Introduction

The scope of the pharmacy profession has recently evolved as a result of pharmacists working in close contact with patients [1]. Previous evidence supported the invaluable role of community pharmacists in providing patient care in a variety of settings, including identifying issues related to drug therapy, patient counseling, and improving patients’ quality of life [2–5].

Extended community pharmacy services (ECPS) refer to additional healthcare services that pharmacists can offer to their patients beyond the traditional dispensing of medications [6,7]. ECPS are becoming increasingly important as pharmacists play a larger role in providing various services related to primary patient care, such as medication therapy management, patient counseling, chronic disease management, smoking cessation programs, and point-of-care testing such as blood glucose or blood cholesterol testing [8]. A previous study found that the general population in Ethiopia had a high acceptance rate of various ECPS, such as blood pressure, blood glucose, and lipid level measurements. The participants reported several reasons for their positive response, including the lack of need for appointments, shorter waiting times compared to primary care centers, and the convenience of proximity to their residences [6]. These services can help improve patient outcomes, reduce healthcare costs, and enhance the overall quality of care [9]. In addition to patients, pharmacists can also profit from ECPS in a variety of ways, such as by improving their professional standing and sense of fulfillment in their line of work. However, it might result in a heavier burden for pharmacists and a potentially tense working relationship with physicians [10]. A systematic review found that pharmaceutical care services and healthcare promotion services were the most frequently provided ECPS, with both pharmacists and the public holding positive perceptions towards them. However, challenges such as a lack of time and staff shortages hinder the implementation of these services [11].

In developed countries like the USA, community pharmacists showed wide practice of ECPS, where they have the permission to administer vaccines, prescribe medications for some chronic diseases, perform laboratory testing, and create care plans [12]. In comparison, ECPS in developing countries is not well-practiced [10]. ECPS are either infrequently employed or not employed at all in the United Arab Emirates (UAE) and a number of other Arab nations that share almost the same community pharmacy practice scenario [10]. According to a study conducted in Saudi Arabia, most of the pharmacists have never provided ECPS, including health screening services, vaccination services, and medication therapy management services [13]. Researchers in the UAE discovered that the influence of pharmacists on pharmaceutical practice was limited, with only 9.2% of them showing a positive response to reducing prescribing errors and identifying drug-related problems [14]. In spite of the general public’s positive perspectives and strong beliefs on the importance of ECPS provision [15], several variables were found to affect the implementation of these services, such as pharmacists’ age, years of experience, lack of interest or urgency on the part of the patients, time constraints, unclear understanding of the pharmacists’ professional role, communication barriers, and lack of financial benefits[14]. Therefore, it is crucial to investigate pharmacists’ perceptions and willingness to provide such services in the presence of many obstacles to their implementation, because positive views and high readiness towards ECPS will enhance the provision of these services.

In addition to the paucity of research findings, the present research is the first to evaluate pharmacists’ attitudes and willingness to provide ECPS, to assess the barriers to ECPS implementation, and to explore the factors associated with a lower attitude and willingness to implement such services in the UAE. The findings of this study should aid in the development of coordinated approaches from all stakeholders, including the government, healthcare providers, and patients, to surmount the obstacles that stand in the way of ECPS implementation.

Materials and methods

Results

The present study enrolled 409 pharmacists with a median age of 27 (27–28) years. The majority of the pharmacists were female (78.2%), had a pharmacy degree (80.9%), were working in independent pharmacies (80.5%) and had an internet connection (95.8%). The median for work experience was 3 years (3–4), and the average number of visiting patients was 35 (35–40). Table 1 describes the sociodemographic characteristics of the participating pharmacists.

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Table 1. Sociodemographic characteristics of the participating pharmacists (n = 409).

https://doi.org/10.1371/journal.pone.0310141.t001

The median of the attitude’s score was 36 (36–37) out of the maximum possible score of 55. Hence, 240 (58.7%) of the enrolled participants were in the low attitude group, and 169 (41.3%) were in the high attitude group. More than three-quarters of the participants strongly agreed or agreed that ECPS might generate extra revenue (81.1%) and require major upskilling of clinical knowledge (77.7%). On the other hand, a very small number of pharmacists strongly disagreed or disagreed that doctors and other health professionals will not support an ECPS role for pharmacists (7.8%), and that pharmacy education never provided them with the skills needed for ECPS (15.6%). Participants’ responses to the attitudes toward implementing ECPS’s are presented in Table 2.

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Table 2. Pharmacists’ attitude toward implementing ECPS (n = 409).

https://doi.org/10.1371/journal.pone.0310141.t002

The median of the willingness score was five (5–6) out of the maximum possible score of six. Thus, 243 (59.4%) of the participants were in the low willingness group, and 166 (40.6%) were in the high willingness group. The participants demonstrated the highest willingness to measure blood pressure (96.6%), followed by blood sugar testing (94.1%), ear piercing (86.6%), calculating body mass index (71.4%), and pregnancy testing (69.7%), while they were least willing to do body fat analysis (52.6%).

Results of the bivariate analysis using the Chi-squared and Mann-Whitney U-test revealed that variables including sex, average number of daily-dispensed prescriptions, number of pharmacists, and the education background had a P value < 0.2 and therefore were included in the bivariate logistic regression analysis.

As shown in Table 3, the results of the binary logistic regression analysis showed that females had fewer odds of having a positive attitude towards ECPS (OR = 0.425, 95%CI:0.242–0.747). A higher number of daily prescriptions (OR = 1.066, 95%CI: 1.029–1.105) and being a Pharm D graduate (OR = 2.664, 95%CI: 1.439–4.932) increased the odds of having a high willingness to provide ECPS. On the other hand, an increased number of employed pharmacists decreased the odds of willingness to provide ECPS (OR = 0.518, 95%CI: 0.397–0.676).

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Table 3. Factors associated with attitude towards ECPS and the willingness for its implementation.

https://doi.org/10.1371/journal.pone.0310141.t003

As shown in Table 4, the most recognized barriers to the implementation of ECPS were that patients are usually busy (76.5%), a lack of specific training (76.3%), a lack of clinical problem-solving skills (74.6%), and a lack of a private consultation room (74.6%).

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Table 4. Barriers to implement ECPS (n = 409).

https://doi.org/10.1371/journal.pone.0310141.t004

Discussion

Numerous professional organizations for pharmacists are working to improve the quality of patient-centered care provided by community pharmacies globally [19,20]. One of the best approaches for the advancement of community pharmacy practice is the establishment of ECPS [21]. However, it is imperative to examine how pharmacists perceive and are willing to offer these services, as well as the obstacles and variables preventing their implementation, which was the main purpose of this study.

Most of the current study participants showed unsatisfactory levels of attitudes and willingness towards ECPS implementation, with several identified barriers. Female gender was significantly associated with a negative attitude, whereas a lower number of daily prescriptions, having a pharmacy degree, and a higher number of employed pharmacists significantly reduced the willingness to provide ECPS.

When compared with the present study, earlier research findings reported a better attitude among community pharmacists in this regard [16,17,22,23]. Although the majority of the current study participants perceived that ECPS could be used to generate extra revenue, they believed that healthcare providers would not support the ECPS role of pharmacists. In comparison, more pharmacists who were enrolled in an earlier study disagreed with this statement [17]. Furthermore, most of the participants in the current study thought that ECPS requires major upskilling of clinical knowledge (77.7%), and that pharmacy education never provided them with the skills needed for ECPS (84.4%). In comparison, 87.7% of the pharmacists who took part in an earlier study acknowledged that ECPS needs upskilling in clinical knowledge. Nonetheless, only 25.6% thought they had never acquired the skills necessary for ECPS during their pharmacy education [17]. These findings clearly demonstrate the need for targeted interventions to enhance pharmacists’ attitudes toward expanding their services, especially when considering the assistance of other healthcare providers and the requirement for clinical knowledge upskilling. It is deemed necessary to support pharmacists’ collaboration with other healthcare professionals in order to establish a welcoming atmosphere for ECPS. It is also crucial to design and implement continuing education initiatives that give pharmacists advanced clinical knowledge related to ECPS, thus bridging the knowledge gap that exists between present education and the skills for expanded roles.

The present study found that females had a significantly lower attitude toward ECPS than males. Female pharmacists tend to perform more domestic caregiving duties and have less time to dedicate to ECPS. Hence, their attitudes toward ECPS may be influenced by the notion that this service will necessitate more time and effort, potentially affecting their work-life balance.

The majority of the current study participants expressed a low willingness to implement ECPS. On the other hand, several other studies reported a high willingness to provide ECPS among community pharmacists [17,24]. Although more than 90% of the participants in our study showed a high willingness to perform blood pressure measurement and blood glucose testing, only 52.6% were willing to conduct body fat analysis. Similar results were found in an earlier study [17]. Previous literature reported that most communities support the introduction of the extended roles of community pharmacists and the provision of ECPS [6,25–27].

Results revealed that pharmacists who handled more prescriptions and those who worked with fewer pharmacy staff showed a noticeably higher willingness to provide ECPS. Given their heavy workload and the wide range of cases they encounter daily, it is feasible that such pharmacists developed awareness of patients’ interests and what benefits their health. Thus, regardless of the number of prescriptions, pharmacists might be more willing to provide ECPS because they may be more conscious of its benefits and more confident in their ability to provide it. Additionally, a smaller workforce at the pharmacy might have led to pharmacists taking on more duties and developing a stronger sense of obligation to serve the community, which would have increased their willingness to implement ECPS.

Pharm D graduates demonstrated a higher willingness to provide ECPS than B Pharm holders in this study. Pharm D graduates typically receive more extensive training in clinical pharmacy practice, patient counseling, and pharmacotherapy management than pharmacists with a Bachelor of Pharmacy degree [28]. Thus, the increased willingness to provide extended services may be due to the expanded scope of practice that is inherent in the Pharm D curriculum because Pharm D programs place a greater emphasis on patient care and inter-professional collaboration, which may encourage graduates to seek out opportunities to provide a higher level of care to patients.

In the current study, the most commonly recognized barriers to the implementation of ECPS were patients’ preoccupation, a lack of specific training, a lack of clinical problem-solving skills, and a lack of a private consultation room. A previous study reported that lack of time by customers to interact with the pharmacist was the barrier to providing health-promotion and preventive services in community pharmacies [29]. A systematic review reported that lack of knowledge, skills, and time were the most common barriers to performing ECPS [8]. In Pakistan, even though the majority of the participants were unaware of pharmaceutical care, they were willing to accept a change in practice if given the necessary knowledge and training [16]. Pharmacists’ concerns about the availability of pharmacy consultation rooms were reported as a barrier to the provision of ECPS in another review [30]. Lack of a counseling space was also identified as a barrier in other studies conducted in Canada [29], South Africa [31], Malaysia [32,33], and Jordan [34].

The current study has some limitations. The cross-sectional study design cannot confirm the cause-and-effect relationship. Furthermore, the use of the self-report method used in the study survey may expose the results to social-desirability bias.

Conclusions

Pharmacists’ attitudes and willingness to provide ECPS need improvement, and there are several barriers to overcome. Hence, it is advisable to implement training and educational programs that improve clinical problem-solving skills and fill the gap in unsatisfactory pharmacy education. Establishing private consultation rooms in pharmacies is also advised in order to support private patient-pharmacist interactions, which are crucial for the efficient administration of ECPS. When putting these strategies into practice, special attention should be paid to female pharmacists, those who have fewer daily prescriptions, bachelor’s pharmacy holders, and pharmacists working in pharmacies with a higher number of employed pharmacists.

Acknowledgments

The authors wish to thank all the people who completed the present study survey.