Discussion
To our best knowledge, this study is among the first cross-sectional
study conducted in Malaysia to understand the context in which community
pharmacists’ responses, roles, and perceptions in the control of the
COVID-19 transmission. We found that most community pharmacists were
generally well prepared to cope with the pandemic, and had a positive
outlook towards keeping themselves and their customers safe, which
further affirm the instrumental role of community pharmacists in public
health. While most community pharmacies had adapted their environment to
minimize the risk of spreading infection, some community pharmacies went
further in innovating new services, such as providing a drive-through as
well as home delivery service to further minimize contacts among their
customers. Interestingly, another key collaboration that was developed
was referral services among other community pharmacies as well as with
primary care doctors within the vicinity, which is rarely practiced in
Malaysia due to competing commercial interests.
However, we found that less than one in every five community pharmacists
in the survey reported to have installed acrylic glass barriers or
perspex in front of the counter for the collection of medicine and
utilized baskets to receive payments at cashier. This might be due to
limited floor space and lack of infrastructure feasibility for reducing
physical contact. Notwithstanding, the employees were protected with the
complimentary use of gloves and hand sanitizers. Furthermore, there was
a growing opportunity for community pharmacists to exploit technologies
to facilitate remote consultations, as presently practiced by 31.1% of
the respondents. Investment has been insufficient in developing health
technology industry. The COVID-19 pandemic has propelled the use of
telehealth solutions to facilitate social and physical distancing, while
maintaining quality of clinical care. To realize a telehealth-enabled
future, novel engineering designs, products, and innovations, for
instance, smart phones, wearable devices, and instrumented (smart) homes
can be accoutred with environmental and biological sensors that are
interconnected using 5G networks to monitor patient health and send
messages to responsible clinicians and pharmacists when emergency
situations are detected [14-16].
We observed an overall decrease in level of perception on the dimensions
of safety, resilience, and support with increasing age of pharmacists.
The majority of participants surveyed (74.7%) were mid-career
pharmacists aged 30 to 49 years, while only 2.3% aged 60 years or
older. It has been suggested that pharmacists’ response to work-related
conditions and experiences is dependent on age, with middle-age
pharmacists expressing less satisfaction compared to both younger and
older practitioners [17]. Our study resonated previous observations
reporting that pharmacists 45 to 59 years old were more dissatisfied
with their workload and attached more importance of their jobs to
patients than did younger or older pharmacists [18]. We believe that
this could be because senior members of the profession had prior
experience to coordinate the response to past series of influenza
outbreaks that were similarly been characterized by novel virus
subtypes, specifically SARS outbreak of 2003, H1N1 Influenza of 2009,
and New Avian Influenza Viruses H7N9 and H10N8 of 2013 [19]. As
such, they could acclimatise better to the policies and work environment
for which they have served over numerous years.
Data from this study also found some evidence of gender disparity in
organizational support. Albeit a tactful bit of literature found no
evidence for gendered differences in ability, the variation in
perceptions demonstrates a potential effect of local social norms and
cultural influences in achieving supportive organizational culture which
is governed by the shared values and beliefs that influence workplace
and employee behaviour [20]. As such, effective strategies involving
legislation, allyship, leadership, and professional development of core
competencies could transform organizational culture and climate towards
gender equality in science, medicine, and global health, thereby
optimizing health, social, and economic gains [21]. In many
countries, the limited opportunities for hiring, merit, promotion, and
access to productive resources of women in the fields of science and
medicine warrant policy changes. This is needed in order to address and
remove barriers to that will ultimately ensure engagement and
participation of women in the workforce, resulting in increased
satisfaction and more diverse recruitment [20].
The surprising correlation between perceived workplace safety and
occupational role could be plausibly explained by external covariates,
including the availability of higher operating budget, business revenue,
and staff education programmes. Being the owner, partner or executive
officer of a community pharmacy generally has the ultimate
responsibility and authority to decide on the company’s capital
allocation, decision making, and operational management processes.
Hence, the extent to which pharmaceutical care of patients and welfare
of staff were distributed under the condition of a pandemic would stem
from decisions and actions from the corporate boards.
The study has several limitations that are worth mentioning. As we did
not perform a probability-based sampling method, our results may not be
representative of the full diversity of the Malaysian population with
respect to race and ethnicity. The questionnaire scope did not measure
responses by race or ethnicity of the pharmacists, socio-economic status
of the communities surrounding the pharmacies, geographical locations,
and presence of public health programmes in the local settings.
Nevertheless, we believe that a holistic approach to infectious disease
control should embrace community pharmacies with public health agencies
to address the upstream determinants of health. As such, community
pharmacies represent an important infrastructure within the primary
health care systems for combating the pandemic, serving a part in
patient education, disease surveillance, and dealing with medical
supplies to be stockpiled or redirected in an emergency [22]. The
services that can be delivered in community pharmacy settings include
medication dispensing for chronic and acute conditions, chronic disease
management, recommendations for over-the-counter medications, medication
management and adherence support, self-care recommendations,
vaccinations, specimen collection, and point-of-care screening or
testing services for rapid diagnosis and education of patients about
results, lifestyle recommendations, and referral to specialty care if
necessary [23-25].
There may be variations in responses regarding planning and preparedness
of community pharmacies to disease outbreaks prior to stringent laws and
stricter enforcement by the authorities since March 18, 2020 [26].
As such, the results of this study cannot explicitly refute other
ecological drivers of change, which may have influenced results of this
study. It is also noteworthy that the perceptions of pharmacists may
change over time in response to social and physical environmental
factors. Strict enforcement would improve compliance to rules and
standard operating procedures introduced by the government and thus
minimizing the risks of community transmission in pharmacies and public
areas [27]. As compared to face-to-face interviews, our study was
conducted through online survey which might lead to biased results
because it could have dismissed those with high workload, scarce time,
and limited connectivity.
The repercussions of lockdown are now being observed in the Malaysian
society, where furloughs have turned into redundancies and recession
takes effect. As such, we believe it is reasonable to anticipate not
only sustained distress and considerable deterioration in supply chain
and affordability of long term personal protective equipment along with
pharmacy business and profit downturn, but emergence adverse health
impacts of economic recessions due to the precarious job markets and
weak social protection systems. The COVID-19 pandemic has engendered
numerous daunting challenges for health service provision, especially
with differing access to housing, food security as well as social
connectivity, all which are related to public health. Therefore,
appropriate and proportionate clinical duties and response to mitigate
or manage coronavirus crisis require multidisciplinary high-quality
pharmaceutical care from the community pharmacies, alongside
sufficiently resourced services supported by government policies and
programmes.