Study design

The study utilised a quantitative cross-sectional survey to satisfy the study objectives. Quantitative research is based on positivist philosophical underpinnings. Positivism asserts that there is a single reality applicable in different settings and that reality can be influenced by other factors (independent variables) that can be modified to control reality [16]. The authors identified the roles of Lesotho community pharmacists in preventing and controlling CVDs utilising a qualitative interview of a convenient sample size [17]. The researchers found a quantitative study approach a suitable method to determine the level of involvement of and factors influencing community pharmacists’ provision of services to CVD patients.

Study setting

Lesotho is a small land-locked country in Sub-Saharan Africa with a population of approximately 2 million people [18]. Geographically, Lesotho comprises mostly plateaus, hills, mountains (highlands), and lowlands where the capital city (Maseru) is located. Administratively, the country is divided into 10 districts. The majority of community pharmacies (90%) are established in four districts in the lowlands, namely, Maseru, Berea, Mafeteng, and Leribe [8]. The population of people living in these four districts is estimated at 1.3 million people (65% of the national population) [19]. The study included community pharmacies based in the Maseru, Berea, Mafeteng, and Leribe districts.

Participant recruitment and sampling

A database of community pharmacies and responsible registered pharmacists was obtained from the Ministry of Health of Lesotho. The study population was pharmacists working in community pharmacies in Maseru, Mafeteng, Leribe, and Berea districts who were registered with Lesotho Medical, Dental, and Pharmacy Council and had at least 6 months of community pharmacy experience. Records showed that there were 71 community pharmacies registered with the Ministry of Health of Lesotho across the four districts in 2022. The minimum sample size was calculated using a standard formula for a known population size for a cross-sectional study (Ellen, 2012): where:

n = sample size of the target study population

N = total number of target population

e = error margin (at 0.05)

n = 71/(1+71(0.05)²)

= 60 participants.

Previous community pharmacy surveys reported a response rate of 44% in Iran, 83% in Lesotho, and 94% in Ethiopia [20–22]. Therefore, the authors included all 71 community pharmacies to accommodate non-response. This approach is supported by literature that advises a census sample size when the population size is less than 200 [23]. All 71 community pharmacists were considered to participate in the survey because of the small population size. A convenient sample of community pharmacists willing and available to participate in the study during a 5-month data collection period (March to July 2023) was realised [24]. For invitations to participate in the study, emails were sent to all 71 community pharmacists, followed by a phone call. Upon acceptance of the invitation, participants were requested to sign an informed consent form and to facilitate the signing of a gatekeeper’s agreement by the pharmacy owners.

Inclusion and exclusion criteria

The study participants were community pharmacists who had at least 6 months of community pharmacy experience, working on a full-time or part-time contractual terms at a community pharmacy recognised by Lesotho’s Ministry of Health, and registered with Lesotho Medical, Dental, and Pharmacy Council (according to the Ministry of Health community pharmacy database). Community pharmacists who were pharmacy owners but were not directly working in the front shop or with patients, pharmacy technicians, non-pharmacy staff, and pharmacy students practising in community pharmacies were excluded from participating in the study, as well as community pharmacists who were not willing to participate.

Data collection

A self-administered, semi-structured questionnaire was developed guided by Theory of Planned Behaviour (TPB) constructs [25]. The researchers utilized findings of a previous qualitative survey of Lesotho community pharmacists’ role in preventing and controlling CVDs [17]. A standard Heart Disease Fact Questionnaire was utilised for questions assessing knowledge of CVD risk factors by community pharmacists [26]. The questionnaire was composed of 8 sections and 25 questions covering questions about socio-demographic details and pharmacy settings, involvement of community pharmacists in preventing and controlling CVDs, knowledge of CVD risk factors, barriers and facilitators of health promotion services to CVD patients, community pharmacists’ attitudes and perceptions of their role in preventing and controlling CVDs, cost of health promotion services, and availability of tools. The questions were composed of closed-ended questions, including multiple choice questions, a 5-point Likert scale, true or false, and a binary (available or not available) scale for availability of tools. Other questions, such as the cost of services, were left open-ended. Open-ended responses were coded and grouped into categories. The reliability of the Likert scale was measured using the Cronbach’s alpha coefficient [27]. A Cronbach’s alpha coefficient of ≥0.7 was considered satisfactory [28].The questionnaires were distributed from 01^st March to 30^th July 2023 through email or hand-delivered at the community pharmacies based on the participants’ preferences. To enhance validity, the questionnaire was reviewed and approved by the study team of supervisors (VB) and co-supervisors (KBM, NP, and RP), all of whom have extensive experience in pharmacy, psychology, academics, and research. Both online and paper-based versions of the questionnaire were pilot-tested with a convenience sample of five pharmacists with backgrounds in academic and community pharmacy. Minor modifications were made to enhance the clarity of the questions. The principal investigator (NFM) holds a Bachelor of Pharmacy (honours) and a Master of Technology in Pharmaceutical Sciences degree and is a current Doctor of Philosophy student.

Data analysis

Data were analysed using the International Business Machines Corporation (IBM) Statistical Package for Social Sciences (SPSS) version 26 [29]. Descriptive analysis was performed, and data were presented as distribution frequencies and percentages, mean and standard deviations for each variable, and median for cost of services. An independent sample t-test was performed to calculate the mean differences between the independent variable groups, and p<0.05 was set as a cut-off point for significant differences. The Likert scale results were presented as frequency and frequency percentages for each scale division and the mean and standard deviation. The mean scores for the extent of community pharmacists’ involvement in providing services to CVD patients were further classified as less involved (less than the weighted mean average) and highly involved (equal to or above the weighted mean average). Similarly, the mean scores for the barriers and facilitators were categorised as most common (equal to or above the weighted mean average) (and less common (less than the weighted mean average) relative to the weighted mean average. Community pharmacists ’ knowledge of CVD risk factors was calculated as the proportion of correct responses. "I do not know" responses were regarded as incorrect. Scores <50%, 50%-59%, and ≥70% demonstrated low, moderate, and good knowledge, respectively [30]. Attitudes and perceptions mean scores ≥3 were considered positive attitudes or perceptions, and negative attitudes or perceptions were regarded as mean scores <3 [31].

Data management and storage

NFM captured data into a Microsoft Excel sheet [32] and performed three repeated checks to verify the correctness of captured details against paper-based questionnaires. Data from paper-based questionnaires were merged with data from online questionnaires in a Microsoft Excel sheet. The data were then imported to SPSS. Data were manipulated for consistency of entries. For instance, the currency unit was deleted from the cost of services and the value was left as a computer-readable digit/continuous data. Subjects were removed from the final data analysis if the proportion of missing data was ≥ 10% of the questions [33] or there was no data on the main outcome variable (type of service) or invalid responses (e.g., number of working hours in a week written as (8 am–6 am). While missing data may significantly affect results and their application to a larger population, the literature suggests an acceptable limit ranging from 5% to 10% [Schafer JL., 1999, as cited in 33, 34], while other authors argued that mechanisms and patterns of missing values guide the informed decision on handling the data [35]. Respondents with missing data from other variables were kept because missing data were found to be random (in terms of geographical locations) and less than 10% per variable based on the questionnaire completion criteria. The respondents were de-identified by allocating a code (e.g., CPM001) and removing information such as the name of the pharmacy and email addresses from the paper-based questionnaires. Data were stored in a password-protected computer and lockable metal cabinets for paper-based data.

Ethical considerations

The study’s protocol was approved by the Humanities and Social Sciences Research Ethics Committee of the University of Kwazulu-Natal (Ref: HSSREC/00003205/2021) and the Research and Ethics Committee of the Ministry of Health of Lesotho (Ref: ID101-2021-Renew 01). A study information leaflet was emailed to participants to familiarise themselves with the study contents and their rights as participants. Additionally, the purpose of the study and an outline of the participants’ rights were provided on the introductory page of the questionnaire. All potential participants gave consent before participating in the study by signing a consent form or selecting "yes" to whether they agreed to participate in the study for paper-based and online questionnaires, respectively. Pharmacy owners granted permission by signing a gatekeeper’s agreement. Participation in the study was voluntary and depended on the willingness and availability of the participants.

Sociodemographic characteristics of the participants and pharmacy setting

Only 62 of the 71 targeted community pharmacists were reachable through emails and/or phone calls. Nine emails were undelivered or not responded to, while some phone numbers were unreachable. The unreachable participants were found to be random (in terms of geographical area since other demographic variables were not known to the authors). The unavailable participants were from Maseru (6), Leribe (2) and Mafeteng (1) districts. Therefore, 62 questionnaires were distributed through emails or hand-delivered. Out of the 62 questionnaires, 50 were returned, resulting in an overall response rate of 80.6% (22% online, 78% paper-based). Two paper-based questionnaires were incomplete. These were a male (18–29 years) and a female (30–44 years) community pharmacists operating in Maseru and Leribe respectively. Therefore, 48 respondents were included in the final data analysis.

The socio-demographic details of the respondents and pharmacy operating hours are presented in Table 1 and Fig 1, respectively. More than half of the respondents were males (58.3%, n = 28), dominated by young pharmacists aged 18–29 years (60.4%, n = 29). Many of the respondents had 1 to 4 years of community pharmacy experience, while 10+ years was the least common number of years of experience (12.5%, n = 6). One pharmacist held a postgraduate qualification above the Bachelor of Pharmacy degree. All respondents received a CVD education during their pharmacy training, but the majority (83.3%, n = 38) had never received a related training postgraduate. Full-time employment was the most dominant status (81.2%, n = 39), either as employees (47.9%, n = 23) or pharmacy owners (33.3%, n = 16). Most respondents work for over 45 hours weekly. There was a more comparable representation of pharmacies in urban (43.7%, n = 21) and suburban (50.0%, n = 24) areas compared with rural area (6.3%, n = 3). Most pharmacies were independent stores with daily operating hours ranging from 8 to 12 hours during the week (Fig 1(a)). While 8 am to 6 pm was the most common operating hour, some community pharmacists open as early as 7 am and close late at 7 pm (Fig 1(a)). Most pharmacies operate with one pharmacist (72.9%, n = 35)) and at least one other healthcare professional (54%, n = 26)), with no general assistants (66.7%, n = 32).

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Fig 1. Community pharmacy weekly operating hours.

https://doi.org/10.1371/journal.pone.0314487.g001

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Table 1. Socio-demographic characteristics of respondents (n = 48).

https://doi.org/10.1371/journal.pone.0314487.t001

The extent of involvement of community pharmacists in preventing and controlling CVDs in Lesotho

The extent of community pharmacists’ involvement in preventing and controlling CVDs is presented in Table 2. Fig 2 presents the frequency distribution curve. The reliability of the scale was high, with Cronbach’s alpha = 884, n = 19).

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Fig 2. Distribution of the extent of community pharmacists’ involvement mean scores (Shapiro–Wilk p-value = 0.181).

https://doi.org/10.1371/journal.pone.0314487.g002

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Table 2. Extent of community pharmacists’ involvement in preventing and controlling CVDs and cost of service (n = 48).

https://doi.org/10.1371/journal.pone.0314487.t002

Dispensing

Above 80% of the respondents were either often involved or always involved in dispensing prescription-only and over-the-counter medicine (mean = 4.33±.78 and 4.65±.60, respectively). There were significant differences (t(46) = 3.065, p = 0.004 and t(46) = 2.615, p = 0.012) in the mean scores between community pharmacists who had a weight scale and blood glucose testing device (mean = 4.44±.70 and 4.39±.71) and those who did not have the devices (mean = 3.40±.89 and 3.00±1.41) respectively.

Disease screening

Hypertension and diabetes screening were the most common (mean = 4.38±.73 and 4.17±.91, respectively) screening services. Community pharmacists operating from Maseru (mean = 4.34±0.91) were more motivated to perform diabetes screening than those from other districts (mean = 3.69±.75); (t(46) = 2.308, p = 0.001). The mean scores for the screening of hypertension differed between those who possessed and did not possess a weight scale and a blood glucose testing device (t(46) = 3.498, p = 0.001 and t(46) = 4.341, p<0.001, respectively). Most respondents (62.5%) had never performed cholesterol screening tests, while 56.2% rarely or had never screened patients for undiagnosed CVDs. There were significant differences in the provision of a cholesterol screening and the location of a pharmacy, the number of CVD patients seen daily, the availability of a cholesterol testing device, and the availability of standard treatment guidelines in a pharmacy. Firstly, there was a significant difference between community pharmacists working in urban areas (mean = 2.24±1.45) and those in the suburban and rural areas (mean = 1.44±.80); (t(29) = 2.260, p = 0.031). Secondly, community pharmacists seeing more CVD patients daily (mean = 2.30±1.42) differed significantly from those seeing fewer patients (mean = 1.43±.84); (t(28) = -2.460, p = 0.020). Similarly, the availability of a cholesterol testing device (mean = 3.06±1.06) and the standard treatment guidelines (mean = 1.84±1.21) differed significantly compared to groups with no devices (mean = 1.16±.57) and guidelines (mean = 1.00±.00); t(19) = 6.703, p<0.001 and t(44) = 4.700, p<0.001 respectively.

Other services.

The pharmacists mostly (70.2%) often or always follow up with their patients (mean = 3.87). Similarly, the majority of the respondents showed varying levels (mean = 3.41) of involvement in scheduling appointments with their patients, with 3 out of 46 (6.5%) never providing this service. On the other hand, 50% of respondents (n = 46) showed rarely to no involvement in keeping patient medical databases.

Community pharmacists’ attitudes and perceptions. Community pharmacists’ attitudes and perceptions of their role in preventing and controlling CVDs are presented in Table 3. The constructs were classified according to the TPB constructs: attitude, subjective norms, and perceived behavioural.

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Table 3. Attitudes and perceptions of community pharmacists towards their role in preventing and controlling CVDs (n = 48).

https://doi.org/10.1371/journal.pone.0314487.t003

The attitude scale had a reliability of 0.719. Therefore, all the constructs were analysed as one composite variable. A Shapiro-Wilk test showed a p = 0.039, indicating an asymmetric data distribution. Consequently, a non-parametric Mann Whitney U test was used. The respondents showed a unanimous positive attitude (mean = 4.46(±.39) to questions such as "if I provide health promotion services (such as lifestyle modification) to hypertension patients, I feel that I am doing something positive to the patients" (Table 3). The mean scores for the attitude significantly differed between community pharmacies in Maseru (mean rank = 21.49) and those in other districts (mean rank = 32.62); Z = -2.467, p = 0.014. All constructs showed no significant association with the extent of community pharmacists’ involvement in preventing and controlling CVDs, p>0.05.

The subjective norms and perceived behavioural control scales had reliability values of 0.641 and 0.569, respectively. Thus, individual constructs were analysed separately. Similarly to attitude, respondents demonstrated a unanimous positive perception (>3) of all constructs, such as "hypertension patients appreciate the pharmacist’s effort to counsel them (subjective norms)" and "I am confident that I can counsel hypertension patients on lifestyle modification (perceived behavioural control)". There were significant differences in the construct "hypertension patients appreciate community pharmacists’ effort to counsel them" between gender and employment status independent groups. Males (mean = 4.21±.74) than females (3.60±.88) perceived patients as appreciative of their counselling services; t(46) = -2.335, p = 0.024. Similarly, there was a significant difference between community pharmacists who were pharmacy owners (mean = 4.39±.61) and those who were employees (mean = 3.66±.86); t(45) = 3.167, p = 0.003. Compared with other constructs, a modest agreement was observed for the subjective norms "physicians believe that I should advise hypertension patients on lifestyle modification", with less than half of the respondents (40.4%) demonstrating agreement. There were no significant differences between independent groups. In the same way, no significant difference observed in the extent of community pharmacists’ involvement between community pharmacists who agreed and disagreed with the constructs in the subjective norms, p>0.05.

The perceived behavioural control construct "I am confident that I can counsel hypertension patients on lifestyle modification" significantly differed between pharmacies with ≥2 community pharmacists (mean = 4.85±.38) and pharmacies with 1 pharmacist (4.49±.82); t (43) = -2.082, p = 0.043. There was a significant difference in the extent of community pharmacists’ involvement between independent groups of the construct "I am able to initiate lifestyle counselling on my own decision", p = 0.001.

Barriers and facilitators

The barriers and facilitators were assessed against 22 and 8 constructs, respectively (Table 4). The barrier constructs were further categorised into four factors: community pharmacy/pharmacist, patient, inter-professional relations, and regulatory aspects.

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Table 4. Barriers and facilitators in the provision of services to CVD patients in Lesotho (n = 48).

https://doi.org/10.1371/journal.pone.0314487.t004

Recommendations for enhancing community pharmacists’ services.

Most respondents (>70%) agreed to strongly agreed to 7 out 8 constructs as roles needed for the enhancement of community pharmacy services to CVD patients (Fig 3). On the other hand, 42.5% of respondents agreed that a postgraduate internship program should be a prerequisite for pharmacist registration, while 36.2% disagreed. There was no significant differences between independent groups (p>0.05).

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Fig 3. Recommendations for enhancing community pharmacists’ provision of services to CVD patients.

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Tools availability

Table 5 presents the availability of testing devices for blood pressure, blood sugar, cholesterol, body weight, and Lesotho’s standard treatment guidelines. All community pharmacies (n = 48) had blood pressure testing devices, while cholesterol measuring devices were the least common (33.3%). There were significant differences in the availability of a measuring tape, height measuring device, body weight scale, and blood cholesterol measuring device between independent groups in Table 1. Firstly, the availability of a measuring tape was significantly associated with experience (X² = 6.095, df = 1, p = 0.014). A modest difference between age groups (X² = 3.884, df = 1, p = 0.049) was observed. Secondly, the availability of a height measuring device was significantly associated with the district where the pharmacy was located (X² = 4.704, df = 1, p = 0.030). And thirdly, the number of CVD patients seen daily was associated with the availability of body weight scale (X² = 3.981, df = 1, p = 0.046) and blood cholesterol measuring device (X² = 4.286, df = 1, p = 0.038).

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Table 5. Availability of tools in the community pharmacies (n = 48).

https://doi.org/10.1371/journal.pone.0314487.t005

Knowledge of CVDs risk factors by community pharmacists

Table 6 presents the results of community pharmacists’ knowledge of CVD risk factors. The majority of the respondents demonstrated good knowledge in 19 of 23 constructs. Respondents showed moderate knowledge of cholesterol (54.2%) and diabetes-related (64.6%) risk factors and low knowledge (27.1%) of gender and other cholesterol-related risk factors, (p>0.05). Overall, an average knowledge score of 85.3% was achieved, demonstrating good knowledge of CVD risk factors.

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Table 6. HDQF item with correct responses, proportion, and corrected item-total correlation (n = 48).

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Additional services

Table 7 displays the results of extra services community pharmacists are willing to provide in the future. The majority of the respondents believed that they needed to do more for CVD patients. More than 85% of community pharmacists agreed that they should broaden disease education coverage, create social groups to encourage lifestyle modification, increase screening capacity with advanced testing devices, and monitor patients’ treatment. Approximately half (52.1% agreement) of the respondents wanted to see diagnosing and prescribing at a fee added to the community pharmacists’ services to CVD patients.

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Table 7. Additional services in preventing and controlling CVDs (n = 48).

https://doi.org/10.1371/journal.pone.0314487.t007

Involvement of community pharmacists in preventing and controlling CVDs

Apart from dispensing, the most common health promotion activities were hypertension and diabetes screening, weight management services, CVD education, medication management therapy, and referral of and follow-up on patients. This is an important observation considering the increasing prevalence of diabetes and hypertension over the years and the risk they pose towards the development of CVDs [5, 6]. However, the involvement of community pharmacists in cholesterol and undiagnosed CVDs screening was relatively low and needed to be improved. Similar findings were reported in Ghana, where community pharmacists were highly involved in disease screening, lifestyle counselling, and medication management therapy services [37]. Regarding lifestyle modification, community pharmacists were highly involved in weight management counselling. The availability of a weight scale (89.6%) supports the involvement of community pharmacists in weight management activities. However, almost half of the respondents did not have a measuring tape or a height measuring device, which are essential for waist circumference and body mass index measurements [38]. The findings underscore the need for standardisation of community pharmacy practice services.

On the other hand, smoking cessation and alcohol abuse advice were less practised compared to weight management counselling. The results contradict the findings of Sendekie and Netere [21] in Ethiopia, in which pharmacists were highly involved in smoking and alcohol abuse counselling [21]. The disparities could be due to a lack of competency. For instance, community pharmacists with more than 5 years of experience were more involved in alcohol abuse counselling than those with less than 5 years in the current study. This gap can be improved by developing continuous professional development strategies for community pharmacists which is currently lacking. Generally, the study shares similarities with previous findings and shows community pharmacists’ involvement in medicine dispensing, disease screening, lifestyle counselling, and health education in CVDs [20, 31, 39]. Future studies should focus on the effectiveness of these services in reducing CVD risk.

Knowledge of CVD risk factors

Overall, community pharmacists demonstrated good knowledge of CVD risk factors. There is need for continuous professional development to improve knowledge mainly on diabetes and cholesterol-related risk. While all the respondents admitted to receiving CVD management education during their pharmacy training, the majority (83.3%) had never received related postgraduate training. A life-long commitment to learning is crucial in pharmaceutical care since acquiring sufficient pharmaceutical skills and competencies at school is impossible [40]. Thus, community pharmacies in Lesotho must create platforms that support and motivate continuous professional development for community pharmacists. Our results are consistent with findings in Nigeria and Saudi Arabia, where community pharmacists showed good knowledge of CVD risk factors with modest knowledge of cholesterol and diabetes [30, 41].

In contrast, the knowledge score was comparatively higher than that of community pharmacists in Ethiopia (55.6%) [42]. The difference could be awareness of guidelines due to the availability of standard treatment guidelines in most community pharmacies in Lesotho (93.7%) compared with a small proportion of community pharmacists who were aware of national guidelines for CVDs in Ethiopia [42].

Barriers and facilitators

Effective community pharmacists’ health promotion services have been reported in preventing and controlling CVDs [12, 43]. However, community pharmacy practice is surrounded by factors that discourage their scope of practice globally [31, 44, 45]. Lesotho is no exception to global concerns since community pharmacists experience barriers that cut across pharmacy, patient, inter-professional relations, and regulatory factors. The topmost reported barriers were patient factors such as non-adherence to medication, unawareness of community pharmacist services, and lack of time and interest. Consequently, respondents believed that patients’ awareness of community pharmacists’ services should be enhanced.

On the other hand, difficulty getting patients to adopt healthy lifestyles differed significantly between most and less experienced community pharmacists. The findings underscore the need for continuous professional development for pharmacists to encourage standardised provision of services to patients. The enactment of the Lesotho Medicines and Medical Devices Control Authority Act 2023 in August 2023 brings hope to pharmacy practice in Lesotho and possible regulatory changes that can drive service improvement among community pharmacists [46]. The study findings share several similarities with results from LMICs. In Ethiopia, the most reported barriers to CVD health promotion were the unavailability of equipment, lack of financial motivation, and lack of patient acceptance of pharmacists’ services, and the percentage agreement ranged between 64% and 86% [42]. Additionally, Rwanda’s most perceived barriers were poor inter-professional collaboration, unavailability of equipment, and lack of standard guidelines (agreement of 57%-69%) [31]. On the other hand, in Saudi Arabia, the most reported barriers were lack of time (66% agreement), followed by educational resources (41%) and lack of confidence in using devices (36%) [44]. Likewise, Qatar pharmacists perceived a lack of time (53%), a shortage of human resources (42%), and a lack of private areas for counselling [47] as barriers’ to community pharmacists’ service provision. Alavudeen, Easwaran [44] and El Hajj, Abu Yousef [47] suggest that pharmacy/community pharmacist factors influence the most important barriers in HICs, while our findings point to patient factors. Future research should explore the perceptions of patients, other healthcare professionals involved in CVD care, and regulatory authorities regarding the role of community pharmacists in CVD management in Lesotho.

Attitudes and perceptions

Respondents’ attitudes and perceptions were assessed using three TPB constructs: attitude, perceived behavioural control, and subjective norms [25]. The respondents portrayed a positive attitude in support of their role in preventing and controlling CVDs. According to Ajzen [25], attitude is a strong determinant of the intention to perform a certain behaviour [25]. The positive attitude provides the basis for the optimal utilisation of community pharmacists and integration in CVD structures in Lesotho. Furthermore, the majority of the pharmacists perceived themselves as confident in providing lifestyle modification counselling to patients with CVD risk factors. On the other hand, four out of five respondents agreed to strongly agreed that they initiate lifestyle counselling out of their own free will. The findings imply the absence of external pressures, such as regulatory or social pressures, which might subject the provision of services to a lack of consistency. Nonetheless, community pharmacists perceived patients as more appreciative of their health promotion services than physicians. To better understand the influence of social factors, future research should investigate the perceptions of patients and physicians towards community pharmacists’ provision of health promotion services to CVD patients. The findings agree with the results of studies conducted in Rwanda and Yemen [31, 48]. Similarly, Alavudeen, Easwaran [44] posited that Saudi Arabian pharmacists had a positive attitude and perceptions toward their capability to provide health promotion to CVD patients [44].

The study had limitations. Firstly, the study included reachable participants who were available to participate during the 5 months of data collection. The contact phone numbers for some community pharmacists were unreachable, while other pharmacists were not available to partake in the study. Additionally, two questionnaires were excluded from the final analysis due to their non-completion exceeding a 10% set threshold, thus further reducing the sample size below the expected. These could have affected the power of statistical tests, leading to the analysis’s inability to detect small differences between independent groups. For example, a lack of a significant difference between the respondent’s attitudes and subjective norms and the extent of involvement in CVD care could be attributed to the decreased statistical power due to a smaller sample size. Although efforts were made to achieve a higher response rate, including the use of online and paper-based questionnaires, and a relatively extended data collection period, only 50 pharmacists completed and returned the questionnaires. Furthermore, a response rate of 80.6% was comparable to previous similar studies based locally and internationally [20, 22, 49, 50]. Given the 5 month duration of the data collection, a high response rate of 80.6%, and a choice between online and paper-based questionnaires for community pharmacists, the researchers believe that the actual sample size of 50 respondents was practically feasible. Secondly, the study was conducted in four cities in the lowlands of Lesotho, with most participants being from urban areas. Therefore, the results might not be generalisable to community pharmacists in other cities and rural areas, particularly in the highlands of Lesotho. Thirdly, the cross-sectional design employed in this study presents a significant limitation, as it cannot establish the direction of the cause-and-effect relationship [51]. Furthermore, performing robust statistical analyses, such as multiple logistic regression, was not feasible due to the smaller sample size. Logistic regression typically requires a minimum of 10 to 20 events per independent variable [52] to enhance the validity of the findings; however, this study did not meet that requirement. Despite these limitations, the study evaluates Lesotho community pharmacists’ extent of involvement in preventing and controlling CVDs in Lesotho and possesses several strengths. Firstly, the participants had a comparable gender representation of 4:5 females to males and a broad coverage of community pharmacy experience ranging from six months to over 10 years. Secondly, the study represents the role of community pharmacists in preventing and controlling CVDs in different pharmacy settings, from urban and rural geographical areas to independent and chain stores. Additionally, the majority of Lesotho community pharmacies (90%) are established in the four districts studied [8] that serve an estimated population of 1.3 million people (65% of the national population) [19]. Another important attribute is that the results compare with previous findings of similar studies. Therefore, the authors are confident that the findings provide pertinent information to healthcare policy- and decision-makers, regulators in clinical practice, and future research regarding the involvement of community pharmacists in preventing and controlling CVDs. The results can inform policy development in LMICs.