key: cord-0813262-4mmi1nce
authors: Silva-Suarez, Georgina; Reyes, Yarelis Alvarado; Hernandez-Diaz, Ana; Ramirez, Keysha Rodriguez; Colón-Pratts, Frances M.
title: The voices of community pharmacists during the COVID-19 pandemic in Puerto Rico
date: 2021-07-24
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2021.07.013
sha: 47cc1a8b7650fa0f25987875548aae0fa65973c5
doc_id: 813262
cord_uid: 4mmi1nce

Background Community pharmacists have provided healthcare services uninterruptedly throughout the COVID-19 pandemic. However, their public health role is often overlooked. Objectives The purpose of this manuscript is to discuss the roles and the coping mechanisms of community pharmacists working during the COVID-19 pandemic in Puerto Rico. Methods A cross-sectional study, using an electronic survey, was conducted to assess the community pharmacists' response during the COVID-19 Pandemic in Puerto Rico. Two open-ended questions explored community pharmacist's opinions about the pharmacist's role and coping mechanisms during the pandemic. The responses were analyzed following an inductive thematic analysis. Two major themes emerged from their responses: professional and personal experiences. Results Of the 302 participants who completed the survey, 77% of them answered one or both open-ended questions. The answers were diverse, and the respondents went beyond the specific topics asked. In professional experiences, important roles as educators and providing continuity of care and emotional support to their patients were highlighted. They also expressed concerns and frustrations on the profession's shortcomings, feeling overworked yet with a lack of recognition. In personal experiences, most of the respondents were concerned about the impact of having to juggle work and home life. They also reported mental health concerns, expressing feeling stressed, overworked, and worried about the constant risk of exposure and fear of exposing their loved ones. Conclusion Community pharmacists in Puerto Rico ensured the continuation of care, provided education, and managed anxious and stressed patients. Most relied on family members to cope with the extra burden that the COVID-19 pandemic. The lack of recognition created resentfulness among participants. It is essential to listen to our community pharmacists' voices to support and respond to their needs and learn from their experiences as front-line health care workers.

Pharmacists have been essential front-line health professionals that have provided continued services 73 during the COVID-19 pandemic 1-3 . COVID-19, a severe infectious disease caused by a novel coronavirus 74

(SARS-CoV-2), was declared a global pandemic by the World Health Organization on March 11, 2020, 4 . In 75 response to this public health threat, the Governor of Puerto Rico established a curfew and a general 76 lockdown on March 15. Essential businesses, including pharmacies, remained open and were among the 77 few healthcare establishments accessible to the public 5 . Since then, community pharmacists have 78 provided their healthcare services uninterruptedly throughout the pandemic. The impact of this 79 experience among community pharmacists has yet to be explored. 80

Since the onset of the pandemic, pharmacists have ensured the continuity of care, including being the 81 first point of contact for many patients, providing education, managing medication shortages, engaging in 82 virtual consultation, and screening and triaging COVID-19 patients 6 . In Puerto Rico, community 83

pharmacists have also been allowed to test and, more recently, to vaccinate for COVID-19 7 . Pharmacists 84

are recognized as one of the most accessible healthcare professionals and are key for reaching the 85 desired vaccination rates against COVID-19 in the US and worldwide 8, 9 . The population of Puerto Rico is 86 approximately 3 million with a life expectancy at 80.9 years 10 . Chronic diseases such as hypertension, 87

diabetes, asthma, chronic kidney diseases and mental health disorders are prevalent and place a financial 88 toll on the Puerto Rico health system. In Puerto Rico, there are about 900 community pharmacies 89 distributed among 76 municipalities 11 . They provide essential healthcare services in their communities 90 especially in times of need, such as in the aftermath of Hurricane Maria 11 . 91

However, regardless of pharmacists' proximity to their communities and the crucial role they have played 92

during the pandemic, their public health role is often overlooked. When the first COVID-19 case was 93 identified in Puerto Rico on March 13, 2020, the Governor of Puerto Rico appointed a Medical Task Force 94

(MTF) to establish a public health response. This interprofessional group was composed of volunteer 95

scientists and healthcare professionals 12 . Although initially, pharmacists were not part of this group, later, 96 a pharmacist with infectious disease expertise was invited to be part of this task force. On May 27, 2020, 97

the Governor of Puerto Rico approved financial incentives for health care essential workers 13 , but 98

pharmacists were not included. In response, the Colegio de Farmacéuticos (PR Pharmacists' Association) 99

issued a press announcement on August 17, 2020, claiming that pharmacists and pharmacy technicians 100

should be awarded a financial incentive 14 . These are some examples of the lack of recognition of the role 101 and efforts of the pharmacy profession in response to the emerging COVID-19 pandemic in Puerto Rico. 102

Despite the uncertainty of COVID-19, pharmacists have continued to provide services in their 103

communities. By September 2020, there was no information or study regarding community pharmacists' 104 response during the COVID-19 pandemic in Puerto Rico. The purpose of this manuscript is to discuss the 105 roles and the coping mechanisms of community pharmacists working during the COVID-19 pandemic 106 from their own perspectives. 107 108

A cross-sectional study was conducted to assess the community pharmacists' response during the 19 Pandemic in Puerto Rico. An electronic survey was developed based on previously published surveys 111 J o u r n a l P r e -p r o o f community pharmacy were excluded. 129

The open-ended questions were analyzed following a thematic analysis approach. The thematic analysis 131 aimed to identify, analyze, and report patterns within the data 20 (see figure 1 ). Following a thematic 132 analysis allowed the production of a detailed description of the data set and interpretation of our 133 research topic. 134

Three of the authors (GSS, AHD, & KRR) approached the data set and followed the steps proposed by 135

Braun, Clarke 20 (see figure 1 ). GSS is a Hispanic female researcher with an educational background in 136 public health who has worked with vulnerable populations and public health emergencies, like natural 137 disasters. She is an assistant professor at Nova Southeastern University (NSU) College of Pharmacy (COP) 138

at the San Juan Regional Campus. She has conducted and is currently involved in various qualitative 139 research projects and has had formal and informal training in conducting qualitative interviews and focus 140 groups. AHD & KRR were fourth-year pharmacy students at NSU-COP San Juan Regional Campus at the 141 time of the analysis while participating in an Academic Rotation with GSS. They are both Hispanic and 142 female and were trained in qualitative research and data analysis by the first author. 143

The sanitized data, without any identifiable information, was exported from REDCap to a pdf file. The 144

aforementioned authors engaged in their own independent analysis of the entire data set by reading, re-145 reading, and noting the initial ideas. Then the questions were split evenly between two of the authors 146

(AHD & KRR) which generated initial codes for their respected questions. The first author analyzed and 147 generated codes for the entirety of the data set. 148

After having the data set completely coded, each author, independently, reviewed their codes, evaluated 149 their pertinence, and collated them into themes. The emerging themes were then cross-checked by each 150 J o u r n a l P r e -p r o o f Page 5 of 11 author. When this procedure revealed discrepancies in topics, the coders clarified and discussed other 151 possible interpretations, refined, or created a new code or theme. 152

The researchers reviewed the themes that were generated and created a final thematic map. The final 153

report is being presented in this manuscript. the COVID-19 pandemic and their coping mechanisms were diverse, and the participants went beyond 168 the specific topics that were asked. 169

After following an inductive thematic analysis process 19 codes were originally identified. These were 170

narrowed down based on their recurrence, relevance, and relationship across them. Eleven codes were 171 categorized into four consensus-based categories, and further classified into two major themes: 172

professional and personal experiences (see figure 2 ). These two themes helped better understand the 173 community pharmacist's experiences during COVID-19. Actual quotes from the participants' responses 174 are presented to support the results. Original quotes are included in Appendix A. 175

Regarding their professional experiences, most community pharmacists considered that they had an 177

important role as educators in providing continuity of care and emotional support to their patients. Also, 178 they expressed their concerns and frustrations on the shortcomings of the profession, most of them 179 expressing feeling overworked yet with a present lack of recognition as essential health care providers. 180

Most participants felt that their central role was to educate patients, considering themselves as a primary 182 source of information. They provided education regarding preventive measures for COVID-19, symptom 183

identification, tips to improve the immune system, and recommendations for over-the-counter products. 184

They educated about the proper use of masks, hygiene, and physical distancing. As one of the study 185 participants stated about their role: "Educate clients and patients about prevention, keeping a healthy 186 lifestyle, being ready to respond questions and providing resources for anybody's needs." (Female, owner 187 of an independent pharmacy). 188

Another vital role highlighted by the study participants was to maintain the continuity of care. This was 190

accomplished by dispensing maintenance medications to patients with chronic conditions, such as 191 diabetes and hypertension, that required continued treatment and evaluation. A frequent 192

recommendation mentioned was to take home the 90-day supply of medications to decrease the number 193 of visits to the pharmacy and avoid unnecessary exposure. 194

Participants stated that they also had had to provide emotional support to their patients. They mentioned 195 that some of their patients visited the pharmacy looking for a sense of stability, security, and words of 196 comfort that would alleviate the anxiety caused by the COVID-19 pandemic. In the words of a participant, 197 "Many times, we notice in our consults that they just want to hear words of encouragement and security 198 amid the crisis, and that has also become part of our role. This is because patients know that we are 199 health professionals prepared, accessible, and have gained their trust." (Female, floating pharmacist, in an 200 independent pharmacy). 201

The community pharmacists expressed having to deal with an increased workload, identifying factors 203 such as lack of employees, shorter work hours, and taking on the roles of other health care professionals. 204

Some mentioned that physicians had remained closed initially during the pandemic, and they had to 205 attend to their patients. Others remarked having to take on extra shifts because of other "floater" 206

pharmacists refusing to work. Adding to normal pharmacist's duties, participants described having the 207 extra load of getting personal protective equipment for their employees, creating new protocols, and 208 dealing with anxious staff and patients. As a respondent said, 209 "At first, it was very hard because the pharmacy never closed, and we had to make many changes in the 210 way we worked, on the protocols and the physical structure. It was not easy to find protective equipment 211 and educating, not only patients but staff also. The workload increased, and at the same time, the work 212 hours shortened. Also, there is the fear of bringing the virus home." (Female, pharmacy manager working 213

in an independent pharmacy). 214

There was also an overwhelming underlying outcry from the participants about the lack of recognition for 215 their work and their efforts during the pandemic. Not only from their employers but specifically directed 216 towards the government and the professional pharmacists' associations. Many participants reported 217 feeling forgotten and outraged at the fact that pharmacists were left out of all projects aimed at 218 recognizing and incentivizing essential workers and health care professionals, despite providing continued 219 service since the start of the pandemic. One pharmacist commented: 220 owner and manager of an independent pharmacy). 245

Another pharmacist, who had given birth during the pandemic, commented on how difficult it had been 246

for her to take care of her newborn while still working and being exposed in the pharmacy. 247

Along with family obligations and responsibilities came the financial instability during the pandemic. Many 248

pharmacists reported feeling worried about dwindling sales in their pharmacies, lack of financial stimulus 249 from the government, and no hazard pay from their employers. Some respondents shared that they are 250 considered high risk or are immunocompromised and yet continue working to meet their financial 251 responsibilities. In the words of a participating pharmacist, 252 The COVID-19 outbreak has highlighted the importance of the role of pharmacists in the health care 275 system. They have continued to provide their health services, accompanied by the added workload the 276 current pandemic has brought on 21 . This survey was launched as the pandemic was emerging (early May 277 2020), and there were many uncertainties. Exploring their experiences regarding their roles and their 278 coping mechanisms during this time exposed many issues in both professional and personal aspects.

Evaluating and addressing these concerns can help community pharmacists to better prepare for future 280 public health emergencies. 281

Community pharmacists are aware of the influence they have on their patients and that due to their 282 accessibility, they see them more often than their primary care physicians 22 . Hence in many instances, 283

they are the first point of contact for the resolution of health issues. This remained true during the 284 emerging COVID-19 pandemic. Their role as educators and patient counselors was a recurrent theme 285 among this cohort. This role went beyond physical health and included words of encouragement and 286 support for anxious patients who could not remain calm during these uncertain times. Studies have 287

shown that, for many people, the COVID-19 pandemic resulted in psychological deterioration 6,23,24 . 288

Additionally, pharmacists have had to step up and take on a more active role with patients since, as 289 stated by participants, many doctor's offices were closed, or patients were just not able to contact their 290 primary care physicians 21 . 291

Community pharmacists typically have a long list of responsibilities that have expanded to meet the 292 needs of COVID-19, specifically a growing need to educate both patients and their staff and conduct both 293 testing and vaccinations for COVID-19 2,25,26 . Many study participants expressed their exhaustion due to 294

having to keep up with their usual duties with less staff, shorter working hours, and the confusion of 295 scared patients. Pharmacists reported an increase in the workload and how being overworked may have 296

consequences on the quality of care. 297

The reported increase in workload accompanied by the fear and uncertainty of COVID-19 was 298 exacerbated by their perceived lack of recognition from the public and the Puerto Rico government. 299

Leaving pharmacists out of the financial incentives caused outrage and hurt in the pharmacy community 300 27 . In Ontario, Canada, pharmacists had to endure similar situations. They failed to be recognized as 301 frontline health care professionals and were left without the economic stimulus provided by the local 302 government 28 . The comments expressed as part of this study reveal the work that pharmacists do daily 303 J o u r n a l P r e -p r o o f Page 9 of 11 and the augmented stress and increase in workload that they experienced. Community pharmacists in 304 this survey clearly resented their exclusion from governmental recognition and felt pharmacy associations 305 underrepresented them. They expressed a desire that their profession is taken as seriously as their 306

contributions to the health of society. 307

The under-appreciation of pharmacists during the pandemic and the stress of managing the COVID-19 308 requirements added an extra burden to their mental well-being 6,29 . Amidst a worldwide pandemic, 309

anxiety, stress, and fear are rampant because so many aspects of daily life have been altered 30 . However, 310

for those who never got a chance to interrupt their work to attend to their personal responsibilities, these 311

issues were heightened. A study conducted in Wuhan, China, concluded that mental health problems 312 such as anxiety, depression, and insomnia, were significantly greater in frontline medical workers 30 . The 313

respondents reported the overwhelming stress they had been subjected to and how little was being done 314

to address their concerns. Overworked, underappreciated, stressed, and fearful pharmacists could lead to 315 medical errors 31 . This is a major issue that should be recognized and addressed in educational efforts to 316

prepare for future public health threats. 317

This study was conducted in May 2020, when there was still significant uncertainty about COVID-19. Data 318

collection was conducted about three months after the lockdown was implemented, and pharmacists had 319

continued to provide services without the option of telehealth or other alternatives available to other This study explored the community pharmacists' experience regarding their role and coping mechanism 328 during the COVID-19 pandemic in Puerto Rico. Being the first point of contact for their patients, they 329 ensured the continuation of care, provided education, and even managed anxious and stressed patients.

Most relied on family members to cope with the extra burden that the COVID-19 pandemic put on them 331

and on taking "one day at a time." The reported lack of recognition put an extra toll on them, creating 332 resentfulness among participants. It is essential to listen to the voices of our community pharmacists to 333 support and respond to their needs and learn from their experiences. ¨Educate clients and patients about prevention, keeping healthy lifestyle, be ready to respond to questions and providing resources for anybody's needs. ¨ ¨Muchas veces nos damos cuenta que en sus consultas solo quieren escuchar palabras de aliento y seguridad en medio de la crisis y eso también se ha convertido en parte de nuestro rol. Esto es así porque los pacientes saben que somos profesionales de la salud preparado, accesibles y hemos ganado su confianza. ¨ ¨Al principio fue difícil porque la farmacia nunca cerró y tuvimos que hacer muchos cambios en la forma de trabajar, protocolos, en la estructura física, no fue fácil conseguir el equipo de protección y orientar tanto a los pacientes como al equipo de trabajo. El volumen de trabajo aumentó y a la vez se redujo horario. También miedo de traer el virus a mi hogar. ¨ ¨Es retante como profesional de la Salud, arriesgar nuestra propia salud y la de nuestras familias para poder cumplir con nuestro compromiso con la salud de la comunidad. Además entiendo que [las asociaciones de farmacia] no han sido proactivos ni diligentes en abogar por nuestra profesión, nos han dejado al margen completamente ante la población y el mismo gobierno de PR. Cuando los Farmacéuticos estamos en la primera línea de batalla, recibiendo a toda la población porque somos los profesionales de la salud más accesibles a ellos. Y cada vez se nos delegan más tareas y responsabilidades, por el mismo salario y con la misma escasez de empleados en el recetario. Entiendo deben emular a otros Colegios que han defendido a sus profesionales ante la solicitud de ayudas o incentivos del gobierno y defendiendo los roles de sus profesionales. ¨ ¨The workload in terms of [number of prescriptions] hasn't increased, but the support systems to handle them have suffered. I now have to divide my time between child care for 2 kids ages (3&6), homeschooling, house up keep plus all the pharmacy related tasks. All this without daycare, schools, family to help out, puts a very serious strain on family and work dynamics. Taking it day by day and doing the best we can. Not easy, but we will get through it. ¨ ¨Financial insecurity and inability to self-isolate for a long period of time or work from home if needed due to health concerns. Not having sick benefits as an exempt employee causes emotional hardship when deciding between a paycheck or being safe and protecting yourself and co-workers. Constant stress about PPE availability at work as it's not secured. Experiencing frequent panic attacks and guilt from not been able to provide care as I wish because of fear. ¨ ¨Al principio se me hizo difícil, me sentí depresiva, constantemente escuchaba las noticias y tenía miedo. Ahora lo asimile, esta es nuestra realidad y hay q vivir con eso. Hoy dia que me enojo y "Muchas veces nos damos cuenta que en sus consultas solo quieren escuchar palabras de aliento y seguridad en medio de la crisis y eso también se ha convertido en parte de nuestro rol. Esto es así porque los pacientes saben que somos profesionales de la salud preparado, accesibles y hemos ganado su confianza."

"Many times, we notice in our consults that they just want to hear words of encouragement and security amid the crisis, and that has also become part of our role. This is because patients know that we are health professionals prepared, accessible, and have gained their trust." (Female, floating pharmacist, in an independent pharmacy).

"Muchas veces, notamos en nuestras consultas que solos quieren escuchar palabras de aliento y seguridad en medio de la crisis, y eso también se ha convertido en parte de nuestro rol. Esto se debe a que los pacientes saben que nosotros somos profesionales de la salud, preparados, accesibles, y que nos hemos ganado su confianza." (Farmacéutica flotante, una farmacia independiente)

"Al principio fue difícil porque la farmacia nunca cerró y tuvimos que hacer muchos cambios en la forma de trabajar, protocolos, en la estructura física, no fue fácil conseguir el equipo de protección y orientar tanto a los pacientes como al equipo de trabajo. El "At first, it was very hard because the pharmacy never closed, and we had to make many changes in the way we worked, on the protocols and the physical structure. It was not easy to find protective equipment and educating, not only patients but staff also. The workload "Al principio, fue muy difícil porque la farmacia nunca cerró, y nosotros tuvimos que hacer muchos cambios en la forma en trabajamos, sobre los protocolos y la estructura física. No fue fácil encontrar equipo de protección y educar, no solo a los pacientes si no también al volumen de trabajo aumentó y a la vez se redujo horario. También miedo de traer el virus a mi hogar."

increased, and at the same time, the work hours shortened. Also, there is the fear of bringing the virus home." (Female, pharmacy manager working in an independent pharmacy).

personal. La carga de trabajo aumentó y, al mismo tiempo, se redujo las horas de trabajo. Además, existe el temor de llevar el virus a casa." (Directora de farmacia, que trabaja en una farmacia independiente)

Es retante como profesional de la Salud, arriesgar nuestra propia salud y la de nuestras familias para poder cumplir con nuestro compromiso con la salud de la comunidad. Además, entiendo que [las asociaciones de farmacia] no han sido proactivos ni diligentes en abogar por nuestra profesión, nos han dejado al margen completamente ante la población y el mismo gobierno de PR. Cuando los Farmacéuticos estamos en la primera línea de batalla, recibiendo a toda la población porque somos los profesionales de la salud más accesibles a ellos. Y cada vez se nos delegan más tareas y responsabilidades, por el mismo salario y con la misma escasez de empleados en el recetario. Entiendo deben emular a otros Colegios que han defendido a sus profesionales ante la solicitud de ayudas o incentivos del gobierno y defendiendo los roles de sus profesionales. "Es un desafío como profesional de la salud, arriesgar nuestra propia Salud y la de nuestras familias para poder mantener nuestro compromiso con la salud de la comunidad. Creo que [las asociaciones de farmacéuticos profesionales] no han sido proactivos ni diligentes en abogar por nuestra profesión. Nos han dejado completamente al margen del público, incluso de nuestro propio gobierno, cuando los farmacéuticos hemos estado en primera línea, recibiendo a todo el público, porque somos los profesionales de la salud más accesibles para ellos. Asignados más tareas y responsabilidades, por el mismo salario y con la misma falta de empleados. Creo que deberían emular a otras Asociaciones que han defendido a sus profesionales de la salud en cuanto a incentivos económicos y ayudas del gobierno y defendiendo el rol de sus profesionales." (Propietaria de una farmacia independiente) "Al principio se me hizo difícil, me sentí depresiva, constantemente escuchaba las noticias y tenía miedo. Ahora lo asimile, esta es nuestra realidad y hay q vivir con eso. Hoy dia que me enojo y quiero llorar por las frustraciones de médicos desaparecidos, pacientes mal informados, el alza de recetas, pero un día a la vez. Creo q deben de resaltar nuestra labor porque nunca se nos toma en "It was very hard for me at first, I felt depressed, constantly listening to the news, and I was scared. It has sunken in now; this is our reality, and we must live with it. There are days that I get angry, and I want to cry out of frustration due to physicians who disappeared, ill-informed patients, and a rise in prescriptions, but I must take it one day at a time." (female, staff pharmacist of a chain pharmacy).

On the frontline against COVID-19: Community pharmacists' 346 contribution during a public health crisis

Pharmacists at the frontline beating the COVID-19 349 pandemic

Pharmacist intervention amid the coronavirus disease 2019 (COVID-19) 351 pandemic: from direct patient care to telemedicine. Journal of pharmaceutical policy and 352 practice

WHO Director-General's opening remarks at the media briefing on COVID-19 -11

Orden Ejecutiva de la Gobernadora de Puerto Rico

Para Viabilizar los Cierres Necesarios Gubernamentales y Privados Para Combatir los Efectos del

COVID-19) y Controlar el Riesgo de Contagio en Nuestra Isla

Mental health issues impacting pharmacists during 360 COVID-19

Administración de pruebas para detectar el

FIP's response to the COVID-19 pandemic: Global 365 pharmacy rises to the challenge

Pharmacy as a Destination for Receiving Vaccines During the COVID-19 Pandemic

Cultural Sensitivity and Global 369 Pharmacy Engagement in the Caribbean: Dominica

Echan raices las farmacias de la comunidad. Primera Hora

Public health academic alliance for COVID-19 374 response: The role of a national medical task force in Puerto Rico

Resolución Conjunta 555: Incentivo económico a profesionales de la salud

Colegio de farmacéuticos de Puerto Rico reclama nuevamente al gobierno incentivo para 379 farmacéuticos y técnicos de farmacia

J o u r n a l P r e -p r o o f 1 Standards for Reporting Qualitative Research (SRQR)* http://www.equator-network.org/reporting-guidelines/srqr/

Title -Concise description of the nature and topic of the study Identifying the study as qualitative or indicating the approach (e.g., ethnography, grounded theory) or data collection methods (e.g., interview, focus group) is recommended 1/1Abstract -Summary of key elements of the study using the abstract format of the intended publication; typically includes background, purpose, methods, results, and conclusions 2/37-58

Problem formulation -Description and significance of the problem/phenomenon studied; review of relevant theory and empirical work; problem statement 3/ 73-105Purpose or research question -Purpose of the study and specific objectives or questions 3/105-107

Qualitative approach and research paradigm -Qualitative approach (e.g., ethnography, grounded theory, case study, phenomenology, narrative research) and guiding theory if appropriate; identifying the research paradigm (e.g., postpositivist, constructivist/ interpretivist) is also recommended; rationale** 4/127-134Researcher characteristics and reflexivity -Researchers' characteristics that may influence the research, including personal attributes, qualifications/experience, relationship with participants, assumptions, and/or presuppositions; potential or actual interaction between researchers' characteristics and the research questions, approach, methods, results, and/or transferability 4/135-143 Context -Setting/site and salient contextual factors; rationale** 1/81-91Sampling strategy -How and why research participants, documents, or events were selected; criteria for deciding when no further sampling was necessary (e.g., sampling saturation); rationale** 4/121/125Ethical issues pertaining to human subjects -Documentation of approval by an appropriate ethics review board and participant consent, or explanation for lack thereof; other confidentiality and data security issues 4/125-126Data collection methods -Types of data collected; details of data collection procedures including (as appropriate) start and stop dates of data collection and analysis, iterative process, triangulation of sources/methods, and modification of procedures in response to evolving study findings; rationale** 4/110-125 J o u r n a l P r e -p r o o f 2 Data collection instruments and technologies -Description of instruments (e.g., interview guides, questionnaires) and devices (e.g., audio recorders) used for data collection; if/how the instrument(s) changed over the course of the study 4/ 111-119Units of study -Number and relevant characteristics of participants, documents, or events included in the study; level of participation (could be reported in results) 5/150-169Data processing -Methods for processing data prior to and during analysis, including transcription, data entry, data management and security, verification of data integrity, data coding, and anonymization/de-identification of excerpts 4-5/ 144-148 Data analysis -Process by which inferences, themes, etc., were identified and developed, including the researchers involved in data analysis; usually references a specific paradigm or approach; rationale** 4/ 152-152Techniques to enhance trustworthiness -Techniques to enhance trustworthiness and credibility of data analysis (e.g., member checking, audit trail, triangulation); rationale** 4/149-152

Synthesis and interpretation -Main findings (e.g., interpretations, inferences, and themes); might include development of a theory or model, or integration with prior research or theory 5/160-175Links to empirical data -Evidence (e.g., quotes, field notes, text excerpts, photographs) to substantiate analytic findings 5-8/177-272

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Conflicts of interest -Potential sources of influence or perceived influence on study conduct and conclusions; how these were managed 1/27Funding -Sources of funding and other support; role of funders in data collection, interpretation, and reporting n/a *The authors created the SRQR by searching the literature to identify guidelines, reporting standards, and critical appraisal criteria for qualitative research; reviewing the reference lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to improve the transparency of all aspects of qualitative research by providing clear standards for reporting qualitative research.J o u r n a l P r e -p r o o f 3 **The rationale should briefly discuss the justification for choosing that theory, approach, method, or technique rather than other options available, the assumptions and limitations implicit in those choices, and how those choices influence study conclusions and transferability. As appropriate, the rationale for several items might be discussed together.