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.