key: cord-0922989-yglpoh8m authors: Basheti, Iman A.; El‐hajji, Feras; Nassar, Razan; Thiab, Samar; Barakat, Muna; Basheti, Mariam; Berardi, Alberto; Saini, Bandana title: Pharmacists’ Awareness of COVID‐19 and Perceptions of their Roles, Barriers, and Roles of Policymakers: exploring the Middle East and North Africa (MENA) date: 2021-02-06 journal: Int J Clin Pract DOI: 10.1111/ijcp.14074 sha: 97ee6b4927e369a5b1da84e7fd705ad9b166b6ff doc_id: 922989 cord_uid: yglpoh8m BACKGROUND: The coronavirus disease (COVID‐19) was declared in January 2020 as a public health emergency of international concern. The Middle East and North Africa (MENA) suffered from several pandemics previously. Pharmacists have vital roles to play to prevent the spread of this virus. OBJECTIVES: To assess the COVID‐19 awareness amongst pharmacists from Arabic‐speaking countries located in the MENA region, and to assess their perspectives of their role, barriers, and roles of the educational institutions/pharmaceutical associations. METHODS: An online survey was conducted to run a descriptive cross‐sectional study in Jordan from 12(th) to 22(nd) April 2020. The questionnaire was validated (face validity) and put on Facebook and directed for pharmacists only (clarified in the introduction of the questionnaire). Assessment of pharmacists’ awareness (20 questions) about pandemics and COVID‐19, their perceived roles and barriers, and roles of the educational institutions (e.g. universities) and pharmaceutical associations (e.g. Pharmacists Syndicate) was done. Data were analyzed using Statistical Package for the Social Science (SPSS). RESULTS: Study participants (n= 2589) had a mean age of 29.3 (8.2) years and 1329 (51.5%) were females. Most of the participants were from Egypt (n= 819, 40.8%), followed by Jordan, Algeria, and Syria. Regarding the sources of information about coronavirus management, 60.8% of participants got their information from the social media. Fear from contracting the coronavirus while performing their duties was reported by the majority of pharmacists as the main barrier to delivering their roles (82.3%). The majority of pharmacists identified positive roles for the pharmaceutical institutions (74.8%) and pharmaceutical associations (63.6%). CONCLUSION: Pharmacists from the MENA countries believe they got enough education previously about pandemics, and the majority follow the latest coronavirus updates from social media. Fear was reported as the major barrier that requires resolution by the policymakers. Certain gaps in the awareness about COVID‐19 were identified. According to the World Health Organization (WHO), a pandemic is the worldwide spread of a new disease. 1 Viral pandemics are caused by viruses that possess a surface protein to which the majority of people lack immunity, which then spreads between people within the population extending beyond national borders. 2 Historically, many viral pandemics have been documented. The most notorious of these is the Spanish influenza pandemic of 1918-1920, which was caused by the H1N1 virus and was responsible for about 40 million deaths worldwide. 3 Other pandemics include the Asian influenza officially called SARS-CoV-2, belonging to the family Coronaviridae. 5 The coronavirus genome consists of a single strand positive sense ribonucleic acid (RNA). 4 The virions (virus particles) are enclosed in a lipid envelope characterized by the presence of crown-like spikes on the surface which have led to the nomenclature-where 'corona' implies the crown like appearance created by these bulbous spikes. 4 SARS-CoV-2 usually causes mild symptoms such as fever, dry cough, and sore throat. However, it can sometimes lead to fatal complications such as severe pneumonia, pulmonary This article is protected by copyright. All rights reserved edema, Acute Respiratory Distress Dyndrome (ARDS), organ failure and septic shock. 6 The spread of the virus to many countries around the world in a short space of time with no clear treatment or vaccine in sight as yet, is alarming and has resulted in high workload for healthcare teams globally. [7] [8] [9] Effective strategies currently followed to slow the spread of the virus included hygiene practices such as proper hand washing, hand sanitizing and wearing facemasks and gloves (personal protective equipment), in addition to social distancing and public quarantine measures. 10 Community pharmacists (or retail pharmacists as they are known in some countries) have a crucial role to play during pandemics. 11, 12 One of the most important role of community pharmacists is to ensure the availability of effective therapy, in addition to health education and health promotion activities and vaccination provision. [13] [14] [15] [16] Moreover, community pharmacists need to engage with patients, providing them with counseling regarding the safety precautions to minimize exposure and infection probabilities as well as psychological and mental health support during a pandemic. Pharmacists would be expected to support general health care teams in infection prevention, as well as alerting public health officials of potential outbreaks/cases. 17, 18 During pandemics pharmacists' role in managing minor ailments increases as doctors and hospitals become overwhelmed. 17 This article is protected by copyright. All rights reserved directives for pandemics, pharmacists' awareness (a state wherein a subject is aware of some information when that information is directly available to bring to bear in the direction of a wide range of behavioral actions) 24 and perspectives around roles during pandemics in different regions of the world need to be assessed. In light of the repeated pandemic experiences in the MENA region, the aim of this study, therefore, was to assess the awareness of COVID-19 amongst pharmacists from countries located in the MENA region and to assess their perspectives of their role, barriers, and roles of the educational institutions (e.g. universities) and pharmaceutical associations (e.g. Pharmacists Syndicate) in preparing them to be able to deal with the pandemic. This study was conducted from the 12 th of April to the 22 nd of April 2020 over 10 days during the COVID-19 outbreak and public quarantine in most of the Arabic-speaking countries located in the MENA region including Egypt, East Mediterranean countries which included five Arabic-speaking countries (Jordan, Palestine, Syria, Iraq, and Lebanon), North Africa including Algeria, Libya, Morocco, Tunisia, Mauritania, the Gulf countries including Saudi Arabia (KSA), United Arab Emirates (UAE), Qatar, Kuwait, Oman, Bahrain, and other Arab countries (Yemen, Sudan, Somalia, Djibouti, Comoros). A descriptive cross-sectional study design (an online survey) was used to address the study objectives. The research team (IB and co-investigators) developed an online survey (based on the current information regarding the COVID-19 1, 5, 6, 9, 11, 17, 18 , in order to meet the study objectives which included assessing Arab speaking countries in the MENA region pharmacists': a) readiness to combat any pandemic with a focus on the COVID-19 pandemic, assessing their clinical awareness, and b) views on the role of the pharmacy educators/educational institutes/pharmaceutical associations (e.g. universities and Pharmacists Syndicate, respectively) in preparing future pharmacists to deal with pandemics and the COVID-19 specifically. Any licensed pharmacist or enrolled pharmacy student in the Arab speaking countries in the MENA region (community or hospital pharmacist, academic, industry based pharmacist, etc.) was deemed eligible for participation in the study. No risk was posed to the participants' and their participation was This article is protected by copyright. All rights reserved voluntary. The research team considered completing the survey as informed consent by pharmacists for participating in this study. Ethics approval was obtained from the Faculty of Pharmacy, Applied Science Private University, Jordan. An extensive review of the literature was conducted to provide the needed information for the development of the items included within this survey. 11 The survey was administered in the Arabic language (common across the MENA region). A variety of questions relevant to the study objectives, were also sourced from many avenues that the research team had (e.g. FIP/WHO documents). The research team revised the survey in order to eliminate duplicates and refine question. The team further checked for local context and the aptness of language (slight regional variations in nuanced meanings of words). In order to ensure survey face validity, six expert academics in pharmacy practice and education were requested to evaluate the first draft. A pretest for the survey was conducted and necessary refinements were made. The pretest included evaluating the survey from different aspects such as the wording and the clarity of the questions and whether each question is relevant for inclusion with respect to the study objectives. As a final point in the survey development, the research team re-examined each question and made sure that the survey was suitable for online administration (relevance, clarity, context, response categories, format and layout). The final version (contained 60 questions; Appendix 1) of the survey was organized into five main sections that address several topics of interest. The first section included items aimed at collecting participant's demographic data. The latter four sections included several items relevant to the study objectives ( Figure 1 ). Countries of the participants were grouped into geographic clusters (regions) that are: East Mediterranean countries and Iraq, Egypt, North Africa, Gulf countries, and other Arab countries. Social media (Facebook and WhatsApp) was used to recruit the participants. An invitation was sent to all pharmacists in Jordan via the social media. Those willing to consider participation could open a link to initially view ethics committee approved information about the study and then proceeding to This article is protected by copyright. All rights reserved the survey. The survey questions could be completed within an average of 10 minutes. Participants were able to view the ethics committee approval and the information about the purpose of the survey and what participation entailed before completing the survey. The COVID-19 statistics of cases and deaths announced at the beginning and around the end of the study period (12 th to 22 nd of April 2020) for the countries which had at least one confirmed case at the beginning of the study were collected from the WHO Coronavirus Disease (COVID-19) Dashboard. Sample size calculation was performed using the following formula: n = P × (100 -P) × z2/d2. Where P is the anticipated awareness score percent, d is the desired precision, z is the appropriate value from the normal distribution for the desired confidence interval. Using 95% confidence levels, 5% precision level and an anticipated 50% proportion of participants receiving an appropriate score (this conservative value results in the highest possible sample size that can be used in this study, as no previous studies in this area where found to indicate level of awareness), a sample size of 385 was required. Following data collection, the survey responses were coded and entered into a customized database using the Statistical Package for the Social Sciences (SPSS), Version 24.0 (IBM Corp., Armonk, New York, USA). Descriptive results were presented as means and standard deviations for continuous variables and percentages for qualitative variables. A one-way ANOVA test was performed to analyze regional differences in perception scores. All tests were two-tailed. A P-value of <0.05 was considered statistically significant. Pearson's correlation between awareness score (out of 20) and the COVID-19 statistics of cases and deaths announced at the beginning and end of the study period (12 th to 22 nd of April 2020) for the countries which had at least one case at the beginning of the study was also conducted. Linear regression was used to screen for the factors affecting participants' awareness score about coronavirus pandemic versus chosen independent variables in the study , i.e. age, area of residency This article is protected by copyright. All rights reserved Study included 2,589 participants with a mean age of 29.3 (8.2) years, and the majority were females (n= 1329, 51.5%) as shown in Table 1 . Most of the participants were from Egypt (n= 819, 40.8%), followed by Jordan (n= 274, 13.7%), Algeria (n= 258, 12.9%), and Syria (n= 184, 9.2%). More than 80% of the participants lived in urban areas (including capital cities). About 75% of the participants had, as a highest level of pharmacy education, either a bachelor degree in pharmacy or Pharm.D., while the rest were either pharmacy students or technicians, or they had received other post-graduate degrees. The majority were alumni of public universities (75.7%). More than half of the participants were working either in community pharmacy or in hospital, years of work-experience tended to be short, i.e. less than and up to 5 years, and the number of attended professional development workshops was low on average. While only 30% of the participants had received enough education about pandemics and updates about coronavirus management, 91.2% of them do follow the latest coronavirus updates on the management. Results were almost similar across all regions ( Figure 2 ). As for the sources of information about coronavirus management among the study participants, 60.8% reported that they This article is protected by copyright. All rights reserved sourced their information from social media, followed by WHO reports (57.2%), and published articles (50.2%) as shown in Figure 3 . Awareness scores (out of 20) were very similar across regions (Table 2) , with a mean of 13.9 (out of a maximum of 20), no statistically significant difference was found between the regions (n= 2589, p= 0.193, one way ANOVA). A significant correlation between awareness scores across study countries was found (p= 0.026, Pearson correlation= -0.054) with the COVID-19 mortality statistics as they stood on the 15 th of March 2020 for the countries which had at least one case at the beginning of the study. 25 Awareness score was higher in countries with lower mortality. No significant correlation was noted with other statistics of COVID-19 cases and deaths as they stood 15 th of March, and 1 st and 15 th of April 2020. Table 3 presents the total percentage and the percentages of participants from the participating countries answering each of the awareness statements correctly. Interestingly, univariate analysis of the awareness score versus chosen independent variables showed significant association with many variables. This was reflected in the linear regression results, where older age participants, graduates of public universities, higher annual attendance rates at professional workshops yearly, participants who practice in community pharmacy and hospital settings, participants who reported to have had previous knowledge from their graduating institute, participants who sourced their information about COVID-19 from published studies, and those who were highly satisfied with their knowledge after 4 months of COVID-19 had higher knowledge scores (Table 4 ). More than 90% of participants agreed with the statements provided regarding the role of the educational institutes (pharmaceutical faculties) expect for the statement 'Your faculty/educational institute has a role in preparing you to deal with any pandemic' (74.8%). As for the role of the pharmaceutical associations, more than 90% of pharmacists agreed with the statements provided except for 'The pharmacists associations and societies (e.g. Pharmacists Syndicate) have a role in preparing you to deal with pandemics such as the coronavirus' (63.6%). More than 80% of participants agreed with the statements provided regarding their role as pharmacists with the highest percentage being about the statement 'If you suspect someone may have coronavirus, you know how to seek immediate medical attention' (97.2%) followed by the statement 'You ensure your personal safety by wearing gloves and masks and avoid close contact with patients' (97.1%). Significant This article is protected by copyright. All rights reserved differences were seen regarding the regional distribution of study participants' perceptions about the current role of the faculties of pharmacies/educational institutes with regards to dealing with pandemics and coronavirus specifically (n= 1998), while no significant differences were seen with regards to perceptions about the current role of pharmacists' associations and societies and current role of pharmacists ( Figure 4 , Table 5 ). Most pharmacists believed that working in the pharmacy increases their fears from getting infected with the coronavirus (n= 2131, 82.3% strongly agree/agree). Significant differences found between regions (p= 0.009). In addition, participants believed that they should receive training programs on how to provide mental health support for people during epidemic and pandemic outbreaks (n= 2257, 87.7% strongly agree/agree) with no significant difference found between the regions (p= 0.426). Nowadays, the world is facing a predatory pandemic infection caused by the COVID-19 requiring a concerted effort by health care professionals and public health experts to contain the rate of infection and the havoc it wreaks. Pharmacists, as essential health service providers, are important in the management and control of COVID-19 16, 26, 27 . Hearteningly, the results of this survey indicated that pharmacists in the Arab speaking countries in the MENA region have good awareness about the COVID-19 and acknowledge the different roles they can play during these times. Further, this study revealed that pharmacists are aware of the important responsibilities of the different educational faculties/educational institutes and pharmaceutical associations in preparing them to take on their roles during pandemics. Barriers impeding pharmacists from acting to their full potential were also explored, with fear from contracting the virus while performing their duty emerging as an important barrier that requires resolution. One of the unique features of the results of this study is that it included participants from various countries covering many Arabic-speaking populations located in the MENA region. Data and results presented in this manuscript were clustered into East Mediterranean countries, North Africa, Gulf countries, Egypt, and other Arab countries. Of noteworthy, Egypt was presented alone here, and not within the North African countries for two main reasons. Egypt has the largest population (a population of 95, 689, 000) among the Arabic-speaking countries, 28 and hence the largest proportion Accepted Article of participants included in this study came from Egypt. Secondly, although Egypt is a country geographically located in North Africa, it has not been classified as one of the North African Arabicspeaking countries; these countries have their own council within the Arab League, with Egypt not being included. 29 The source of information gathered by healthcare professionals is important as it can affect clinical practice. The results of this study illustrated that more than 90% of the pharmacists monitor closely COVID-19 news, with the major sources of information being social media, WHO reports, and Many medications for the management and treatment of the coronavirus have been discussed within the media/social media. Chloroquine and Hydroxychloroquine for example have been frequently mentioned as potential treatments for the virus. In this study, 35% of the pharmacists reported that these medications can be used not only for treatment but for the prevention of the virus. Given that there is no evidence supporting their use, this belief is disturbing. Currently more than 140 clinical trials to test the COVID-19 efficacy of these medications alone or in combination with other medications, such as the antibiotic Azithromycin, have been registered worldwide to explore their use as treatment/prevention options for COVID-19. 32 However, on the 24 th of April 2020, the United States Food and Drug Administration (FDA) issued a warning on the use of Chloroquine and Hydroxychloroquine for treating COVID-19. 33 The warning was due to reports of serious cardiac rhythm problems associated with the use of these medications particularly in combination with Azithromycin, causing QT interval prolongation, a measure of delayed ventricular repolarization. 34 As another example, the majority of the study participants concurred that the use of Non-Steroidal This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved Administration (JFDA) allowed community pharmacists and hospitals to provide free delivery of medications to patients' homes. Before the COVID-19, this practice was not allowed by the local laws, 41 which is the case in most countries in the MENA region. The majority of participants in this study were willing to deliver medicines to patients' homes. This provides an example of an effective service that can be successfully delivered everywhere if the safety of pharmacists from COVID-19 was guaranteed. Social media was employed in the conduct of this study, which facilitated a large and rapid collection of sample size from numerous countries in the MENA region. It is of note that a significant correlation between pharmacists' awareness across the countries included in this study and the COVID-19 statistics of cases and deaths was found. This may indicate that countries with people (hence pharmacists) of higher awareness are likely to end with lower numbers of COVID-19 cases. The fact that this study was conducted via an online survey brings limitations just as it brought strengths. Such sampling technique led to a convenience sample which is a type of non-probability sampling that allows for data collection from a group of people easy to contact and/or reach. 42 Such approach may introduce sampling bias, as pharmacists who use social media more frequently had a better chance to participate in this study, giving results which may not be representative of all of the pharmacists groups in the Arab speaking countries in the MENA region. 43 Although the questionnaire was sent to pharmacists only, it was difficult to ensure that all participants were pharmacist oriented; this might explain the relatively young age of the study participants, as men and older individuals are generally known to be underrepresented on social media. 43 Pharmacy students who participated in this study did not report their year of study, which can unveil useful information if indicated. Fifth-year students for example are expected to have different awareness levels compared to first and second-year students. Finally, although the survey was not completely validated (construct validity was not conducted), the items incorporated in it were done in real-time, based on the literature and reviews of a team of clinical pharmacy specialists. This article is protected by copyright. All rights reserved Pharmacists from the Arab speaking countries in the MENA region believed that they got enough education previously about pandemics, and the majority follow on the latest coronavirus updates on treatments mostly from social media followed by the World Health Organization reports and Specific contributions of each contributor to the paper: All authors were involved in all parts of study and manuscript preparation including literature search, study design, analysis of data, manuscript preparation, and review of manuscript. What is a pandemic? 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