Study design and participants

This cross-sectional survey was conducted among CPs in all 14 states of Malaysia between November 2021 to July 2022. Using Raosoft calculation, the target sample size is 343, with a ±5% margin of error and a confidence level of 95% [17]. Calculated sample size is based on the latest number of registered community pharmacists in the country which is 3078. This information was obtained from website of Pharmacy Division, Ministry of Health, Malaysia [18]. The self-administered survey was conducted online via Google Form and shared in relevant groups involving CPs on Facebook, Whatsapp and Telegram platforms. Several strategies were used to reach as many respondents as possible from all states of Malaysia and from all types of pharmacy, either chain or independent pharmacy. Professional and personal networks of the researchers was used to reach the pharmacy’s association leaders to disseminate the survey. Only the first and corresponding authors have access to the information of the participants. The inclusion criteria of the study include CPs practicing in Malaysia either as full-time, part-time or locum, registered with the Pharmacy Board of Malaysia and owned a License A. License A holder is a license given to the registered pharmacist to import, store and manage all medications by retail or retail and wholesale. Written consent was obtained at the initial part of the questionnaire, prior to answering the first section of the questionnaire. CPs who were unable to grant consent to participate in the study or who were training pharmacists (known as Provisionally Registered Pharmacists (PRP) throughout the study were excluded.

Study instrument

The questionnaire was adapted from El Hajj and colleagues who had used the questionnaire and conducted the study in Qatar [19]. Permission had been granted for the questionnaire to be used in this study. For face and content validity, the first version of the adapted questionnaire was reviewed by two academicians withestablished background in CVD research in community pharmacy, and two community pharmacists. The content validity and clarity of the questions were reviewed. The questionnaire was then pilot tested among 20 community pharmacists for further improvement. The Cronbach alpha determined for each subscale was as follows CVD involvement subscale (Cronbach alpha = 0.851), dyslipidemia involvement subscale (Cronbach alpha = 0.92), perceived barriers subscale (Cronbach alpha = 0.548), and finally contents of educational materials subscale (Cronbach alpha = 0.792)Other than measuring the Cronbach–alpha, the participants from the pilot study were requested to provide feedback on the questionnaire’s face and content validity, the appropriateness of the response alternatives, whether any items needed to be updated, removed, or added, and how the survey’s layout could be improved. Questions relevance, necessity and clarity were reviewed thoroughly. Modifications were made based on the feedback given. The questionnaire was then distributed using Google Form by convenience sampling method.

The final structured questionnaire consisted of 5 separate sections. Only respondents who consented to participate in this study were involved. Section 1 is the sociodemographic data of the respondents. Relevant data was asked in this section especially pertaining to the pharmacy’s information and the CP’s background. Section 2 was aimed to determine the current involvement of CPs in CVD-related health promotion activities. The CPs were asked to rate their current involvement using a Likert scale (Never, Rarely, Often, Always). In addition to that, in section 3, the CPs were asked on how often they offer dyslipidemia care services. In order to determine the factors influencing the CVD health promotional activities with dyslipidemia care services, for section 2 and 3, a scoring method was done where the participants will be scored with ‘0’ for ‘never’, ‘1’ for ‘rarely’, ‘2’ for ‘often’ and ‘3’ for always. The total score will be added including all statements/questions for that section. The perceived barriers were also identified in section 4. This is done by listing all possible barriers that may be encountered by the CPs and they may choose more than one option. Finally, in section 5, CPs were asked to choose the contents of educational materials which they think appropriate to be included.

Data analysis

The statistical analysis in this study was done using IBM® Statistical Package for Social Science (SPSS) version 28. Descriptive statistics was used where the socio-demographic and practice characteristics were summarized using frequency distribution except for age where the mean and standard deviation were used. The score of CVD related-health promotion activities was quoted as total CVD score and total of dyslipidemia practice was quoted as total dyslipidemia score. The CVD and dyslipidemia scores were added to generate a total score for each respondent, respectively. The scores were then further analysed for normality. Both Kolmogorov-Smirnov and Shapiro-Wilk test yield p-value less than 0.05, which indicate that the total CVD and dyslipidemia scores were not normally distributed. Non-parametric tests consisting of Mann-Whitney U test and Kruskal-Wallis test were conducted to determine the significance differences from the demographic characteristics such as gender, mode of practice, ethnicity, location of pharmacy, years of practice, total number of staffs available, completion of dyslipidemia training, background of family members and finally interest in having dyslipidemia training. Meanwhile, for age, Spearman correlation was used. P-value less than 0.05 was considered significance. Significance values (p-value <0.05) showing differences between groups were also extracted. No replacements were made for the missing data. For perceived barriers and contents of educational materials, data were analyzed descriptively using percentage and frequency.

Patient counselling

For CVD-related health promotion activities, our study reported that CPs exhibited satisfactory practice in providing counselling. However, this provision of counselling was done without the usage of any educational materials. This is consistent to barriers perceived by CPs in which a lack of CVD-related educational materials was reported as the second highest barrier. From this study, it can be assumed that the CPs are using their own materials or did not use any educational materials to ensure the effectiveness of the counselling. This finding then serves as an opportunity to explore the comprehension of patients to the counselling provided by the CPs. When patients can comprehend and grasp the information, it will enable them to improve their adherence towards the recommendations provided. The opportunity for educational materials is discussed further in the perceived barriers section below.

Risk assessment

For CVD-related promotional activities, the majority of CPs did not use any cardiac risk assessment tool or provide patients with the risk assessment tool to be explored by themselves. Similarly, in dyslipidemia care services, most of the CPs were reported to never or rarely analyse the lipid profile once it is outside the targeted range. Nevertheless, majority of CPs reported being frequently involved in screening patients’ CVD risk factors such as hypertension and dyslipidemia. This might be due to the availability of a fully automated sphygmomanometer and a point-of-care cholesterol testing device on the premise. This practice is aligned with World Health Organization which recommends early detection and management of people who are at high risk of developing CVD [20]. To measure and control cardiovascular risk, it is necessary to establish and advocate highly accessible screening programmes implemented in the community settings.

Upon providing recommendations for prevention and therapy, it is recommended to have a precise estimate of the absolute risk of experiencing a first CVD incident using instruments like the Framingham Risk Score [21]. Although the Framingham Risk Score is available in the national guideline for CVD and dyslipidemia, the practice of using the risk assessment tool is still found to be lacking. This might be due to the fact that CPs in Malaysia did not receive appropriate training to perform the risk assessment. Improved knowledge and skills are expected after the provision of training or any educational programme. This is supported by a study conducted in 2020 by Zolezzi and colleagues, who conducted a workshop series to educate CPs about CVD risk assessment measures. At the end of their study, the authors concluded that the educational programme had successfully improved CPs’ knowledge and skills related to CVD [21].

Collaborative care

For the perceived barriers, almost half of the CPs agreed that there is a lack of communication with other healthcare providers. As communication is an integral part of collaborative care, this can be interpreted as current interdisciplinary teamwork among healthcare professionals in the private sector is still weak. This might be due to several challenges encountered by healthcare professionals to work collaboratively. The collaboration of healthcare experts in diverse locations, such as private clinics and community pharmacies, can be challenging. However, this situation is different in the hospital setting, where efficient communication has been observed to happen regularly in Malaysia. This could be because all departments are contained within one healthcare institution by nature, and all patient information is computerized and centralized.

Collaborative care in treating patients with cardiovascular disease offers a multifaceted approach that significantly offers benefit and enhances patient outcomes. A recent systematic review revealed a successful impact of such intervention on patients’ psychosocial or cognitive component of mental health status. Along with the cholesterol levels, the behavioural outcomes of caloric intake and physical activity also significantly improved in studies practising collaborative care approach [22].

Collaborative care landscape is still evolving to address the healthcare needs of patients with dyslipidemia. Unfortunately, a study conducted by Mubarak et al. (2019), asserted that general practitioners and CPs collaborate the least in Malaysia [23]. To navigate this issue, the readiness of healthcare professionals should be examined further. A study was conducted by Roslan et al., regarding the perception from medical doctors about collaborative care [24]. The participants of the study agreed that collaboration is key to ensuring both the best possible health outcomes for patients and the well-being of medical personnel [30]. Several participants also suggested that medical doctors should exhibit attributes of strong leadership, good communication and outstanding behaviours when working together with other health professionals [24].

Perceived barriers to providing cardiovascular diseases prevention services

Limitations

There are several limitations in this study. Firstly, the data collected was based on self-reports by CPs which may lead to social desirability bias. Secondly, the number of respondents from each region is not similar due to the heterogenicity of the number of community pharmacies available. West region comprising W.P Kuala Lumpur, Selangor and W.P Putrajaya have more community pharmacies in comparison to other regions. Nevertheless, this study managed to include sufficient representatives from all the 14 states in Malaysia. To the best of our knowledge, this is the first study conducted in Malaysia to determine the practice and perceived barriers faced by CPs in the provision of CVD-related promotional activity and dyslipidemia services. Future qualitative studies are highly recommended to explore any other issues or problems that occur in the setting. This will also enable the problems identified such as lack of manpower, lack of training and educational materials or other possible problems to be solved from the root causes.