiple linear regression analyses were used to examine
the determinants of knowledge in the study population.
Results: Over 80% of study participants agreed that they have an important role to play in weight management.
However, 50% of pharmacists did not agree that weight loss products are well regulated and 81.1% thought that
companies marketing weight loss products are making false promises. The majority of pharmacists always/often
sold weight loss products (84.7%) and counseled their patients for diet (86.3%) and physical activity (91.7%). Despite
taking weight and height measurements, 50% of pharmacists rarely/never calculated BMI. Among the pharmacists
who reported side effects of weight loss products (46.5%), the majority (91.3%) did so to the pharmaceutical
company. The knowledge of pharmacists was better for the use of weight loss products as opposed to their side
effects and interactions. Significant predictors of knowledge were holding a Masters/ PhD degree in Pharmacy,
graduating from a university inside Lebanon, obtaining weight management training within the academic degree,
and receiving inquiries about weight management in the pharmacy more than once daily.
Conclusions: The results of the study provided important insights on the beliefs, practices and knowledge of
community pharmacists in weight management in Lebanon. These findings could be used to inform the
development of future evidence-based community pharmacists led weight management service provision
nationally and internationally.
Keywords: Weight management, Obesity, Community pharmacy, Lebanon
* Correspondence: fn14@aub.edu.lb
2
Nutrition and Food Sciences Department, Faculty of Agriculture and Food
Sciences American, University of Beirut, Beirut, Lebanon
Full list of author information is available at the end of the article
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Hijazi et al. BMC Health Services Research
(2020) 20:386
Background
Over the past 30 years, the prevalence of obesity has been
increasing at an alarming rate worldwide. It is described as
a global pandemic with currently more than 1.9 billion
adults being overweight of which more than 650 million
are obese [1]. Obesity is associated with increased morbidity and mortality and is a major risk factor in the etiology
of many non-communicable diseases including type 2 diabetes, stroke, coronary artery disease, dyslipidemia, hypertension, pulmonary disease and cancers [2]. In addition to
its physical consequences, obesity has also been linked to
an increased risk for many psychiatric disorders, such as
depression, impaired body image, low self-esteem, eating
disorders, stress and poor quality of life [3]. The continuous rise in obesity is hence considered a global public
health challenge and is threatening health improvements
in many countries. Therefore, there is an eminent need to
control the escalating burden of obesity through the implementation of evidence-based interventions for weight
management [4].
Although physician recommendations have consistently
been shown to exert a powerful influence on weight management, time constraints, limited access to resources for
lifestyle changes, and low reimbursement are barriers between patient and provider [5]. Accumulating evidence
suggested that a multidisciplinary approach that utilizes a
broad range of health care expertise with proven synergy is
most likely to be effective [6]. Among these health care
expertise, community pharmacists are often considered the
first contact point between patient and the health care
system, perceived as accessible and trustworthy and have
frequent contact with patients due to prescription dispensing schedules [7]. Ideally situated within the community,
they can be involved in a broad range of health promotion
campaigns and services, including prevention of chronic
diseases such as hyperlipidemia, hypercholesterolemia,
diabetes, osteoporosis, as well as obesity and weight management [8–13]. In fact, the American Society of HealthSystem Pharmacists recommends that pharmacists work
with obese patients to manage lifestyle modifications [14].
A significant component of the pharmacists’ academic education covers etiology of obesity, its risk factors, management and treatment which qualifies as a strong foundation
for providing lifestyle management counseling [15]. A recent scoping review of studies addressing the role of pharmacists in weight management counseling concluded that
weight and obesity management interventions delivered by
community pharmacies resulted in some weight loss,
which, despite being modest, can be clinically significant as
it improves surrogate markers of cardiovascular disease
[16]. The majority of studies included in this scoping review
were however conducted in developed countries [17–19]
with limited evidence in many developing counties, including those in the Eastern Mediterranean Region (EMR),
Page 2 of 12
where the prevalence of obesity is escalating at an alarming
rate [10, 20].
Lebanon, similar to neighboring countries in the EMR,
is also witnessing a sharp increase in obesity prevalence
with rates doubling between years 1997 and 2009. In
2009, among adults, obesity prevalence was 28.2% compared to 17.4% in 1997 [21]. This increase in obesity
prevalence was also seen among children [21, 22]. The
increase in obesity prevalence in Lebanon necessitates
the inclusion of a multi-disciplinary team for a proper
obesity management [23] among which pharmacists in
Lebanon are highly trusted and recognized as having expertise in the health field [24]. In fact, a previous survey
of community pharmacists in Lebanon investigating
their role in managing hypertension showed that the
majority advised and counseled patients on lifestyle
habits and behaviors, addressing smoking, alcohol abuse,
and healthy eating choices [24]. Furthermore, a recent
study by our group examining the role of community
pharmacists in Complementary and Alternative Medicine (CAM) showed that 80% of the surveyed pharmacists believed that providing information to customers
about CAM products is a pharmacist’s professional responsibility, and 64.5% of pharmacists were always or
often advising patients on safe use of CAM products and
ask for their feedback after use [25]. These positive attitudes and practices of Lebanese pharmacists, in addition
to their convenient and affordable accessibility, represent
a potential opportunity to explore their role in weight
management services. Therefore, the aim of this study is
to examine the involvement of community pharmacists
in Lebanon in overweight and obesity prevention and
treatment, specifically studying their beliefs towards their
role in weight management, current practices, services,
and knowledge. In addition, the study aims to investigate
the barriers to deliver optimal weight management services among community pharmacists in the country.
Methods
In this study, a national cross-sectional survey of pharmacists in Lebanon was conducted between August 2018 and
January 2019. The target population was pharmacists practicing in community pharmacies in Lebanon, while the
study population included pharmacists recruited from a
nationally representative sample of community pharmacies
in the country. The sampling unit for this study was the
pharmacy. A comprehensive list of community pharmacies
in various governorates of Lebanon was obtained from the
Order of Pharmacists in Lebanon (OPL). Pharmacies were
chosen from this list using a stratified random sampling.
The stratification was at the level of the six Lebanese governorates. Within each stratum (governorate), random
samples of pharmacies were selected whereby numbers of
pharmacies selected from each stratum was proportional
Hijazi et al. BMC Health Services Research
(2020) 20:386
to the total number of pharmacies in that particular
stratum. In a few pharmacies, more than one pharmacists
were present at the time of the conducting the survey, in
which case one pharmacist was selected at random, using
the Kish method [26]. Sample size calculations showed that
a minimum of 342 pharmacists need to be recruited in
order to detect an expected outcome at a prevalence of
50% with a 95% confidence interval (CI) and a margin of
error of 5%. The calculations for sample size were conducted using Raosoft sample size calculator [27]. The study
protocol was approved by the Institutional Review Board at
the Beirut Arab University under the protocol number
2019H-0059-P-R-0300.
The study protocol involved conducting a survey among
community pharmacists in the selected pharmacies. Data
collection was carried out by field workers who were
trained extensively on interviewing techniques and administration of the questionnaire. Prior to starting the survey,
field workers introduced the study and assured the
pharmacist of the confidentiality of data collected and that
he/she has the right not to answer any of the questions in
the questionnaire and to withdraw at any point during the
survey. Interested pharmacists signed a written consent.
Completing the survey lasted 20–25 min.
The development of the questionnaire used in the data
collection for this study was designed by a detailed review of relevant past literature [15, 28–37]. The questionnaire was further reviewed by an expert panel of a
community pharmacist, a professor of pharmacy, a nutrition epidemiologist, and a clinical nutritionist. The
main aim of this review was to ensure content validity,
clarity, as well as relevance to the Lebanese context. The
questionnaire was written in English, translated to
Arabic and then back translated to English to ensure
parallel form reliability. The developed questionnaire
was administered for pilot testing to 16 community
pharmacists in various governorates in Lebanon. The
pharmacies for the pilot test phase were conveniently selected. Results of the pilot test were not included in this
study. The main changes that were introduced to the
questionnaire, because of the pilot testing, were in relation to the technical translation of certain terms, in
order to enhance the cultural and context specificity of
the questionnaire. A copy of the English version of the
questionnaire is found in Additional file 1. The final version of the questionnaire consisted of five sections: the
first section addressed demographic characteristic of the
pharmacist (age and gender), education information
(level of education (Bachelors, Masters, Pharm D or
PhD), location of the university he/she graduated from
(inside or outside Lebanon), receiving education/training
related to weight management during his/her university
education years or post-graduation), employment (employment status, number of years of experience as
Page 3 of 12
community pharmacist), characteristic of the pharmacy
(number of pharmacists in the pharmacy, duration for
which the pharmacy open for) and frequency of queries/
day the pharmacists receive about weight management
products. The second section of the questionnaire focused on participants’ beliefs of a few issues related to
weight management such as the role of the pharmacists
in weight management, the exclusivity of sale of weight
management product in pharmacies, whether or not
they believe weight management should be addressed
through a multidisciplinary team approach and whether
other healthcare professions are more suited than pharmacists to deal with weight management and the need
for continuous education for pharmacists in weight
management. In addition, this section included the pharmacists’ perception regarding the regulatory framework
of weight management products in Lebanon, the use/
abuse of weight management products by consumers,
and the role the companies and media play in orienting
the consumers’ behavior. The third section of the questionnaire included questions assessing the pharmacist’s
practices in weight management, such as selling, advising patient on safe use, reporting of adverse effects,
checking for drug or food interactions, counseling patients on (behaviors related to weight management such
as low calorie diets, physical activity, pharmacotherapy,
etc.), the provision of weight related measurements
(weight, height, waist circumference, Body Mass Index
(BMI) calculations, blood glucose, body fat, blood pressure measurements), referrals of customers to dieticians
and follow up on possible side effects of weight management. The fourth section of the questionnaire assessed
pharmacist’s perceived barriers in providing weight management service such as time, staff, space, equipment,
the need for additional payment, the lack of knowledge
and interest. For sections 2, 3 and 4, responses were
measured on a 5-point Likert scale (1-strongly agree, 2agree, 3-neutral, 4-disgaree and 5-stronglt disagree). The
last section of the questionnaire addressed the pharmacist’s knowledge toward weight management. Ten questions were selected to address general knowledge in
overweight and obesity as well as the uses, side effects
and drug interactions of commonly sold weight management products [15, 28–36]. The weight management
products used in the questionnaire included herbal
(green tea), laxative and orlistat; and were selected based
on consultation with a panel of pharmacists who suggested that these products were the most commonly
used products in the market for weight management in
the Lebanese market. This panel of pharmacists consisted of the President of OPL, the chief executive officer
of the largest wholesaler in Lebanon, and a sale manager
from a pharmaceutical company. This panel, based on
their experience and their sales data, suggested a list of
Hijazi et al. BMC Health Services Research
(2020) 20:386
commonly sold products. This list was further vetted by five
community pharmacists, one from each of the Lebanese
governorate, in order to select the three most commonly
sold products for weight management in the country.
A copy of the questionnaire used in data collection is
provided as supplementary file to this manuscript.
Statistical analysis
Data collected were entered into the Statistical Package for
Social Sciences (SPSS, version 25). Accuracy of the collected
data was evaluated by visual inspection and examination of
ranges and logic checks. Frequencies and proportions were
used to summarize the subjects’ characteristics, as well as
the beliefs, practices, barriers and knowledge of study participants. For knowledge, in addition to the aforementioned
descriptive statistics, a knowledge score corresponding to
the sum of points a pharmacist obtains for all the knowledge
questions, whereby he/she is given one point for a question
that they answered correctly and ‘0’ point if their answer
was either wrong or ‘I don’t know’ answer’. Therefore, the
knowledge score ranged between ‘0’ and ‘10’, with higher
values of the score reflecting more correct answers and
hence better knowledge. In order to determine the correlated of knowledge, simple and multiple linear regression
analyses were conducted. In these regression analyses, the
knowledge score was considered as the outcome variable
while the socio demographic factors were entered as independent variables. Of the socio-demographic characteristics,
variables that were found significantly associated with knowledge score in the simple regression were entered in the
multiple regression. Regression diagnostics were examined to ensure that the assumptions for the MLR
were met, including linearity between the independent
and the dependent variables, homoscedasticity, and
multicollinearity. The results of the diagnostics are
presented in Additional file 2. A p-value < 0.05 was
considered statistically significant.
Results
Three hundred and eighty three pharmacists were
approached, 341 of whom agreed to participate in the
study (89% response rate). The distribution of the pharmacies in Lebanon and the study sample, across the 6
Lebanese governorates are shown in Table 1. The study
sample showed similar proportions of pharmacies
among the various governorates.
The characteristics of the study population are presented in Table 2.The pharmacists were of varied age
groups, with most of them aged 40 and below (66.4%).
The proportion of males (51.9%) and females (48.1%)
were comparable. The study sample included pharmacists who were employed in the selected pharmacies
(41.8%) or owners of these pharmacies (58.2%). As for
the education level, more than half of the study
Page 4 of 12
Table 1 Distribution of pharmacies across governorates in this
study in comparison to national distribution of pharmacies n = 341
Pharmacies in
the study n(%)
Pharmacies
in Lebanon n(%)
Beirut
27(7.9)
238(7.8)
South
40(11.7)
353(11.6)
North
50(14.7)
436(14.3)
Mount Lebanon
147(43.1)
1311(43.1)
Beqaa
51(15.0)
482(15.8)
Nabatieh
26(7.6)
223(7.3)
Total
341
3043
population were holders of a Bachelor’s degree (57.5%),
while 42.6% had attained higher degrees: 22.3% a Pharm
D degree and 20.2% a Masters or PhD degree. Sixty-four
percent of the pharmacists attained their university
education in Lebanon. Only 35.3% of the pharmacists
reported receiving weight management training during
their university education and a lower proportion
(21.5%) underwent a post-graduation training in weight
management. Forty-four percent of the pharmacists had
more than 10 years of work experience, followed by
32.1% having 4–10 years of experience and 24.1% having
1-3 years of experience. Most of the pharmacists work in
a pharmacy that has been open for more than three
years (81.1%). Almost half of the pharmacists (47.5%) reported receiving more than 1 query a day about weight
management products.
The majority of pharmacists (87.9%) were strongly
agreeing or agreeing that obesity is a growing problem
in Lebanon. Overall, the study participants strongly
agreed or agreed that pharmacists have a role to play in
the field of weight management (84.8%), that providing
information about weight management products is a
pharmacist’s professional responsibility as extension of
their role as health professional (83.1%) and that weight
management products should be sold only in pharmacies
(83.8%) (Table 3). A total of 82.7% of participants
strongly agreed or agreed that a multidisciplinary team
approach to weight management will work best (82.7%).
Eighty-two percent strongly agreed or agreed that continuous education of pharmacist should include weight
management and training. In general, the participant
showed negative beliefs toward the market by strongly
agreeing or agreeing that customers are abusing weight
management drugs (76.9%) and companies are abusing
customers by making false promises (81.1%). In addition,
more than half (54.9%) disagreed or strongly disagreed
that that weight loss products are well regulated.
The majority of the pharmacists (84.7%) participating
in this study reported that they always/often sell weight
loss products in their pharmacy and 88.7% reported always/often being asked for weight loss products
Hijazi et al. BMC Health Services Research
(2020) 20:386
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Table 2 Characteristics of study sample. (n = 341)
Frequency
Percentage
Age range
< 30 years
114
33.5
31–40 years
112
32.9
≥ 41 years
114
33.5
Gender
Male
177
51.9
Female
164
48.1
Employments status
Employed
142
41.8
Pharmacy owner
198
58.2
Bachelors
196
57.5
Pharm D
76
22.3
Masters/PhD
69
20.2
Highest educational
level attained
University you
graduated from
Outside Lebanon
123
36.3
In Lebanon
216
63.7
During your university
education, did you
receive any weight
management training?
Yes
120
35.3
No
220
64.7
Did you receive any
postgraduate education/
training on weight
management?
Yes
73
21.5
No
266
78.5
Years of work experience
1–3 years
82
24.1
4–10 years
109
32.1
Above 10 years
149
43.8
263
77.4
How many pharmacists
work in this pharmacy?
1–2 pharmacist
3–5 pharmacist
More than 5 pharmacist
74
21.8
3
0.9
How long has this
pharmacy been
opened for?
1–3 years
64
18.9
4–10 years
117
34.5
Above 10 years
158
46.6
How many times per
day do you get queries
about weight management
products at your pharmacy?
Once daily or less
179
52.5
More than once daily
162
47.5
(Table 4). Eighty-six percent reported always/often
counselling customers who request to buy products for
weigh management on the safe and effective use of the
product and 77.6% always/often check for drug or food
interaction while dispensing weight loss products. The
majority were always/often advising the patients to eat
low calorie diet (86.3%), increase physical activity
(91.7%), and increase consumption of soluble fibers
(80.9%). In addition, participated pharmacists reported
that they always/often provide weight and height measurement for their patients (80 and 60%, respectively).
However, the majority (81.7%) were rarely/never providing waist circumference measurements for patients.
Most participants answered always/often provide blood
glucose and blood pressure measurements (83.7 and
89.0%, respectively) at their pharmacy, but only 15.3% of
them provided body fat measurement. Around 66% of
the surveyed pharmacists reported referring patients to
dieticians, on as needed basis. Most of the pharmacists
(73.6%) reported that they always/often ask customers for
any side effects or undesirable reactions after taking
weight loss products; however, 53.5% of the pharmacists
rarely/never reported any toxicity or adverse reaction of
weight loss products. Among those who reported the incidence of toxicity or adverse reactions, 91.3% of pharmacists were reporting to the pharmaceutical companies and
only 1.9% reported to the OPL, whereas the remaining reported to physician (3.9%) and MOPH (2.9%) (Table 5).
Over 30% strongly agreed/agreed to the following barriers to weight management services; I don’t have time
(30.4%), I don’t have enough staff (36.5%), I don’t have
enough space to have private consultation area (37%), I
don’t have the relevant equipment (39.8%), I would need
additional payment (31.8%). On the other hand, fewer
pharmacists strongly agreed or agreed that adequate
knowledge (21.5%) or interest in the weight management
(18.6%) were barriers for them to provide weight management services (Table 6).
Table 7 displayed the results of self-knowledge assessment of community pharmacists with regards to weight
management. The assessment included 10 questions
addressing general knowledge about overweight and
obesity as well as the uses, side effects and interactions
of commonly sold weight management products in
Lebanon, namely green tea, herbal laxative and orlistat.
While 71.1% of pharmacists answered correctly the
question related to BMI cutoff for obesity, only 25%
knew about weight loss targets and 51% realized the
importance of weight maintenance, after reaching the
target weight. The percentage of pharmacists answered
correctly the side effects and interactions of laxatives
was greater than those for green tea and olistat (83.4
and 79.2% for laxatives as compared to 45.2 and 17.3%
for green tea and 67.1 and 54.6% for olistat).
Hijazi et al. BMC Health Services Research
(2020) 20:386
Page 6 of 12
Table 3 Community pharmacists’ beliefs towards their role in weight management*. (n = 341)
Strongly
agree
Do you think obesity is a growing problem in Lebanon
Agree
Neutral Disagree Strongly
disagree
221(66.8) 70(21.1)
27(8.2)
9(2.7)
Do you believe that pharmacists have a role to play in the field of weight management
198(58.1) 91(26.7)
24(7.0)
17(5.0)
Providing information about diet products is a pharmacist’s professional responsibility as
extension of their role as health professional
166(49.4) 114(33.7) 35(10.4) 14(4.1)
17(5.0)
4(1.2)
11(3.2)
9(2.7)
Do you think that weight loss products should be sold only in pharmacies
235(69.3) 49(14.5)
22(6.5)
16(4.7)
Do you feel other healthcare professionals are more appropriately suited to be involved
in this area
135(40.1) 105(31.2) 60(17.8) 26(7.7)
11(3.3)
Do you think that multidisciplinary team approach to weight management will work the
best
196(58.8) 80(23.9)
9(2.7)
34(10.1) 16(4.8)
Continuous education of the pharmacist should include weight management and training
180(53.3) 97(28.7)
40(11.8) 12(3.6)
9(2.7)
Do you think that customers are abusing weight loss products
163(48.8) 94(28.1)
46(13.8) 24(7.2)
7(2.1)
Do you think that companies marketing weight loss products are making false promises?
174(52.3) 96(28.8)
32(9.6)
12(3.6)
Do you believe that herbal weight loss products are well regulated?
37(10.9)
53(15.6)
63(18.6) 79(23.3)
107(31.6)
Do you think that media and advertisements are playing a positive role in educating customers
towards weight loss products and weight management
112(33.0) 54(15.9)
43(12.7) 52(15.3)
78(23.0)
19(5.7)
Values in this table represent n (%)
*
For the overall score of knowledge, results of the multiple linear regression revealed few factors that were associated with a higher score, indicated by a significantly
positive value for ß. The magnitude of the latter indicated
the difference in knowledge score between the categories
compared. These factors included: Holding a Masters or
PhD degree in Pharmacy as compared to Bachelor’s
degree (ß =0.79, 95%CI: 0.37–1.21), graduating with a
pharmacy degree from a university in Lebanon as opposed
to abroad (ß =0.88, 95%CI: 0.5–1.26), obtaining weight
management training within the academic degree (ß =
0.42, 95%CI: 0.08–0.75), and receiving inquiries about
weight management in the pharmacy more than once
daily (ß =0.41, 95%CI: 0.1–0.73) (Table 8).
Table 4 Current practice towards weight management services among community pharmacists in Lebanon*. (n = 341)
Always
Often
Sometimes
Rarely
No
Do you dispense weight loss products at your pharmacy
188(55.5)
99(29.2)
32(9.4)
14(4.1)
6(1.8)
Do your patients ask you for weight loss products
212(62.7)
88(26.0)
21(6.2)
8(2.4)
9(2.7)
Do you counsel customer who request to buy products for weight
management on the safe and effective use of the product
224(66.9)
65(19.4)
26(7.8)
10(3.0)
10(3.0)
Do you check for drug or food interaction while dispensing weight
loss product
193(57.8)
66(19.8)
35(10.5)
22(6.6)
18(5.4)
Do you advice the patients to eat low calorie diet
235(69.7)
56(16.6)
30(8.9)
8(2.4)
8(2.4)
Do you advice the patients to increase physical activity
262(78.0)
46(13.7)
14(4.2)
8(2.4)
6(1.8)
Do you advice the patients to increase consumption of soluble fiber
214(63.9)
57(17.0)
35(10.4)
19(5.7)
10(3.0)
Do you provide weight measurements for patients
222(66.1)
46(13.7)
22(6.5)
14(4.2)
32(9.5)
Do you provide height measurements for patients
150(44.6)
45(13.4)
18(5.4)
23(6.8)
100(29.8)
Do you provide waist circumference measurements for patients
21(6.3)
15(4.5)
25(7.5)
34(10.1)
240(71.6)
Do you provide BMI calculation for your patients
101(30.0)
33(9.8)
38(11.3)
28(8.3)
137(40.7)
Do you provide blood glucose measurement at your pharmacy
243(71.9)
40(11.8)
16(4.7)
10(3.0)
29(8.6)
Do you provide blood pressure measurement at your pharmacy
253(75.1)
47(13.9)
13(3.9)
3(0.9)
21(6.2)
Do you provide body fat measurement at your pharmacy
39(11.5)
13(3.8)
21(6.2)
15(4.4)
250(74.0)
Do you refer your patient to dieticians when needed
156(46.3)
69(20.5)
58(17.2)
17(5.0)
37(11.0)
Do you ask customers for any side effect or undesirable reaction after
taking weight loss products
186(55.2)
62(18.4)
44(13.1)
11(33.3)
34(10.1)
Do you report any toxicity or adverse reaction of weight loss products?
89(26.5)
31(9.2)
36(10.7)
27(8.0)
153(45.5)
Values in this table represent n (%)
*
Hijazi et al. BMC Health Services Research
(2020) 20:386
Page 7 of 12
Table 5 To whom do you report any toxic or undesirable effect
that occurred with patients using weight loss products??
n = 103
%
Manufacturing company
94
91.3
Ministry of Public Health (MoPH)
3
2.9
Order of Pharmacy in Lebanon (OPL)
2
1.9
Physician
4
3.9
Discussion
This is the first national study to examine the role of
pharmacists in weight management in Lebanon and to
shed light on their beliefs, practices and knowledge regarding weight management and weight loss products.
Overall, the study findings highlighted a general positive
belief among pharmacists regarding their role in weight
management while acknowledging the role of other
health care professionals in managing overweight and
obesity. Pharmacists participating in this study, however,
expressed reservations towards the regulatory framework
governing the market of weight loss products in the
country. With regards to practices, despite engaging in
counseling for weight management as well as dispensing
weight loss products, a sizeable proportion of pharmacists were rarely carrying out important diagnostic measures, such as BMI calculations or waist circumference
measurements. In addition, even though 73% of pharmacists in this study inquired about products’ side effects,
only 35% reported such effects with the majority doing
so to the company selling the products or to its medical
representative. This study revealed important gaps in the
knowledge of pharmacists, most importantly with
regards to the side effects of certain weight loss products
and their interaction with other medications. In this
study, factors significantly associated with better knowledge were higher education (Masters or PhD), earning
the pharmacy degree from a university in Lebanon,
obtaining formal education in weight management, and
receiving frequent inquiries about weight management
from patients/customers.
In this study, the majority of pharmacists believed that
their role is important in weight management and that
dispensing diet and weight loss products ought to be the
pharmacist responsibility solely. More specifically, the
findings indicated that while pharmacist perceived that
they have a role to play in the area of weight management, they also believed in the importance and effectiveness of a multidisciplinary team and that other health
care professionals may be better suited to take lead on
that front. These findings are in line with previous research, whereby a survey of 128 community pharmacists
in Scotland showed positive attitudes to the provision of
healthy weight management services [38]. Furthermore,
a qualitative study in Australia investigating the pharmacists’ opinion about provision of weight management
services indicated that participants clearly perceived an
important role for pharmacists in weight management, as
part of a multi-disciplinary team [17]. Also in Australia, a
more recent study conducted among pharmacy students
and early career pharmacists showed that participants
were positive about their perceived role in providing
weight management services [39].
These positive beliefs of pharmacists towards their role
in weight management were contrasted with the doubts
that many surveyed pharmacists casted on the regulations governing the market for CAM products including
those for weight loss. Such doubts were also reported by
other studies [25, 40–42]. In fact, since only few of the
hundreds products sold in pharmacies for weight loss
are licensed medicines, they are not subject to the strict
control required for medicines, in terms of efficacy,
safety, quality or provision of a standardized patient information leaflet [43]. In Lebanon, several weight loss
products were promoted and sold for many years before
Table 6 Barriers in providing weight management services among community pharmacists in Lebanon.* (n = 341)
n(%)
I don’t have enough time to provide weight management services
Strongly
agree
Agree
Neutral
Disagree
Strongly
disagree
55(16.2)
48(14.2)
59(17.4)
64(18.9)
113(33.1)
I don’t have enough staff to provide weight management services
70(20.6)
54(15.9)
51(15.0)
66(19.5)
98(28.9)
I don’t have enough space to have a private consultation area to
provide weight management services
74(21.9)
51(15.1)
39(11.5)
59(17.5)
115(34.0)
I don’t have the relevant equipment (e.g. weighing scale,etc) to
provide weight management services
78(23.0)
57(16.8)
41(12.1)
56(16.5)
107(31.6)
I would need additional payment to provide weight management
services
69(20.4)
38(11.2)
40(11.8)
43(12.7)
148(43.8)
I don’t have the enough knowledge to provide weight
management services
36(10.6)
37(10.9)
47(13.9)
72(21.2)
147(43.4)
I don’t have the interest to provide weight management services
36(10.6)
27(8.0)
48(14.2)
76(22.4)
152(44.8)
Values in this table represent n (%)
*
Hijazi et al. BMC Health Services Research
(2020) 20:386
Page 8 of 12
Table 7 Evaluation of self-knowledge towards weight management among community pharmacists in Lebanon. (n = 341)
The cut off for body mass index (BMI) to indicate obesity is > 29.9 kg/m2.
True/
False
% answered
correctly
% answered
incorrect
% answered
I don’t know
T15
239(71.1)
41(12.2)
56(16.7)
82(24.3)
175(51.9)
80(23.7)
27,28,36
An initial weight loss goal should be to lose more than 10% of current
body weight in 6 months
F
Once a weight loss goal is achieved it is okay to discontinue treatment.a
F29
172(51.0)
146(43.3)
19(5.6)
Laxatives are considered very useful method to lose weight in obese
persons.
F
30
262(77.5)
66(19.5)
10(3.0)
Herbal Laxative (like senna, cascara, etc) are recommended for pregnant
or breast feeding women
F31
282(83.4)
42(12.4)
14(4.1)
High consumption of green tea may exert toxicity to liver cells.
T32
152(45.2)
71(21.1)
113(33.6)
Orlistat use is associated with a higher incidence of gastrointestinal
adverse events compared with placebo.
T
33
226(67.1)
71(21.1)
40(11.9)
The chronic use laxatives may potentiate the effects of diuretics which
may lead to significant losses of fluid and electrolytes, including
sodium, potassium, magnesium and zinc.
T34
267(79.2)
41(12.2)
29(8.6)
Concomitant use of large quantities of green tea may increase the
effectiveness of anticoagulation drugs (warfarin).
F
58(17.3)
143(42.7)
134(40.0)
Orlistat is contraindicated in patients with cardiovascular diseases.
F33
184(54.6)
109(32.3)
44(13.1)
a
30,31,35
Interviewers were trained to indicate that ‘treatment’ in this question referred to ‘dietary changes’
the Ministry of Public Health (MoPH) withdrew them
from the market and prevented their uses because of
contamination, presence of unauthorized ingredients, or
counterfeits [44].
In this study, the positive belief of the surveyed pharmacists regarding their role in weight management was also
reflected in their practices, whereby the majority of pharmacists always/often dispensed weight loss products and
counseled patients on healthy lifestyle habits, including
diet and physical activity. A few studies reported more
elaborate interventions for weight loss as part of the pharmacist’s role such as patient-centered weight loss programs [45, 46] and conducting slimming courses [47].
However, and in support of the study findings, the supply
of medication and counseling for weight loss remain the
two most common pillars of the pharmacist role in weight
management [17]. Alarmingly, in this study, a few practices that were reported by the surveyed participants jeopardized the efficacy and safety of their role in weight
management. For instance, although the pharmacists
reported taking height and weight measurements, only a
few calculated the BMI or provided assessments for waist
circumference and body fat, raising questions regarding
the sensitivity of their diagnosis of obesity and consequently the relevance of their consultation. It is indisputable that weight and height measurements alone are poor
indicators of obesity, if not used to calculate BMI. In fact,
most of the scientific reports call for other anthropometric
measurements (in addition to height and weight) such as
waist circumference and body fat to classify obesity [48].
Another disconcerting finding in this study is related
to the practices of dispensing weight loss medications.
First, over 40% of surveyed pharmacists did not discuss
with their patients the side effects or undesirable reactions of these medications. Certain drugs advertised for
weight loss could pose significant adverse effects, for example Garcinia cambogia extract and hepatic failure
[49] and low dose Human Chorionic Gonadotrophin injections and increased thrombosis risk [50]. According
to the American Pharmacists Association, a patientcentered discussion on safe and effective medication use
is among the main medication-related responsibilities of
pharmacists as it is directly linked to improving patient
safety [51]. Therefore, it is important for the pharmacist
to heighten the patients’ awareness of potential health
implications while dispensing weight loss medication.
Second, over 50% of surveyed pharmacists indicated that
they do not report toxicity or adverse effects of drugs
when encountered. Moreover, of the few pharmacists
who reported these adverse effects, the vast majority did
so to the manufacturing/distributing company. Similar
practices were also observed among community pharmacists in Lebanon in the case of complementary and alternative products [25]. These practices threaten public
health safety, since many of the adverse effects remain
not reported and could lead to serious health implications. Furthermore, communicating these adverse effects
to the manufacturing/distributing company, whose main
objective is financial gain from drug sales, raises a serious ethical question over such practices. Alternatively, it
could be argued that such a practice stemmed from the
fact that a large proportion of pharmacists reported little
trust in the regulatory bodies of the market in Lebanon.
In both cases, these findings call upon the MoPH to
Hijazi et al. BMC Health Services Research
(2020) 20:386
Table 8 Predictors knowledge score (related to weight
management products) among community pharmacists in
Lebanon. n = 341
B, 95% CI
Adjusted B, 95% CI
Ref
Age range
< 30 years
Ref
31–40 years
−0.32(−0.72, 0.09)
0.05 (−0.44,0.54)
≥ 41 years
−0.73(−1.13, − 0.32)
−0.10(− 0.75,0.56)
Gender
Male
Ref
Ref
Female
0.37 (0.04,0.71)
0.17 (−0.17,0.51)
Employed
Ref
–
Pharmacy owner
0.18(−0.17, 0.52)
–
Bachelors
Ref
Ref
Pharm D
0.26(−0.16,0.68)
0.13(−0.27,0.53)
Masters /PhD
0.61 (0.19,1.04)
0.79(0.37,1.21)
Outside Lebanon
Ref
Ref
In Lebanon
0.88(0.55,1.22)
0.88(0.50,1.26)
No
Ref
Ref
Yes
0.45(0.10, 0.80)
0.42(0.08,0.75)
No
Ref
–
Yes
0.14(−0.27,0.55)
–
1–3 years
Ref
Ref
4–10 years
−0.16(− 0.62,0.29)
−0.15(− 0.63,0.34)
Above 10 years
−0.52(− 0.94,-0.10)
−0.16(− 0.80,0.48)
1–2 pharmacist
Ref
–
3–5 pharmacist
0.12(−0.30, 0.53)
–
More than 5 pharmacist
−0.71(−2.88, 1.46)
–
Employments status
Highest educational
level attained
Which university did
you graduate from
During your university
education, did you
receive any weight
management training?
Did you receive any
postgraduate education/
training on weight
management?
Years of work experience
How many pharmacists
work in this pharmacy?
How long has this
pharmacy been
opened for?
1–3 years
Ref
–
4–10 years
−0.25 (− 0.74, 0.23)
–
Above 10 years
− 0.46(− 0.93,0.02)
–
Once daily or less
Ref
Ref
More than once daily
0.42(0.09, 0.76)
0.41(0.10, 0.73)
How many times do you
get queries about weight
management products
at your pharmacy?
Page 9 of 12
upscale the health care system and implement a proper
reporting system for the pharmacists and other healthcare provider as well.
In this study, the beliefs and practices of pharmacists
with regards to weight management were contrasted by
significant knowledge gaps in this domain. More specifically, over 50% of participants in this study missed critical concepts such as the recommended percent weight
to be lost over a certain period of time and the need to
maintain healthy dietary habits after the target weight is
reached. 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 [52–54]. 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 results of this
study showed that considerable proportions (more than
30%) of surveyed pharmacists agreed that resources in
terms of time, space, staff, remuneration, and relevant
equipment were all common barriers to providing weight
management services. The majority of these barriers were
also cited in previous studies [10, 15, 17, 38]. A recent
Hijazi et al. BMC Health Services Research
(2020) 20:386
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]. Recommendations proposed to overcome the ‘time’ barrier included (in addition
to proper staff) the formation of multi-disciplinary practice models, within which pharmacists and other health
care team members work together [15] and increasing the
involvement of technicians and students/residents in the
dispensing role, hence freeing the pharmacist for counseling [56]. 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 Lebanon, such a
barrier still existed despite that, according to OPL Decree
No. 2622 issued in 1992, a section in the pharmacy should
be dedicated to reception and counseling of patients. In
fact, this decree specified that a minimum of 32 m2 is required to register a pharmacy which should be divided
into four sections:1-reception 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. To achieve such a response rate, the field
workers were trained to present the objectives of the research in a manner to illicit the interest of the pharmacist
and hence increase his/her chance of participation. 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. However, the likelihood that pharmacists who
were less interested in weight management were more
likely to decline participation, further underscores the implications of this study’s findings. 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
Page 10 of 12
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.
Conclusions
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 this study,
higher education (Masters or PhD), earning the pharmacy
degree from a university in Lebanon, obtaining formal
education in weight management, and receiving frequent
inquiries about weight management from patients/customers were all significant predictors of better knowledge.
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.
Hijazi et al. BMC Health Services Research
(2020) 20:386
Supplementary information
Page 11 of 12
6.
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12913-020-05258-7.
7.
Additional file 1.
Additional file 2.
Abbreviations
BMI: Body Mass Index; OPL: Order of Pharmacists in Lebanon; CI: Confidence
interval; FIP: International Pharmaceutical Federation; ACPE: Accreditation
Council for Pharmacy Education
Acknowledgements
N/A
Authors’ contributions
FN, MAH, designed the data collection form and the methodology. MAH
managed the data collection. MAH, FN and HS wrote the first draft of the
manuscript. HS performed the statistical analysis. HAR assisted in the
development of the questionnaire and conducted data entry. AEL and MAE
critically reviewed the manuscript. All authors have read and approved the
final manuscript.
8.
9.
10.
11.
12.
13.
14.
Funding
No financial support.
15.
Availability of data and materials
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.
16.
Ethics approval and consent to participate
The study protocol was approved by the Institutional Review Board at the
Beirut Arab University under the protocol number 2019H-0059-P-R-0300. The
informed consent obtained was written and all respondents have agreed to
take part in the research and signed a free informed consent form.
18.
17.
19.
20.
Consent for publication
Not applicable.
21.
Competing interests
The authors declare that they have no competing interests.
22.
Author details
Faculty of Pharmacy, Department of Pharmaceutical Sciences, Beirut Arab
University, Beirut, Lebanon, P.O. Box: 11 5020, Beirut, Lebanon. 2Nutrition and
Food Sciences Department, Faculty of Agriculture and Food Sciences
American, University of Beirut, Beirut, Lebanon.
1
23.
24.
25.
Received: 5 August 2019 Accepted: 28 April 2020
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J. of the Acad. Mark. Sci. (2018) 46:317–337
DOI 10.1007/s11747-016-0508-3
ORIGINAL EMPIRICAL RESEARCH
Hey big spender! A golden (color) atmospheric
effect on tipping behavior
Na Young Lee 1 & Stephanie M. Noble 2 & Dipayan Biswas 3
Received: 2 November 2015 / Accepted: 3 November 2016 / Published online: 15 November 2016
# Academy of Marketing Science 2016
Abstract This research examines how gold-related color in
atmospherics might influence customer tipping behavior at
restaurants. A series of five studies shows that the color gold
(as opposed to other colors) in a service atmosphere positively
influences consumer tipping. First, a field experiment (Study
1) demonstrates that customers presented with a gold-colored
(vs. black-colored) service prop (i.e., bill folder) leave larger
tips. Study 2 further confirms this effect of the color gold by
validating the findings of Study 1 with a different service prop
(i.e., tablecloth). Process evidence demonstrates the underlying mechanism of this effect, whereby a gold-colored service
prop increases tipping by influencing status perceptions about
the restaurant and the self (Study 3). Additional studies further
confirm this by ruling out novelty of the color in this mechanism (Study 4) and by highlighting the effect of status on
tipping through status priming (Study 5). The findings of this
research have implications for strategic use of color in
servicescape design and atmospherics in general.
Kelly Haws served as Area Editor for this article
* Stephanie M. Noble
snoble4@utk.edu
Na Young Lee
nlee15@utk.edu
Dipayan Biswas
dbiswas@usf.edu
1
University of Tennessee, 305 Stokely Management Center,
Knoxville, TN 37996-0530, USA
2
University of Tennessee, 310 Stokely Management Center,
Knoxville, TN 37996-0530, USA
3
University of South Florida, BSN 3218, Department of Marketing,
4202 E. Fowler Avenue, Tampa, FL 33620, USA
Keywords Color . Gold . Payment behavior and tipping .
Servicescape . Service props . Sensory cues . Atmospherics .
Retail ambience . Frontline employee . Retail strategy
Marketers are extensively using colors to create corporate images, build brand personalities, attract consumers, and shape
consumer perceptions (Abril et al. 2009; Labrecque and Milne
2012; Madden et al. 2000). Recent industry trends point to an
even greater interest in the use of color as a marketing tool to
influence consumer behavior. Apple is incorporating the color
gold in their design narratives for strategic purposes to associate their brand with luxury (Strange 2015), and GE provides
a wide range of color choices to ensure their refrigerators
resonate with consumers (Barry 2015). Hyatt has used the
color gold in their BGold Passport^ loyalty program to convey
the notions of exclusive benefits and higher status to customers who join the program (Henderson et al. 2011).
Across industries, a wide range of color options are available
for mobile phones, laptops, and even home appliances
(Labrecque et al. 2013). In accordance with these industry
trends, academic researchers have recognized the role of color
and have provided empirical support for its importance in
marketing, including the impact of color on branding
(Labrecque and Milne 2012), purchase intention, choice likelihood (Biswas et al. 2014a), and shopping behavior (Babin
et al. 2003; Bellizzi and Hite 1992).
Despite these agreements on the importance of color as a
marketing tool (Geboy 1996), our understanding of the effects
of color remains limited (Crowley 1993; Labrecque and Milne
2012). Most color-related studies in the relevant marketing
literature have investigated color effects by using an arousalevaluation framework and they provide a limited perspective
in terms of understanding the complex nature of the color
phenomenon (Labrecque et al. 2013). For example, an
318
arousal-evaluation framework posits that consumers respond
to color in two ways: arousal or evaluation (Crowley 1993).
Consumers respond to red (vs. blue) by being more active or
stimulated (i.e., arousal), but they respond to blue (vs. red) by
showing pleasant or relaxed responses (i.e., evaluative)
(Crowley 1993). This stream of literature has focused on the
dichotomized color hue in the investigation of color effects:
red/warm vs. blue/cold. Since color hues are dichotomized
based on wavelength, the meaning of color as assessed by
consumers (Madden et al. 2000) and colors that are hard to
place on the spectrum of red/blue or warm/cold have gained
little attention in this stream of literature. To overcome this,
some recent works have examined the effects of color on
brand personality by using an embodied-referential meaning
framework (Labrecque and Milne 2012; Zeltner 1975). More
attention, however, is needed to understand the ways in which
color influences consumers’ behavior when color has associated meanings, whereby consumers associate words or meaning with particular colors (Labrecque et al. 2013) (e.g., white
might indicate cleanliness to some, such as in white bedding
sheets (Berry et al. 2006)). In addition, extant color research
has examined the effects of color by focusing on consumer
behavior in retailing, branding, or advertising settings (Babin
et al. 2003; Bellizzi and Hite 1992; Lohse and Rosen 2001).
However, questions about how colors might influence consumer tipping behavior, which is a pervasive activity in restaurant settings, remain unanswered.
Our study extends prior literature by investigating how
gold-colored service props influence consumers’ tipping.
Service props are the objects used in service delivery and help
create the overall atmospherics in a service setting (Fisk et al.
2008). Tip amount is an important variable behind the viability of many businesses. To understand the ways in which goldcolored service props influence consumers, we employ a referential meaning of color framework. Anecdotal evidence and
research studies suggest that the color gold is associated with
status perception (Drèze and Nunes 2009). Building on the
referential meaning of color framework, we posit that consumers activate gold–status (color–meaning) associations
when they encounter the color gold. Thus, we incorporate
consumers’ assessment of color–meaning in our investigation.
The color gold is widely used in marketing practices (e.g.,
The Hunger Games gold-colored special edition book cover), but has gained little attention in the marketing literature.
By investigating an understudied but important color, the
present research enriches the color marketing literature.
Additionally, the present study contributes to service literature. Although their importance in the creation of service atmospherics and service delivery is widely accepted (Berry
et al. 2006; Fisk et al. 2008), there is little empirical support
in the literature for the strategic use of service props.
Moreover, the results of our study could have significant managerial implications for the service industry given the
J. of the Acad. Mark. Sci. (2018) 46:317–337
economic importance of tipping; consumers spend $27 billion
every year on tipping in US restaurants (Azar 2007a).
A series of five studies shows that gold-colored service
props (vs. other-colored service props) enhance consumers’
tip amount through consumers’ status perceptions. The first
two studies (Studies 1 and 2) demonstrate the positive effects
of gold-colored service props on tipping, the last three studies
(Studies 3–5) examine the underlying mechanism of the gold
effect. More specifically, in Study 1, a field experiment conducted at a restaurant, we demonstrate that a gold-colored (vs.
black-colored) service prop (i.e., bill folder) leads to higher tip
amounts (in terms of percentages). In Study 2, we validate this
effect of the color gold in a more controlled lab environment.
Moreover, we use a different service prop in Study 2 (i.e.,
tablecloth) to enhance the generalizability of the findings.
Delving into the process of the gold effect, we unveil status
perception as a mediation mechanism in Study 3 and further
confirm this by ruling out a potential explanatory variable
related to the novelty of the color in Study 4. In Study 5, we
provide further evidence of status as the underlying mechanism by examining the effects of priming status.
The remaining sections are organized as follows. We first
review the literature on color, atmospherics, and tipping.
Building on the theoretical framework in the color literature,
we link these literature streams to propose our hypotheses. We
then test our hypotheses with the help of five studies. Finally,
we present our conclusions by outlining our contributions and
limitations, in addition to providing suggestions for future
research.
Theoretical background
Color
A significant body of research in marketing literature has examined the role of color in the context of two key research
questions: (1) BWhich colors influence consumers?^ and (2)
BWhat effects do colors have on consumers and what are the
associated implications for businesses?^ (Crowley 1993).
A stream of literature has addressed the first question based
on three dimensions of color: hue, chroma, and value (Gorn
et al. 1997, 2004). Hue refers to the pigment of a color such as
blue, yellow, and green. Chroma refers to the amount of pigment in color, for example, low chroma colors are dull and
high chroma colors are rich and deep. Value is the degree of
lightness of a color on a scale ranging from low (black) to high
(white) (Gorn et al. 1997). Among the three dimensions of
color, hue has been the main focus of color-related studies,
especially in the marketing literature.
Although marketers use a wide array of color hues in marketing contexts, most researchers have studied dichotomized
color hues such as warm versus cool (or red vs. blue) and
J. of the Acad. Mark. Sci. (2018) 46:317–337
examined consumers’ reactions to them. A wide range of studies has shown the effects of color on different aspects of consumer behavior and the associated marketing implications
(Madden et al. 2000). For example, consumers’ purchase intentions were higher for merchandise displayed on a bluecolored background (Babin et al. 2003), and consumers rated
a blue-colored shopping environment as more pleasant
(Crowley 1993). Although these studies provide meaningful
insights, color hues other than red and blue also need to be
studied given the variety of colors used by marketers. Our
study intends to contribute to the literature by exploring a
less-studied color hue, that is, the color gold.
In investigating the second question (i.e., BWhat effects do
colors have on consumers? and what are the associated implications for businesses?^), researchers have focused on the
effects of color mostly in the contexts of retailing, advertising,
and branding (Bellizzi and Hite 1992; Labrecque et al. 2013;
Lohse and Rosen 2001). Psychology literature has noted that
the effects of color could be context dependent, for example,
red clothing motivates approach behavior at a dinner party but
the same color motivates avoidance behavior in a street sign
(Elliot and Maier 2014).
In sum, the present research extends the extant color marketing literature in two ways. First, we expand the color hue
spectrum in the marketing literature beyond red/blue or warm/
cold to a different color (gold). Second, we extend the study
context of the color effects to tipping in a service setting, which
is a novel setting and has been under-explored thus far. Table 1
presents a summary of the key color studies in greater detail as
well as highlights our contribution. In the next section, we build
the theoretical foundation for our hypotheses.
Referential meaning of color Earlier studies in the marketing
literature have supported a two-dimensional framework, the
arousal-evaluation dimension, in explaining color effects
(Crowley 1993; Labrecque and Milne 2012). Recent studies
have turned their attention to embodied and referential meaning frameworks (Labrecque and Milne 2012; Labrecque et al.
2013), focusing to a greater extent on the effects of the meanings associated with a given color. This theory originated in
aesthetics philosophy literature, where Zeltner (1975) originally conceptualized referential and embodied meanings to
explain how aesthetics-related stimuli influence people’s perceptions. Drawing from this theory, Zhu and Meyers-Levy
(2005) used the referential and embodied meanings of music
to explain how music influences customers’ perceptions (i.e.,
how music conveys a meaningful message to customers).
Labrecque and Milne (2012) applied this theory to color, calling it the referential meaning of color, and used the resulting
conceptual framework to explain the effect of color on brand
personality.
The embodied part of the theory refers to the meanings
intrinsic to stimuli that evoke hedonic or valenced feelings
319
(Labrecque and Milne 2012; Meyers-Levy and Zhu 2010).
For example, the embodied meaning conveyed through red
evokes arousal, and blue elicits feelings related to happiness
(Bagchi and Cheema 2013; Hemphill 1996).
Although the referential meaning framework was not a
dominant conceptual framework in early color marketing literature, color associations have been studied as a topic in color
psychology literature (Elliot and Maier 2014; Whitfield and
Wiltshire 1990) and a few earlier studies in color marketing
literature have investigated color–meaning associations. For
example, consumers’ color preference for certain logos or
brands have been found to vary across cultures because of
dissimilarities in the meanings of the color activated by color–meaning associations (Block and Kramer 2009; Madden
et al. 2000). In this study, we explore the effect of the color
gold, which is associated with status perception (discussed in
greater detail below); thus, we apply the referential meaning
of color as the theoretical framework for our hypotheses. In
the next section, we review works on color–meaning associations to identify the meaning associated with the color gold in
order to develop our hypotheses from a referential meaning
perspective.
Color–meaning associations Color possesses not only aesthetic value but also informative value that conveys a specific
meaning (Elliot et al. 2007). Repeated pairings of colors and
particular concepts or messages create a strong or implicit
learned color association over time. As a result, even the mere
presence of color in a particular situation activates color associations (Elliot et al. 2007; Elliot and Maier 2014).
The color gold is often associated with status concepts (Drèze and Nunes 2009). Status is defined as an
individual’s position or ranking in society and is associated with entitlement, prestige, exclusivity, admiration,
and respect from others (Anderson et al. 2015; Drèze
and Nunes 2009).1 Consistent with this concept, it is
customary to award golden trophies or gold medals for
the first place in competitions, as is done for example,
in the Olympics (Drèze and Nunes 2009). Words that
begin with Bgolden^ are considered the first or the best
(e.g., golden age, golden voice). Consumers are likely
to develop a gold–status association through repeated
pairings in marketing practices as well. For example,
gold is one of the most widely used color hues to convey the meaning of wealth and status in marketing practices. Specific examples include gold labels being widely used in companies’ loyalty programs to symbolize
high status and exclusive benefits for their loyal customers (e.g., American Airlines’ gold membership card).
1
Power is conceptually different from status. Unlike status, which is determined by Bthe eyes of others,^ power is defined as the ability to influence
others through control over resources or through the capacity to punish them
(Anderson et al. 2015; Emerson 1962; Fiske 1993; Magee and Galinsky 2008).
Full color vs. black (hue)
Red vs. blue (Hue)
Retail: interior color
of furniture store
Advertising
Advertising
Online auction,
background color
Crowley (1993),
Marketing letters
Gorn et al. (1997),
Mgt. Science
Lohse and Rosen
(2001), JA
Bagchi and Cheema
(2013), JCR
Branding
Labrecque and
Milne (2012), JAMS
Hue, saturation and value
Color warmth
Online shopping
(warm vs. cold color)
(visual elements
and saturation
of online shopping)
Kaltcheva and
Weitz (2006), JM
Hue, chorma and value
Online, screen
color
Gorn et al. (2004), JMR
Chroma, value and
hue (red vs. blue)
Red, yellow, green,
blue (Hue)
Cool vs. warm color:
red, yellow, green,
blue and white (Hue)
Retailers’ interior
color
Bellizzi et al. (1983), JR
Orange vs. blue (Hue)
Red vs. blue (Hue)
Retail wall color
Babin et al. (2003),
JBR
What color (IV)
Bellizzi and Hite (1992), Shopping
Psychology
environment
and Marketing
(background color
of merchandise)
Context
Summary of key studies on the effects of color in marketing
Study
Table 1
Affective and
cognitive
evaluations
Arousal and affective
dimension of color
Embodied-referential
meaning of color
Arousal
Purchase intention and
pleasantness of shopping
environment
Brand personality,
purchase intention
Feelings of relaxation
Auction bidding ($) Arousal
Arousal and
hedonic state
Arousal-evaluation
Approach
Evaluation
orientation
(Physical attraction)
Shopping time
Behavioral
Theoretical
framework
Perceived download
quickness, attitude
toward and likelihood
to recommend website
Attitude toward and
advertiser and ad.
Willingness to pay
Feelings and attitude
toward ad and brand
Arousal and evaluation
of environment and
merchandise.
Perceived store
environment
and product
and price fairness
Pleasure, dominance,
arousal, purchase
intention
Purchase intentions
Attitudinal
What effect (DV)
Color and light together affected perceived
price fairness and purchase intentions
through affective and cognitive responses.
Blue (vs. red) shopping environment leads to
more positive customer outcomes including
more simulated purchases, fewer purchase
postponement and stronger intentions to
shop and browse. Affective perception of
color rather than arousal dimension of color
may be responsible for this outcome.
Warm colors (vs. cool colors) physically attract,
however, it produced less positive responses
(vs. cool colors) in evaluation factor such
as relaxed or favorable.
Evaluative effects are most positive (more
pleasant) in cool colors, whereas warm colors
are more arousing. Two dimensions of color
(arousal-evaluation) are suggested as
theoretical framework for color effects.
High saturation increases likability through
feelings of excitement. High value increases
likability through feelings of relaxation.
Color can signal product quality and credibility
of printed ads.
Red backgrounds increase bidding price in
online auction, whereas it decreases price
offer in negotiation, because red induces
aggressiveness through arousal.
All three color dimensions of background
screen color influence perceived download
quickness through feelings of relaxation,
which would in turn influences attitude
toward website and likelihood of
recommendation
of the website to others.
Consumers’ motivational orientation moderates
the effect of arousal produced by a store
environment (color) on the pleasantness of
the environment. High arousal has a
positive effect on pleasantness for recreationaloriented consumers, but for those who have a
task-orientated motivational orientation,
it decreases pleasantness.
Hue, saturation and value influenced brand
personality, logo shape and likability. Package
color and brand personality needs to be aligned
to increase purchase intention.
Main findings
320
J. of the Acad. Mark. Sci. (2018) 46:317–337
321
Note: JA = Journal of Advertising, JAMS = Journal of the Academy of Marketing Science, JBR = Journal of Business Research, JCR = Journal of Consumer Research, JM = Journal of Marketing,
JMR = Journal of Marketing Research, JR = Journal of Retailing, Mgt. Science = Management Science
Referential
meaning of color
Tipping ($)
Gold
Service, restaurant
atmospherics
This study
Liking of the color,
logo color preferences,
color meanings
Hue, blue, green, white,
black, red, orange,
yellow, brown, purple,
green
Branding
Madden et al. (2000),
Journal of
International
Marketing
Attitudinal
What color (IV)
Context
Study
Table 1 (continued)
What effect (DV)
Behavioral
Theoretical
framework
Color-meaning
association
Main findings
There are cross-cultural patterns of both similarity
and dissimilarity in color preferences and color
meaning associations. Color-meaning
associations
are dependent on cultural background, therefore
culture needs to be considered to manage brand
and corporate image across international markets.
Gold in restaurant atmospherics increases
customer’s tipping through activation of
referential meaning, status perception.
J. of the Acad. Mark. Sci. (2018) 46:317–337
These prevalent practices help reinforce perceptions related to color–status associations. Research shows that
customers in gold and silver tiers perceive themselves
as top-tier customers who hold higher status than others,
whereas those in blue and yellow tiers do not, implying
that the color gold conveys the notion of hierarchy and
status (Drèze and Nunes 2009). In sum, it can be posited that consumers associate the color gold with status.
Drawing from the referential meaning of color, we hypothesize that this gold–status association is activated when consumers encounter the color gold in a service landscape, which
influences their subsequent behavior.
Atmospherics and service props
The influence of atmospheric elements (e.g., color, light,
music, and scent) on consumer behavior is well documented in the literature (Bitner 1992; Biswas et al.
2016; Singh 2006). For example, Madzharov et al.
(2015) found that semantic associations of a warm (vs.
cool) scent in retail atmospherics influence customers’
spatial perceptions, which, in turn, increases power restoration motivation and subsequently enhances the purchase of premium brands. More recently, Biswas et al.
(2017) examined the role of light in atmospherics and
found that changing the ambient light influences restaurant patrons’ alertness levels and their tendency to order
healthy versus unhealthy foods. These studies suggest
that subtle cues in atmospherics impact customers’ behaviors by influencing their perceptions toward the environment and self. In a similar vein, service literature
has recognized the importance of subtle atmospheric elements in service environments because such elements
contribute to the creation of customer experiences and
shape customers’ perceptions of the service provider
(Baker and Cameron 1996; Berry et al. 2006; Bolton
et al. 2014).
Service props are a subtle, but important, aspect of
atmospheric elements in service settings (Fisk et al.
2008). Using the analogy of props in the stage of a service performance, Fisk et al. (2008) referred to the objects
in a service delivery process as service props (e.g., restaurant booth, airline seat, or hotel bedding) and proposed
that they can contribute to and shape consumers’ perceptions of the overall service atmosphere and experience
(Bolton et al. 2014; Fisk et al. 2008; Haeckel et al.
2003). Thus, we posit that the colors of service props
can shape consumers’ perceptions of the service experience. In sum, these literature streams support the notion
that gold–status associations activated by the color of service props should influence consumers’ perceptions of the
service atmosphere and experience. These perceptions
322
about the service atmosphere and experience should in
turn influence tip amounts.
Tipping
Tipping is a prevalent consumer behavior that allows customers to set the price of a portion of a service offering
(Lynn et al. 1993). Consistent with prior research, we conceptualize tipping in percentage terms in all our studies. Although
tipping is widely accepted as a voluntary payment behavior
that demonstrates consumers’ appreciation and gratitude toward service providers, surprisingly, prior research has documented that tip amount has a weak relationship with server’s
efforts, restaurant’s food, or even service quality (Azar 2007a;
Kwortnik et al. 2009; Lynn and Grassman 1990; Lynn and
Latane 1984; Lynn et al. 1993). Several empirical studies have
instead identified several drivers of tipping behavior that are
extraneous to the specific service or meal quality. For example, prior research has documented the relationships between
tip amount and weather conditions or even specific characteristics of the servers (such as servers’ gender, body shape, hair
color, amount of cosmetics, and customer touching behavior)
(Guéguen 2012; Jacob et al. 2010; May 1980; Rind and
Bordia 1996; Stephen and Zweigenhaft 1986). Although color
has not gained much attention as a research topic in this literature stream, a few recent works have tested color as a manipulation stimulus that improves servers’ physical attractiveness
(e.g., lipstick, clothing, or hair color) (Guéguen 2012;
Guéguen and Jacob 2012, 2014; Lynn et al. 2016). Another
stream of research on the motivations for tipping has suggested that tipping is a largely norm-driven behavior (Azar
2007b; Lynn et al. 1993). For example, it has been found that
customers leave a tip to adhere to social norms and to avoid
feeling guilty for not leaving one (Lynn and McCall 2000;
Lynn 1997; Lynn et al. 1993).
In relation to the social norm perspectives, different tipping
customs across countries suggest that consumers use tipping,
in part, as a tool for status display (Azar 2007b; Lynn 1997).
For instance, tipping was found to be more prevalent in countries where achievement or status is highly valued (Lynn et al.
1993). Consistent with this, historical accounts suggest that
tipping could be related to an individual’s motivation toward
status. Historically, tipping has been used as a tool to display
an individual’s status, as the custom of tipping allows wealthy
consumers to demonstrate their socioeconomic status to themselves, their guests, or their servers (Lynn 1997; Shamir 1984).
Although there are differing views as to whether tipping
started in 16th century Europe or whether it was prevalent in
the Roman era, scholars agree that tipping originated as a
socioeconomic status feature (Azar 2004), whereby individuals of economically higher status (i.e., wealthy) gave tips to
people of economically lower status. In essence, tip amount is,
therefore, likely to be influenced by the tipper’s desire for
J. of the Acad. Mark. Sci. (2018) 46:317–337
status and status display (Azar 2007b; Conlin et al. 2003;
Lynn 1997; Lynn and Grassman 1990; Lynn and Sturman
2003; Lynn et al. 1993).
The idea that tipping is, in part, driven by a desire for status
display (Lynn 1997; Shamir 1984) suggests that customers are
likely to leave a generous tip when their status perception
becomes salient. Applying this to a referential meaning perspective, it can be hypothesized that gold-colored service
props will activate consumers’ gold–status associations,
which would, in turn, make their status perceptions salient.
This will lead consumers to leave larger tips since they are
likely to display their status perception activated by the goldcolored service props through tipping. More formally,
H1: Consumers presented with a gold-colored service prop
will leave a larger tip (%) than consumers presented with
a non-gold-colored (e.g., black or white) service prop.
Underlying process for effects of gold color on tipping
behavior
In her seminal piece on servicescape, Bitner (1992) suggested
that atmospherics usually affect individuals’ perceptions of
the environment itself first, which would, in turn, generate
individuals’ internal responses and subsequent behaviors.
Multiple studies have supported this conceptual framework
by showing that atmospherics influence customers’ perceptions of a service provider. For example, customers attribute
service failure to service organizations more frequently when
they see that service environments are disorganized (vs. wellorganized) (Bitner 1990). In a similar vein, it has also been
proposed that atmospherics in a servicescape can be an extrinsic cue for customers to infer the quality of service and that of
the service provider (Baker et al. 1994; Bitner 1992; Zeithaml
1988). Customers infer restaurant service quality from facility
aesthetics, including interior design and décor (Heung and Gu
2012). Along the same line, it has been suggested that service
props influence customers’ perceptions of the serviceproviding organization because they create the overall atmosphere (Berry et al. 2006; Fisk et al. 2008). These perceptions
of the environment itself could influence self-perception in
service contexts such as restaurant settings, because being in
a restaurant and consuming its services could be regarded as
possession of the restaurant’s services, whereby they become
part of the extended self, similar to possessed objects (Belk
1988).
Building on this relationship among service props, overall
perceptions of atmospherics, and their influence on self-perception, we propose that gold-colored service props influence
consumers’ perceptions of the restaurant itself, which would,
in turn, affect consumers’ self-perception, leading to the generation of subsequent behavior. Applying this to the referential
J. of the Acad. Mark. Sci. (2018) 46:317–337
meaning of color framework, we propose a serial mediation
mechanism of the effect of gold, such that encountering goldcolored service props activates consumers’ status perceptions
of a restaurant, which, in turn, elevates individuals’ self-status
perception, subsequently increasing the amount they leave as
tip. Formally,
H2: The effect of a gold-colored service prop on tipping
amount will be serially mediated by status perception
such that: a gold colored (vs. non-gold colored) service
prop → increased restaurant status perceptions → increased self-status perception → tip amount (%).
Across five studies, we test our hypotheses using a bill
folder (Studies 1, 3, 4, and 5) and tablecloth (Study 2) to
manipulate the color of service props. We use these service
props as manipulation instruments for two main reasons: First,
both of them are managerially relevant because they are relatively easy and inexpensive to change on short notice (as
compared to the color of interior décor). Second, bill folders
and tablecloths are the service props that customers encounter
with a high physical proximity in a dining situation, and thus
their colors have greater exposure for customers and can also
be more salient.
Study 1: the effect of the color gold on tipping
Design, participants, and procedure
Study 1, a field experiment, tested H1 that encountering a
gold-colored service prop (a bill folder in this study) increases
tipping. We tested gold-colored bill folders against blackcolored folders because black ones are commonly used in
restaurants. We conducted a two-week field experiment at an
independently owned (i.e., non-chain) restaurant during lunch
hours. During these two weeks, a total of 252 customers had
lunch at the restaurant, and these customers’ payment amounts
were recorded. Across all studies, anyone tipping above and
below three standard deviations of the mean were removed,
consistent with the approach of prior studies (Mandel and
Johnson 2002; Rucker et al. 2011). In Study 1, this resulted
in 17 participants being removed, yielding 235 participants for
analysis. Two participants were excluded from Study 2 based
on the same criterion. In Studies 3, 4, and 5, tipping did not fall
outside this range; hence, no respondents were removed from
those studies based on this criterion.
During the first week of the field experiment (Monday
through Saturday), only gold bill folders were presented to
119 customers. In the second week, only black bill folders
were presented to 116 customers. This method ensured that
the day of the week was not an influencing factor. It should
also be noted that there were no special events or holidays
323
during these two weeks. To rule out the possibility of design
differences such as size and texture of the bill folder, we made
certain that both folders were identical except for their color
(see Fig. 1). We collected data from the merchant copy of each
customer’s receipt, including the price of the meal, tip amount
in dollars, payment method (credit card or cash), and server
name.2 The restaurant did not suggest pre-calculated tips on
the receipts, nor did they add any automatic tip to the check for
parties greater than a certain size.
Results and discussion
To test H1, we conducted an ANCOVA. Tip percentage (tip
amount divided by meal price including tax) was the dependent measure, and color of the bill folder (gold vs. black) was
the independent variable. Based on the tipping literature, we
included several factors that might influence tipping as covariates: server, payment method, and day of the week (Lynn
et al. 1993). Consistent with H1, the results of the ANCOVA
analysis revealed the effect of the bill folder color.
Specifically, customers presented with the gold-colored bill
folder left higher tip amounts than those presented with the
black-colored bill folder (Mgold = 21.5% vs. Mblack = 18.9%;
F(1226) = 4.76, p < .05). Additionally, we explored whether
there were any interactions between color and payment mechanism (cash vs. credit card), server, server gender, and day of
the week on tipping behaviors. No significant interactions
were found (all p-values > .20).
In sum, the first study—a field experiment—revealed that
encountering a gold-colored service prop increased consumers’ tipping amount. Although this study provided support
for the existence of our hypothesized gold effect, it has limitations in terms of the limited controls and measures of extraneous variables (e.g., individual customers’ mood or involvement in tipping) that might influence tip amounts. We address
these concerns in the following studies.
Study 2: robustness of the gold effect
Study 1 showed that customers who encounter gold-colored
(vs. black-colored) bill folders leave larger tips. Although this
gold effect supports H1, it is limited to one service prop, the
bill folder. Moreover, one might have concerns about double
money-priming effects. That is, the gold-colored bill folder
might prime money thoughts twice because a bill folder may
be associated with a payment check and the color gold can
also be associated with money. Thus, a gold-colored bill folder
might heighten the accessibility of the idea of money twice
2
Since individual’s identifiable information could not be collected, returning
customers were not captured. When customers left a tip in cash, wait staff
noted the tip amount on the merchant copy of the receipt.
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Fig. 1 Bill folders used across
studies
J. of the Acad. Mark. Sci. (2018) 46:317–337
Black
(Vohs 2006). This double money-priming effect can potentially influence our results because even a subtle reminder of
money can change subsequent consumer behavior (Vohs
2006; Vohs et al. 2008). Study 2 attempted to address this
concern by investigating a different service prop—the tablecloth. Therefore, the purpose of Study 2 was twofold: (1) to
extend the gold color effect beyond the bill folder context by
examining the effects of the color gold in tablecloths and (2) to
rule out alternative explanations related to the double moneypriming effect because tablecloths are not related to money/
tipping as are bill folders.
Design, participants, and procedure
Study 2 involved two manipulated conditions—gold- vs.
white-colored tablecloths. White was used as the control/
comparison color because white tablecloths are used commonly in fine...
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