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The response to COVID-19 among drug retail outlets in Indonesia: A cross-sectional survey of knowledge, attitudes, and practices

  • The Kirby Institute, UNSW

Abstract and Figures

Background Pharmacists have been at the frontline of the COVID-19 response in Indonesia, providing medicines, advice, and referral services often in areas with limited healthcare access. This study aimed to explore their knowledge, attitudes, and practices during the pandemic, so that we can be better prepared for future emergencies. Methods A cross-sectional online survey of community pharmacists and pharmacy technicians in Indonesia was conducted between July and August 2020. The dataset was analysed descriptively, and logistic regression was used to explore willingness to participate in COVID-19 interventions. Findings 4716 respondents participated in the survey. Two-thirds (66·7%) reported knowing only “a little” about COVID-19 and around a quarter (26·6%) said they had not received any COVID-19 guidelines. Almost all were concerned about being infected (97·2%) and regularly took steps to protect themselves and their clients (87·2%). Stock-outs of Personal Protective Equipment (PPE) and other products (32·3%) was the main reason for not taking any precautions. Around a third (37·7%) mentioned having dispensed antibiotics to clients suspected of having COVID-19. To support COVID-19 response efforts, most respondents were willing to provide verbal advice to clients (97·8%), distribute leaflets to clients (97·7%), and participate in surveillance activities (88·8%). Older respondents, those identifying as male, and those working in smaller outlets were more willing to provide information leaflets. Those working in smaller outlets were also more willing to engage in outbreak surveillance. Interpretation Drug retail outlets continue to operate at the frontline of disease outbreaks and pandemics around the world. These providers have an important role to play by helping to reduce the burden on facilities and providing advice and treatment. To fulfil this role, drug retail outlets require regular access to accurate guidelines and steady supplies of PPE. Calls for drug retail outlet staff to plat in response efforts including the provision of information to clients and surveillance could ease escalating pressures on the health system during future outbreaks. Funding This study was funded by a grant from the Department of Foreign Affairs and Trade, Australia, under the Stronger Health Systems for Health Security Scheme.
Content may be subject to copyright.
The response to COVID-19 among drug retail outlets in
Indonesia: A cross-sectional survey of knowledge,
attitudes, and practices
Yusuf Ari Mashuri,
Luh Putu Lila Wulandari,
*Mishal Khan,
Astri Ferdiana,
Ari Probandari,
Tri Wibawa,
Neha Batura,
Marco Liverani,
Richard Day,
Stephen Jan,
Gill Schierhout,
Djoko Wahyono,
John Kaldor,
Rebecca Guy,
Matthew Law,
Shunmay Yeung,
and Virginia Wiseman
Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
The Kirby Institute, University of New South Wales, Wallace Wurth Building, UNSW, Kensington NSW 2052, Sydney, Australia
Faculty of Medicine, Universitas Udayana, Bali, Indonesia
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
Global Health Programme, Chatham House, London, United Kingdom
Departments of Community Health Sciences and Pathology, Aga Khan University, Karachi, Pakistan
Faculty of Medicine, Universitas Mataram, Mataram, Indonesia
Department of Microbiology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
Institute for Global Health, University College London, London, United Kingdom
School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
Faculty of Public Health, Mahidol University, Bangkok, Thailand
St Vincents Clinical School, University of New South Wales, Sydney, Australia
The George Institute for Global Health, Sydney, Australia
Pharmacotherapy Laboratory and Clinical Pharmacy, Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia
Department of Pharmacy, Universitas Islam Indonesia, Yogyakarta, Indonesia
Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
Background Pharmacists have been at the frontline of the COVID-19 response in Indonesia, providing medicines,
advice, and referral services often in areas with limited healthcare access. This study aimed to explore their knowl-
edge, attitudes, and practices during the pandemic, so that we can be better prepared for future emergencies.
Methods A cross-sectional online survey of community pharmacists and pharmacy technicians in Indonesia was
conducted between July and August 2020. The dataset was analysed descriptively, and logistic regression was used
to explore willingness to participate in COVID-19 interventions.
Findings 4716 respondents participated in the survey. Two-thirds (66¢7%) reported knowing only “a little” about
COVID-19 and around a quarter (26¢6%) said they had not received any COVID-19 guidelines. Almost all were con-
cerned about being infected (97¢2%) and regularly took steps to protect themselves and their clients (87¢2%). Stock-
outs of Personal Protective Equipment (PPE) and other products (32¢3%) was the main reason for not taking any pre-
cautions. Around a third (37¢7%) mentioned having dispensed antibiotics to clients suspected of having COVID-19.
To support COVID-19 response efforts, most respondents were willing to provide verbal advice to clients (97¢8%),
distribute leaflets to clients (97¢7%), and participate in surveillance activities (88¢8%). Older respondents, those iden-
tifying as male, and those working in smaller outlets were more willing to provide information leaflets. Those work-
ing in smaller outlets were also more willing to engage in outbreak surveillance.
Interpretation Drug retail outlets continue to operate at the frontline of disease outbreaks and pandemics around
the world. These providers have an important role to play by helping to reduce the burden on facilities and providing
advice and treatment. To fulfil this role, drug retail outlets require regular access to accurate guidelines and steady
supplies of PPE. Calls for drug retail outlet staff to plat in response efforts including the provision of information to
clients and surveillance could ease escalating pressures on the health system during future outbreaks.
*Corresponding author at: The Kirby Institute, University of New South Wales, Wallace Wurth Building, UNSW, Kensington NSW
2052, Sydney, Australia.
E-mail address: (L.P.L. Wulandari).
These authors contributed equally to this work.
The Lancet Regional
Health - Western Pacic
2022;22: 100420
Published online xxx
lanwpc.2022.100420 Vol 22 Month , 2022 1
Funding This study was funded by a grant from the Department of Foreign Affairs and Trade, Australia, under the
Stronger Health Systems for Health Security Scheme.
Copyright Ó2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (
Keywords: COVID-19 pandemic; Disease outbreak; Health system preparedness and response; Pharmacy; Drug-
store; Indonesia
Research in context
Evidence before this study
Pharmacies and drug stores play an important role in
serving the community as they are often the rst point
of contact within the health system. Calls for drug retail
outlet staff to play a more active role in COVID-19
response efforts are increasing. However, these pro-
viders face major challenges, including increased risk of
transmission inside outlets and a lack of training in pan-
demic preparedness. Our study investigated the
response of community pharmacies in Indonesia to con-
sumer needs during the pandemic. To the best of our
knowledge, this is the largest survey of pharmacists and
pharmacy technicians working at drug retail outlets in a
Southeast Asian country during the COVID-19 crisis.
Added value of this study
We analysed attitudes and self-reported knowledge, and
practice of pharmacists and pharmacy technicians across
Indonesias 34 provinces. The majority of respondents
expressed concern about being infected and were willing
to participate in COVID-19 response efforts. Our study
supports previous research on the potential risks faced
by pharmacists during pandemics, while providing new
evidence on issues such as the common use of antibiot-
ics among suspected COVID-19 patients.
Implications of all the available evidence
This study provides evidence on the importance of drug
retail outlets during the current COVID-19 crisis in Indo-
nesia. Access to guidelines and protocols related to the
pandemic as well as uninterrupted supplies of personal
protective equipment (PPE), is essential for these front-
line health workers. Pharmacists and pharmacy techni-
cians have considerable potential to help combat COVID-
19 and any future pandemics. The Indonesian govern-
ment should increase efforts to engage with them.
In the midst of the COVID-19 pandemic, there are
increasing calls for pharmacists to play a more active
role in the public health response, beyond dispensing of
medicines and other supplies. In particular, it has been
suggested that in the context of pandemics, pharmacists
could be involved in outbreak surveillance,
drug trials,
vaccine delivery,
programs to support patient medication adherence.
These roles become critical when clinical services are
heavily committed, especially in countries where health
systems are under-resourced.
However, the operation
of pharmacies and drug stores during COVID-19 poses
significant challenges. A small but growing number of
studies have pointed to major gaps in measures to con-
trol disease transmission inside pharmacies
as well
as inappropriate behaviour by clients that can under-
mine staff safety.
Studies have also raised concerns
about the lack of appropriate training in pandemic pre-
paredness available to pharmacy staff.
In Indonesia, community pharmacies and drug stores
often serve as the first point of contact with the health
system for many patients. Community pharmacies must
always be attended by a qualified pharmacist and drug
stores by a pharmacy technician, who oversee the dis-
pensing of medicines. Only community pharmacies can
sell prescribed medicines including antibiotics. Hereon
we refer to them both as ‘drug retail outlets’. According
to official data from the Indonesian Ministry of Health
(MOH), the country’s population of around 270 million
is served by approximately 135,000 licensed drug retail
Around 10% of these outlets serve the pro-
vider network for Indonesia’s national health insurance
scheme, the Jaminan Kesehatan Nasional or simply the
‘JKN’, which is designed to make health services accessi-
ble to all citizens by the end of 2024.
There have been increasing calls for greater involve-
ment of pharmacists and pharmacy technicians (who
typically work under the supervision of pharmacists) in
the response to COVID-19,
which is taking a huge
toll on the population and health system of Indonesia.
As of early February 2022, more than 4¢3 million cases
and 144,000 deaths were reported in the country,
including thousands of frontline health workers.
In this paper, we report findings from a survey of the
attitudes, self-reported knowledge and practice of phar-
macists and pharmacy technicians in Indonesia during
the COVID-19 pandemic. After presenting the findings,
we discuss recommendations to strengthen their contri-
bution to future response activities in Indonesia and
2 Vol 22 Month , 2022
other Low- and Middle-Income Countries (LMIC). To
our knowledge, this is the largest empirical study of
health professionals working in drug retail outlets dur-
ing the COVID-19 pandemic in Indonesia.
Participants were registered pharmacists and pharmacy
technicians working in drug retail outlets in Indonesia.
These private practitioners may be part of major retail
chains or small pharmacies owned by individuals or
groups. A pharmacist will have a bachelor’s degree in
pharmacy and a pharmacist registration training certifi-
cate. In contrast, a pharmacy technician will have gradu-
ated from a pharmacy technician school, obtained a
three-year diploma in pharmacy, or received a bachelor’s
degree in pharmacy without holding a pharmacist regis-
tration training certificate. Pharmacists have primary
responsibility for the dispensing of medicines, narcotics,
and psychotropic substances to the public on presenta-
tion of a prescription from a doctor, while pharmacy tech-
nicians may assist pharmacists with dispensing.
Typically, the pharmacy owner and pharmacists-in-
charge will enter into a cooperation agreement covering
salary and profit sharing. By regulation, pharmacists are
entitled to monthly professional fees for managing the
pharmacy, consultation fees, benefits including health
insurance as well as revenue sharing. While a minimum
salary has been determined by some branches of the
Indonesian Pharmacists Association (IAI), the actual sal-
ary is at the discretion of the pharmacy owner.
Study design
A cross-sectional online survey of registered pharma-
cists and pharmacy technicians was conducted between
July and August 2020. The Checklist for Reporting
Results of Internet E-Surveys (CHERRIES)
was used
to guide development of the study design.
Data collection
An invitation to participate in the study was circulated
through the IAI and the Indonesian Pharmacy Techni-
cians Association (PAFI). The invitation, containing a
link to an online survey, was sent via email and What-
sApp to a contact person in all 34 provincial branches of
these two professional organisations. These persons
then forwarded the invitation to more than 500 repre-
sentatives at the district level using their contact lists.
All members of the associations who were currently
working in a pharmacy or drug store were eligible to
take part in the study. Random sampling was not possi-
ble due to the lack of an up-to-date register of all active
pharmacists and pharmacy technicians. At the begin-
ning of the survey, a screening question was asked to
ensure respondents were eligible to participate. A large
target the sample of 2000 respondents was based on
resource constraints and our existing networks with
pharmacy and pharmacy technician associations estab-
lished under the PINTAR (Protecting Indonesia from
the Threat of Antibiotic Resistance) study.
The questionnaire was designed to collect data on
demographic characteristics, knowledge and under-
standing of COVID-19, hygiene and safety measures,
experience of serving clients with suspected COVID-19,
and willingness to be involved in specific pandemic
response activities, including providing verbal advice to
clients, distributing information leaflets on COVID-19,
and participating in disease surveillance (e.g., reporting
the number of clients presenting with symptoms).
Questions on hygiene and safety measures were devel-
oped using the COVID-19 pandemic emergency guide-
lines published by the International Pharmaceutical
Federation (FIP) and other pharmacy professional
as well as the Indonesian national guidelines
for pharmacists.
The original questionnaire was developed in English,
translated into Indonesian, and then back-translated to
confirm accuracy of the translation.
The questionnaire
was refined after being piloted among 46 pharmacy stu-
dents at the Universitas Islam Indonesia in Yogyakarta
and public health researchers in the Center for Tropical
Medicine, at the Universitas Gadjah Mada (UGM) for
improved accuracy and ease of comprehension.
Respondents could access a mobile or desktop ver-
sion of the questionnaire, developed using the REDCap
electronic data collection tool.
The survey was avail-
able online for eight weeks between July and August
2020. Fortnightly follow-up reminders were sent via
the WhatsApp app. At the end of the survey, all respond-
ents were provided with written guidance from UGM on
how to strengthen pandemic response efforts in the
Data analysis
Data cleaning, validation, coding, and analysis were
undertaken by YM and LPLW using STATA version 13,
with oversight from a senior statistician (ML). Descriptive
statistics were used to report means, frequencies, and
percentages, by pharmacy and pharmacy technician sub-
groups. We used the total number of complete responses
to each question as the denominator. Bivariate and multi-
variable analyses were used to explore associations
between participant characteristics and their willingness
to participate in COVID-19 response efforts, using sim-
ple and multivariable logistic regression, respectively.
The outcome of interest was a respondent’s willingness
to participate in specific COVID-19 related activities.
Answers to these questions were re-categorised as binary
variables “very willing” versus “moderately willing” and
“unwilling”. Bivariate analysis was conducted using age,
Articles Vol 22 Month , 2022 3
gender, type of workplace, level of concern about acquir-
ing COVID-19, and number of suspected COVID-19 cli-
ents seen in the last week. Only variables that
demonstrated a statistically significant association in the
bivariate analysis (p<0¢05) were included in the multi-
variable analysis with no adjustment of p-values for mul-
tiple comparisons.
All research activities were conducted in compliance
with a protocol approved by the medical research ethics
committees of the Universitas Gadjah Mada (KE/FK/
0464/EC/2020) and the University of New South
Wales (HC191012). The questionnaire was entirely
anonymous and no personal identifiers (including
name, location, IP address) were collected. Informed
consent was obtained electronically on the first page of
the survey and respondents could only proceed if con-
sent was provided.
Role of the funding sources
The study sponsor had no role in the study design, data
collection, data analysis and interpretation, writing the
report, or the decision to submit the paper for publica-
Characteristics of respondents and their place of work
Of the 7096 staff who clicked on the link to the survey,
6270 were eligible to participate. Of these, three-quar-
ters (4716/6270) gave their consent to participate in the
study (Figure 1). Due to the recruitment methods used
in this study, it was not possible to calculate a response
Participants came from all 34 provinces of Indone-
sia, with a third located in Java: East Java (454/4716;
11¢5%); Central Java (438/4716; 11¢1%); and West Java
(433/4716; 10¢9%) (Figure 2). The mean age of respond-
ents was 32 years with the majority (3356/3985; 84¢3%)
aged between 21 and 40 years. Over three-quarters of
respondents were female (1847/4043; 78¢6%), and two-
thirds had a bachelor’s degree or higher (2659/3982;
66¢8%). The majority worked at an independent drug
retail outlet (3378/3911; 86¢4%), defined as an individ-
ual business that was not affiliated with any chain, and
more than half (2029/4000, 50¢8%) had worked as a
pharmacist or pharmacy technician for 6 years or more.
Around 12% of respondents were also owners of the
facilities where they worked (Table 1).
Table 2 shows that almost all respondents reported
having some knowledge of COVID-19 (3453/3461;
99¢8%) and having received some information on
COVID-19 (3384/3461; 97¢8%). However, two-thirds
(2308/3461; 66¢7%) felt that they still knew only a little
about COVID-19 at the time of this survey. The infor-
mation received about COVID-19 was most commonly
around disease transmission (3134/3384; 92¢6%), while
updates on screening and testing practices were the
least common (1903/3384; 56¢2%). Two-thirds of
respondents (2339/3376; 69¢3%) stated they had read
pharmacy guidelines on COVID-19 that had been pro-
duced by groups such as the World Health Organization
(WHO), FIP, IAI, or the Indonesian MOH. The major-
ity of respondents correctly identified the main ways
that COVID-19 is spread [i.e., through touching infected
Figure 1. Respondent owchart.
4 Vol 22 Month , 2022
objects and then the face (93¢4%) and through inhaling
droplets (79¢1%)]. The vast majority also knew that
drinking dirty water, the faecal-oral route, and mosquito
bites were not main modes of transmission. Pharma-
cists were more likely to have received COVID-19
related information, and were often correct in their
understanding about transmission, compared to phar-
macy technicians.
Figure 3 summarises practices reportedly under-
taken by pharmacists and pharmacy technicians to pro-
tect themselves, other staff, and clients against COVID-
19. The three most common practices were wearing a
face mask (1725/1736; 99¢4% and 1284/1291; 99¢5%),
instructing clients to wear a face mask (1680/1739;
96¢6% and 1255/1291; 97¢2%), and putting hand sani-
tiser at the entrance or cash counter of an outlet (1658/
1741; 95¢2% and 1257/1291; 97¢4%). More than one-
third of the respondents (613/1738; 35¢2% and 641/
1291; 49¢6%) reported that a disinfection chamber had
recently been installed in a store where they currently
worked. The three most common pieces of advice given
to clients by pharmacists and pharmacy technicians
(Figure 4) were to wear a face mask (1436/1516; 94¢7%
and 975/1080; 90¢3%), to wash hands carefully and reg-
ularly (1368/1516; 90¢2% and 924/1080; 85¢6%), and to
self-isolate at home if displaying COVID-19 symptoms
(1246/1516; 82¢2% and 860/1080; 79¢6%).
Client visits during the pandemic
Around a fifth of respondents (532/3034; 17¢5%) stated
that they had been visited by clients whom they sus-
pected of having COVID-19 in the last week. This varied
by province from 0% to 40¢9% (Figure 5). Reasons for
suspecting a client was infected included: presence of
common symptoms (268/532; 50¢4%); travelled to a
high-risk COVID-19 region (233/532; 43¢8%); reported
contact with a close friend or relative with COVID-19
(114/532; 21¢4%); or the client said they thought they
had the virus (25/532; 4¢7%) (Figure 6).
Among those respondents who suspected they had
been visited by a client with COVID-19, the most com-
monly perceived symptoms were a cough (235/268;
87¢7%) and fever (211/268; 78¢7%), but many other
symptoms such as sore throat, sneezing, and diffi-
culty breathing were also reported (Figure 7). Items
commonly purchased by these clients included: vita-
mins, immune boosters (e.g., ImunosÒ), cough medi-
cines, influenza and cold medicines, hand sanitisers,
antipyretics, antiseptics, and PPE such as surgical
masks, and fabric masks. It was more common for
pharmacy technicians to dispense dexamethasone
(120/242; 49¢6% vs. 80/244; 32¢8%), azithromycin
(89/240; 37¢1% vs. 39/242; 16¢1%) and other antibiot-
ics (124/244; 50¢8% vs. 63/246; 25¢6%), to clients
suspected of having COVID-19 compared to pharma-
cists (Figure 8).
Concerns with COVID-19 and safety precautions
Almost all (2505/2576; 97¢2%) respondents expressed
concern about contracting COVID-19, ranging from “a
little worried” to “very worried”. Many respondents
reported taking regular safety precautions with 69¢4%,
54¢3%, and 45¢2% reporting that they wore face masks,
washed their hands, and used hand sanitiser regularly
throughout the day, respectively. An additional 28¢4%,
39¢1%, and 46¢4% of respondents reported taking these
precautions every time they served a client. Among
those who had not taken any safety precautions (12¢8%),
the most common reasons cited were that they were
unable to access PPE and other products such as hand
sanitiser due to stock-outs (32¢3%); found it uncomfort-
able to wear PPE (37¢3%); could not afford PPE and
other products (29¢1%); or were concerned that items
such as face shields might frighten clients (23¢2%).
Figure 2. The number of survey respondents by province.
Articles Vol 22 Month , 2022 5
COVID-19 rapid antibody test kit
Almost half of the respondents (1052/2445;43¢0%) said
that they believed COVID-19 rapid antibody test kits
were sold by some drug retail outlets. A quarter (691/
2445; 28¢3%) of respondents felt that they should be
made available through drug retail outlets, with another
third (842/2445; 34¢4%) reporting they were not sure.
When asked about the likely price and sources of rapid
antibody test kit, 88¢6% (249/1051) estimated them to
be under Rp.500000 (36 USD) and most commonly
obtained from licensed wholesalers (874/1049; 83¢3%),
only 10¢1% (106/1049) suspected they were obtained
from online sellers.
Willingness to be involved in COVID-19 response
Respondents were asked about their willingness to par-
ticipate in public health responses to COVID-19 by pro-
viding verbal advice to clients (e.g., social distancing
and when/where to seek medical advice); distributing
information leaflets about COVID-19 prevention to cli-
ents (e.g., good hygiene practices and how to wear a
face mask); and participating in surveillance activities
(e.g., reporting the number of clients with key symp-
toms). The vast majority of respondents indicated a will-
ingness (i.e., “moderately or very willing”) to be
involved in all activities [i.e., provide verbal advice
(97¢8%), distribute information leaflets on COVID-19
(97¢7%), and participate in surveillance activities
(88¢8%) (Table 3)].
Table 4 shows results of the multivariable analysis of
factors associated with respondents reporting to be “very
willing” to participate in the interventions described
above. Older respondents [age group 34-40 years old
(AOR 1¢26 (1¢04 - 1¢52)) and age group 41-50 years old
(AOR 1¢82 (1¢34 -2¢48))], those identifying as male [AOR
1¢31 (1¢04 1¢66)], and those working in smaller drug
retail outlets with 3 or fewer staff [AOR 1¢31 (1¢10
1¢56)] were more willing to provide COVID-19 informa-
tion leaflets to clients. Respondents who worked in drug
retail outlets with fewer staff were more willing to
engage in COVID-19 surveillance activities [AOR 1¢36
(1¢15 1¢61)]. No correlates of willingness to provide ver-
bal advice on COVID-19 to clients were found to be sta-
tistically significant (Supplementary Table 4).
Many studies have explored the actions and experiences
of public sector health workers during the COVID-19
crisis but far fewer have focussed on pharmacists and
pharmacy technicians working in private drug retail out-
lets. Our study highlights the important roles these pro-
viders perform during the current pandemic in
Indonesia as well as the challenges they face. It was
revealed that reliable information including guidelines
for those working in drug retail outlets has not been
readily available. While stadard operating procedures
were issued by key professional organisations including
the IAI and the FIP in early March 2020,
these had
Variables N (%; 95%CI)
Age group (years) (N= 3985)
30 1779 (44¢6; 43¢1-46¢2)
31-40 1584 (39¢8; 38¢2-41¢3)
41-50 461 (11¢6; 10¢6-12¢6)
>50 161 (4¢0; 3¢5-4¢7)
Missing 731 (15¢5)
Gender (N= 4043)
Male 750 (18¢6; 17¢4-19¢8)
Female 3213 (79¢5;78¢2-80¢7)
Rather not say 80 (2¢0; 1¢5-2¢4)
Missing 673 (14¢3)
Highest education level (N= 3982)
Diploma 1323 (33¢2; 31¢8-34¢7)
Bachelors degree and above 2659 (66¢8; 65¢3-68¢2)
Missing 734 (15¢6)
Occupation (N= 4009)
Pharmacist (not owner) 1809 (45¢1; 43¢6-46¢6)
Pharmacy technician (not owner) 1711 (42¢7; 41¢2-44¢2)
Pharmacy technician and owner 83 (2¢1; 1¢6-2¢5)
Pharmacist and owner 406 (10¢1; 9¢2-11¢1)
Missing 707 (15¢0)
Type of drug retail outlet (N= 3911)
Independent pharmacy 3135 (80¢2; 78¢9-81¢3)
Chain pharmacy 481 (12¢3; 11¢3-13¢4)
Independent drug store 243 (6¢2; 5¢5-7¢0)
Chain drug store 52 (1¢3; 1¢0-1¢7)
Missing 805 (17¢1)
Work experience (years) (N= 4000)
<1 398 (10¢0; 9¢0-10¢9)
1-5 1573 (39¢3; 37¢8-40¢8)
6-10 1015 (25¢4; 24¢0-26¢7)
>10 1014 (25¢4; 24¢0-26¢7)
Missing 716 (15¢2)
Number of outlets currently working at (N= 3986)
1 2975 (74¢6; 73¢3-75¢9)
2 750 (18¢8; 17¢6-20¢0)
3*261 (6¢6; 5¢8-7¢4)
Missing 730 (15¢5)
Number of staff in main outlet where respondent works (N= 3912)
>3 staff members 1893 (48¢4; 46¢8-49¢9)
3 staff members 2019 (51¢6; 50¢0-53¢2)
Missing 804 (17¢0)
Location of main outlet where respondent works (N= 3953)
Java 2255 (57¢0; 55¢5-58¢6)
Outside Java 1698 (43¢0; 41¢4-44¢5)
Missing 763 (16¢2)
Table 1: Respondent characteristics.
* According to the Indonesian Ministry of Health, pharmacists and
pharmacy technicians are prohibited from working at more than three
6 Vol 22 Month , 2022
not reached all providers by the time of the survey. Easy
access to accurate and timely information is crucial,
especially given the proliferation of “infodemic” around
COVID-19, much of which is driven by social media.
Compared to pharmacists, fewer pharmacy technicians
reported having received information about COVID-19.
Increased steps should be taken to ensure guidelines
and training are available to all pharmacists and phar-
macy technicians.
Actions to protect staff and clients from COVID-19
including the wearing of face masks, instructing clients
to wear a face mask, and providing hand sanitiser to
Variables Pharmacist Pharmacy technician Total
N (%; 95%CI) N (%; 95%CI) N (%; 95%CI)
Self-reported level of knowledge about COVID-19** (N=3461)
Know nothing 1 (0¢05; 0¢0-0¢4) 7 (0¢5; 0¢0-0¢9) 8 (0¢2; 0¢1-0¢4)
Know a little 1187 (60¢9; 58¢7-63¢1) 1120 (74¢0; 71¢7-76¢2) 2308 (66¢7; 65¢1-68¢2)
Know a lot 759 (38¢9; 36¢8-41¢2) 386 (25¢5; 23¢4-27¢8) 1145 (33¢1; 31¢5-34¢7)
Missing 1245 (26¢4)
Received any information on COVID-19 (N=3462)
Yes 1913 (98¢2; 97¢5-98¢7) 1471 (97¢2; 96¢2-97¢9) 3384 (97¢8; 0¢97¢2-98¢2)
No 35 (1¢8; 1¢3-2¢5) 42 (2¢8; 2¢1-3¢7) 78 (2¢2; 0¢18¢0-28¢0)
Missing 1254 (26¢4)
Source of information (N=3384)*
Online (e.g., social media, website)** 1793 (93¢7; 92¢5-94¢7) 1295 (88¢0; 86¢2-89¢6) 3088 (91¢3; 90¢2-92¢2)
Ofine (e.g., newspaper, professional organisation,
conversation with friends)**
1790 (93¢6; 92¢3-94¢5) 1314 (89¢3; 87¢6-90¢8) 3104 (91¢7; 90¢7-92¢6)
Both online and ofine** 1730 (90¢4; 89¢0-91¢7) 1175 (79¢9; 77¢8-81¢8) 2905 (85¢6; 84¢6-86¢9)
Missing 1332 (28¢2)
What topics related to COVID-19 have you received information on? (N=3384)*
How COVID-19 is transmitted** 1825 (95¢4; 94¢3-96¢2) 1309 (88¢9; 87¢2-90¢5) 3134 (92¢6; 91¢7-93¢4)
Who is most at risk for COVID-19** 1751 (91¢5; 90¢2-92¢7) 1170 (79¢5; 77¢4-81¢5) 2921 (86¢3; 85¢1-87¢4)
Symptoms of COVID-19** 1728 (90¢3; 88¢9-91¢6) 1125 (76¢5; 74¢2-78¢6) 2853 (84¢3; 83¢0-85¢5)
Causes of COVID-19** 1686 (88¢1; 86¢6-89¢5) 1120 (76¢1; 73¢9-78¢2) 2806 (82¢9; 81¢6-84¢2)
Prevention of COVID-19 1604 (83¢8; 82¢1-85¢4) 1041 (70¢7; 68¢4-73¢0) 2645 (78¢2; 76¢7-79¢5)
Latest number of COVID-19 cases** 1450 (75¢8; 73¢8-77¢6) 942 (64¢0; 61¢5-66¢4) 2392 (70¢7; 69¢1-72¢2)
Latest number of COVID-19 related deaths** 1435 (75¢0; 73¢0-76¢9) 926 (62¢9; 60¢4-65¢4) 2361 (69¢8; 68¢2-71¢2)
Latest number of recovered cases** 1428 (74¢6; 72¢6-76¢5) 913 (62¢1; 59¢6-64¢5) 2341 (69¢2; 676-70¢7)
Treatment for COVID-19** 1303 (68¢1; 65¢9-70¢2) 623 (42¢3; 39¢8-44¢8) 1926 (56¢9; 55¢2-58¢6)
Screening and testing for COVID-19** 1233 (64¢4; 62¢3-66¢5) 670 (45¢5; 43¢0-48¢1) 1903 (56¢2; 54¢6-57¢9)
Missing 1332 (28¢2)
Have you been given any guidelines on COVID-19 that relate to drug retail outlets?** (N=3376)
Yes 1423 (74¢4; 72¢4-76¢3) 916 (62¢5; 60¢0-65¢0) 2339 (69¢3; 67¢7-70¢8)
No 435 (22¢7; 20¢9-24¢7) 464 (31¢7; 29¢3-34¢1) 899 (26¢6; 25¢1-28¢1)
Dont know 54 (2¢8; 2¢1-3¢7) 84 (5¢7; 4¢6-7¢1) 138 (4¢1; 3¢4-4¢8)
Missing 1340 (28¢4)
In your understanding, what are the main ways COVID-19 is spread? (N= 3457)*
Touching an infected surface, then face** 1855 (95¢3; 94¢2-96¢1) 1374 (91¢1; 89¢5-92¢3) 3229 (93¢4; 92¢5-94¢1)
Inhaling droplets** 1683 (86¢4; 84¢8-87¢8) 1052 (69¢7; 67¢3-71¢9) 2736 (79¢1; 77¢7-80¢5)
Touching an infected person 1003 (51¢5; 49¢2-53¢7) 798 (52¢9; 50¢3-55¢3) 1801 (52¢1; 50¢4-53¢7)
Contact with the blood of an infected person 822 (42¢2; 40¢0-44¢4) 588 (38¢9; 36¢5-41-4) 1410 (40¢7; 39¢2-42¢4)
Breathing in the air 238 (12¢2; 10¢8-13¢7) 155 (10 ¢3; 8¢8-11¢9) 393 (11¢4; 10¢4-12¢5)
Faecal-oral route** 138 (7¢1; 6¢0-8¢3) 75 (4¢9; 3¢9-6¢2) 213 (6¢2; 5¢4-7¢0)
Drinking dirty water** 52 (2¢7; 2¢0-3¢5) 25 (1¢6; 1¢1-2¢4) 77 (2¢2; 1¢7-2¢7)
Mosquito bites 11 (0¢6; 0¢3-1¢0) 10 (0¢6; 0¢3-1¢2) 21 (0¢6; 0¢4-0¢9)
Missing 1259 (26¢7)
Table 2: Self-reported knowledge and access to information on COVID-19 among pharmacists and pharmacy technicians.
* Respondents could tick more than one answer.
** p<0.05.
Articles Vol 22 Month , 2022 7
clients were commonly practised. Most respondents
also provided COVID-19 related information to clients
including advice on wearing a face mask and washing
their hands properly. While these safety measures have
been widely implemented by staff working in commu-
nity pharmacies in many countries,
there have
been reports that they have sparked patient anxiety and
even aggression,
fuelled by longer waiting times
increased out-of-pocket costs.
Similarly, our study
showed that some respondents were worried about
frightening clients by using PPE, particularly face
shields. They also reported barriers to accessing PPE
and infection control products such as hand sanitiser, a
challenge experienced in many other LMIC.
highlights the need for further strategies to assist phar-
macists and pharmacy technicians in implementing
safety and security measures during pandemics.
Around a third of respondents mentioned that they
had provided antibiotics to clients suspected of having
COVID-19. Over-the-counter dispensing of antibiotics
without prescription is common in Indonesia, driving
another impending pandemic, antimicrobial resis-
Prior to the COVID-19 pandemic in Indonesia,
we documented the frequent dispensing of Fradiomy-
cin/Gramicidin lozenges by staff at community phar-
macies and drug stores.
In this current study, we
confirmed reports of the increase in demand for the
antibiotic Azithromycin. This is likely because it is spe-
cifically mentioned in specifically in guidelines for man-
agement of patients with COVID-19.
Although most
patients with COVID-19 do not also have a bacterial
infection and therefore do not require any antibiotics, in
the face of the pandemic, avoiding the use of antibiotics
has been challenging. Other studies have also reported
increased use of antibiotics in the community in both
and high income countries.
technicians were more likely than pharmacists, to report
selling antibiotics and other prescription-only medi-
cines. This finding is consistent with a study (pre-
COVID19) from Abu Dhabi showing that pharmacy
Figure 3. Practices of pharmacists and pharmacy technicians related to COVID-19.
Figure 4. Advice provided to clients by pharmacists and pharmacy technicians on COVID-19.
8 Vol 22 Month , 2022
technicians are more likely to sell antibiotics to their cli-
ents compared to pharmacists.
Countries should be
closely tracking the use of antibiotics amid the COVID-
19 pandemic and training health workers on antimicro-
bial stewardship.
Most respondents in this study were willing to sup-
port COVID-19 response efforts by providing verbal
advice to clients, distributing information leaflets, and/
or participating in early warning systems in the event of
a disease outbreak. Given that pharmacists and phar-
macy technicians are often the only point of contact
with the health system for rural and/or remote commu-
nities, there is potential to expand their role as sources
of reliable information both for COVID-19 and future
pandemics. Smaller outlets were more willing to engage
in outbreak surveillance activities. This might have been
due to the less complex administrative issues that the
smaller outlets would have needed to complete com-
pared to the larger outlets, particularly those working in
chain pharmacies.
At the time of the survey, drug retail outlets were not
authorised to sell COVID-19 rapid antibody test kits or
any type of test kits for COVID-19, yet it had been
reported that some were selling these test kits at highly
variable prices.
In our study we asked participants
about whether they suspected test kits were being sold
despite the prohibition, and whether they felt retail
drug outlets had a future role to play in their distribu-
tion. Around half of the respondents in our study
believed these tests (sourced from online sellers or
wholesale sellers) were being sold and conducted at
drug retail outlets and a quarter were in support of this.
Figure 5. Proportion of respondents who suspected seeing clients with COVID-19 in the last week, by province.
Figure 6. Reasons for suspecting a client had COVID-19.
Articles Vol 22 Month , 2022 9
A recent qualitative study from Jordan suggested a
high level of willingness among community pharmacies
to be involved in testing but expressed concerns about
their lack of preparedness and training.
In order to
explore the possibility of extending the role of pharma-
cists or pharmacy technicians in providing COVID-19
testing in Indonesia, it will be important for the govern-
ment to engage with drug retail outlets proactively.
One of the main limitations of this online survey is
that it is difficult to ascertain the non-response rate and
whether there were systematic differences between
those who chose to participate compared to those who
did not, which might have in turn influenced our find-
For example, the under-representation of staff
above 50 years of age, which may have been due to
higher levels of internet illiteracy among older age
Figure 7. Symptoms of clients suspected of having COVID-19.
Figure 8. Medicines and other products sold to clients suspected of having COVID-19.
*including those containing an antibiotic.
**excluding azithromycin and lozenges.
10 Vol 22 Month , 2022
Willingness to provide verbal advice on COVID-19 to the client (N=2353)
Predictors Unwilling
(55/2353; 2¢3%)
Moderately willing
(688/2353; 29¢4%)
Very willing
(1610/2353; 68¢4%)
N (%; 95%CI) N (%; 95%CI) N (%; 95%CI)
Age (years)
<30 27 (2¢5; 1¢7-3¢7) 314 (29¢6; 26¢9-32¢7) 718 (67¢8; 64¢9-70¢5)
31-40 21 (2¢2; 0¢1-3¢4) 278 (29¢3; 26¢5-32¢3) 649 (68¢5; 65¢4-71¢3)
41-50 5 (1¢8; 0¢1-4¢3) 81 (29¢6; 24¢5-35¢4) 188 (68¢6; 62¢7-73¢7)
>50 2 (3¢0; 0¢0-1¢2) 12 (18¢2; 10¢9-30¢3) 52 (78¢8; 66¢2-86¢6)
Male 6 (1¢3; 0¢5-3¢4) 127 (27¢2; 23¢4-31¢4) 333 (71¢5; 67¢2-75¢3)
Female 49 (2¢7; 0¢2-2¢8) 544 (29¢4; 27¢4-31¢6) 1252 (67¢9; 65¢7-70¢0)
Rather not say 0 (0¢0; 0¢0-0¢0) 17 (45¢9; 30¢6-62¢1) 20 (54¢1; 37¢9-69¢4)
Main workplace
Pharmacy 53 (2¢4; 1¢8-3¢1) 643 (29¢4; 2¢7-3¢1) 1484 (68¢2; 66¢1-70¢0)
Drug store 2 (1¢2; 0¢3-4¢6) 45 (26¢8; 20¢6-34¢0) 121 (72¢0; 64¢7-78¢3)
Size of workplace
>3 staff members 27 (2¢4; 1¢6-3¢4) 338 (29¢4; 26¢8-32¢1) 782 (68¢2; 65¢5-70¢8)
3 staff members 28 (2¢3; 1¢6-3¢4) 350 (29¢1; 26¢7-31¢7) 823 (68¢5; 65¢8-71¢1)
Concerned about getting COVID-19
Not worried 3 (4¢8; 1¢5-13¢8) 18 (28¢6; 18¢7-40¢9) 42 (66¢6; 54¢1-77¢2)
A little 22 (2¢2; 1¢4-3¢8) 315 (32¢0; 29¢3-35¢1) 643 (65¢8; 52¢6-68¢5)
Very worried 30 (2¢3; 1¢6-3¢2) 35 (27¢2; 24¢7-29¢7) 920 (70¢5; 68¢0-72¢9)
Number of suspected COVID-19 clients
None 46 (2¢3; 0¢2-3¢1) 582 (29¢7; 27¢7-31¢8) 1329 (68; 65¢8-69¢9)
10 clients 9 (2¢9; 0¢2-5¢5) 82 (26¢5; 21¢9-31¢8) 218 (70¢6; 65¢2-75¢3)
>10 clients 0 (0¢0; 0¢0-0¢0) 688 (29¢3; 20¢4-40¢0) 58 (70¢7; 59¢9-79¢5)
Willingness to distribute information leaets on COVID-19 (N=2350)
Predictors Unwilling
(54/2350; 2¢3%)
Moderately willing
(681/2350; 28¢9%)
Very willing
(1615/2350; 68¢7%)
Age (years)
<30 26(2¢5; 1¢6-3¢6) 349 (32¢9; 30¢1-35¢8) 684 (64¢6; 61¢6-67¢4)
31-40 22 (2¢3; 1¢5-3¢5) 257 (27¢1; 24¢3-30¢0) 669 (70¢6; 67¢6-73¢4)
41-50 6 (2¢2; 0¢9-4¢8) 57 (20¢9; 16¢4-26¢1) 210 (76¢9; 71¢5-81¢6)
>50 0 (0¢0; 0¢0-0¢0) 16 (24¢2; 15¢8-37¢1) 50 (75¢8; 62¢9-84¢1)
Male 5 (1¢1; 0¢4-2¢5) 115 (24¢7; 21¢0-28¢9) 346 (74¢2; 70¢0-78¢0)
Female 49 (2¢7; 2¢0-3¢5) 547 (29¢6; 27¢6-31¢8) 1251(67¢7; 65¢5-69¢7)
Rather not say 0 (0¢0; 0¢0-0¢0) 19 (51¢3; 35¢4-66¢9) 18 (48¢7; 33¢0-64¢6)
Main workplace
Pharmacy 51 (2¢3; 1¢8-3¢1) 638 (29¢3; 27¢4-31¢2) 1492 (68¢4; 66¢4-70¢3)
Drug store 3 (1¢8; 0¢6-5¢3) 43 (25¢4; 19¢4-32¢5) 123 (72¢8; 65¢6-78¢9)
Size of workplace
>3 staff members 33 (2¢9; 2¢0-4¢0) 360 (31¢4; 28¢8-34¢2) 754 (65¢7; 62¢9-68¢4)
3 staff members 21 (1¢7; 1¢1-2¢7) 321 (26¢7; 24¢3-29¢3) 861 (71¢6; 68¢9-74¢0)
Concern of getting COVID-19
Not worried 5 (7¢9; 3¢3-17¢8) 19 (30¢2; 20¢0-42¢6) 39 (61¢9; 49¢3-73¢1)
A little 25 (2¢5; 1¢7-3¢7) 285 (29¢0; 26¢3-31¢9) 673 (68¢5; 65¢4-71¢2)
Very worried 24 (1¢8; 1¢2-2¢7) 377 (28¢9; 26¢5-31¢4) 903 (69¢3; 66¢7-71¢7)
Table 3 (Continued)
Articles Vol 22 Month , 2022 11
groups, could have biased our results. We also could not
determine if a respondent completed the survey more
than once. It is also important to note that this study
was conducted in the initial months of the COVID-19
pandemic. Given how quickly the pandemic is evolving
in Indonesia, it could be that some of the issues identi-
fied have changed or been addressed. Caution should
also be taken when interpreting the result on number of
clients visiting the outlets, as this was based on esti-
mates provided by drug outlett staff.
Our research has identified several key lessons for
future response efforts. First, it has exposed the fragility
of medical supply chains for infection control products
including PPE and the need to strengthen local sourc-
ing and production to help prevent the risk of stock-outs
during any future health crises. Second, our results
point to frequent antibiotic use among COVID-19
patients attending drug retail outlets in Indonesia. The
potential knock-on effects this can have on the contain-
ment of antimicrobial resistance are significant.
Third, it is likely that COVID-19 rapid antibody test kits
were available among drug retail outlets (especially via
online pharmacies) despite not being approved for pur-
chase. Future response efforts must involve the early
monitoring and regulation of these tests to ensure their
safe use in the community. Fourth, provided they have
access to accurate guidance and information, many
pharmacies are willing to actively participate in
response efforts including through surveillance and
communication. Thus, our study supports recent calls
for expanding the role of private drug outlets during
future outbreaks.
Finally, what COVID-19 has shown globally is that
effective whole-of-health system responses are needed
to effectively deal with major public health threats. In
countries like Indonesia where there is a dominant
Willingness to distribute information leaets on COVID-19 (N=2350)
Predictors Unwilling
(54/2350; 2¢3%)
Moderately willing
(681/2350; 28¢9%)
Very willing
(1615/2350; 68¢7%)
Number of suspected COVID-19 clients
None 44 (2¢3; 1¢7-3¢0) 568 (29¢0; 27¢1-31¢1) 1346 (68¢7; 66¢6-70¢7)
10 clients 8 (2¢6; 1¢3-5¢1) 94 (30¢3; 25¢4-35¢7) 208 (67¢1; 61¢6-72¢1)
>10 clients 2 (2¢4; 0¢6-9¢3) 19(23¢2; 15¢3-33¢6) 61 (74¢4; 63¢8-82¢7)
Willingness to participate in surveillance activities (N=2350)
Predictors Unwilling
(264/2350; 11¢2%)
Moderately willing
(1074/2350; 45¢7%)
Very willing
(1012/2350; 43¢1%)
Age (years)
<30 111 (10¢5; 8¢7-12¢4) 516 (48¢6; 45¢6-51¢6) 434 (40¢9; 37¢9-43¢9)
31-40 116 (12¢2; 10¢3-14¢5) 411 (43¢4; 40¢2-46¢5) 421 (44¢4; 41¢3-47¢6)
41-50 32 (11¢7; 8¢3-16¢1) 117 (42¢7; 36¢9-48¢6) 125 (45¢6; 39¢8-51¢6)
>50 5 (7¢8; 3¢2-17¢5) 28 (43¢8; 32¢1-56¢1) 31 (48¢4; 36¢4-60¢6)
Male 50 (10¢7; 8¢2-13¢9) 206 (44¢2; 39¢7-48¢8) 210 (45¢1; 40¢6-49¢6)
Female 209 (11¢3; 9¢9-12¢8) 849 (46¢0; 43¢7-48¢2) 789 (42¢7; 40¢5-44¢9)
Rather not say 5(13¢5; 5¢7-28¢9) 19 (51¢4; 35¢4-66¢9) 13 (35¢1; 21¢5-51¢8)
Main workplace
Pharmacy 242 (11¢1; 9¢8-12¢5) 1012 (46¢4; 44¢3-48¢5) 927 (42¢5; 40¢4-44¢6)
Drug store 22 (13¢0; 8¢7-19¢0) 927 (42¢5; 29¢7-44¢2) 85 (50¢3; 42¢8-57¢8)
Size of workplace
>3 staff members 149 (13¢0; 11¢2-15¢1) 551 (48¢0; 45¢2-50¢9) 447 (39¢0; 36¢2-41¢8)
3 staff members 115 (9¢6; 8¢0-11¢4) 523 (43¢5; 40¢7-46¢2) 565 (46¢9; 44¢2-49¢8)
Concerned about getting COVID-19
Not worried 8 (12¢5; 6¢3-23¢1) 29 (45¢3; 33¢5-57¢6) 27 (42¢2; 30¢7-54¢6)
A little 107 (10¢9; 9¢1-13¢0) 475 (48¢4; 45¢2-51¢6) 399 (40¢7; 37¢6-43¢7)
Very worried 14 (11¢4; 9¢8-13¢3) 570 (43¢7; 41¢0-46¢4) 586 (44¢9; 42¢2-47¢6)
Number of suspected COVID-19 clients
None 218 (11¢1; 9¢8-12¢6) 892 (45¢6; 43¢4-47¢8) 848 (43¢3; 41¢1-45¢5)
10 clients 41 (13¢2; 9¢9-17¢5) 142 (45¢8; 40¢3-51¢4) 127 (40¢9; 35¢6-46¢5)
>10 clients 5 (6¢1; 2¢5-13¢9) 40 (48¢8; 38¢1-59¢6) 37 (45¢1; 34¢7-56¢0)
Table 3: Respondentswillingness to engage in the COVID-19 response, by respondent and workplace characteristics.
12 Vol 22 Month , 2022
private sector, the ability to rapidly mobilise these actors
is critical. What we have observed in this study is that
while pharmacists have taken on many different roles to
protect the community and their staff during the
COVID-19 pandemic, these actions on the most part
have been ad hoc and not well-integrated into national
pandemic management. This is an ideal time for coun-
tries such as Indonesia to begin strengthening and
updating existing regulatory and community health
frameworks to accommodate the changing roles of drug
retail outlets during public health crises.
Conceptualisation: Yusuf Ari Mashuri, Luh Putu Lila
Wulandari, Mishal Khan, Astri Ferdiana, Ari Proban-
dari, Tri Wibawa, Neha Batura, Marco Liverani, Richard
Day, Stephen Jan, Gill Schierhout, Shunmay Yeung,
Virginia Wiseman
Data curation: Yusuf Ari Mashuri, Luh Putu Lila
Wulandari, Astri Ferdiana, Ari Probandari, Tri Wibawa,
Marco Liverani, Matthew Law, Shunmay Yeung, Vir-
ginia Wiseman
Formal analysis: Yusuf Ari Mashuri, Luh Putu Lila
Wulandari, Shunmay Yeung, Virginia Wiseman
Funding acquisition: Ari Probandari, Tri Wibawa,
Marco Liverani, Shunmay Yeung, Virginia Wiseman
Investigation: Yusuf Ari Mashuri, Luh Putu Lila
Wulandari, Mishal Khan, Astri Ferdiana, Ari Proban-
dari, Tri Wibawa, Neha Batura, Marco Liverani, Richard
Day, Stephen Jan, Shunmay Yeung, Virginia Wiseman
Methodology: Yusuf Ari Mashuri, Luh Putu Lila
Wulandari, Mishal Khan, Astri Ferdiana, Ari Proban-
dari, Tri Wibawa, Neha Batura, Marco Liverani, Richard
Day, Stephen Jan, Shunmay Yeung, Virginia Wiseman
Project administration: Yusuf Ari Mashuri, Luh Putu
Lila Wulandari, Shunmay Yeung, Virginia Wiseman
Resources: Yusuf Ari Mashuri, Luh Putu Lila Wulan-
dari, Shunmay Yeung, Virginia Wiseman
Supervision: Ari Probandari, Tri Wibawa, Marco Liv-
erani, Shunmay Yeung, Virginia Wiseman
Validation: Ari Probandari, Tri Wibawa, Marco Liver-
ani, Shunmay Yeung, Virginia Wiseman
Visualisation: Yusuf Ari Mashuri, Luh Putu Lila
Writing original draft: Yusuf Ari Mashuri, Luh
Putu Lila Wulandari, Shunmay Yeung, Virginia
Writing review & editing: Yusuf Ari Mashuri, Luh
Putu Lila Wulandari, Mishal Khan, Astri Ferdiana, Ari
Predictors Willingness to distribute leaets on
COVID-19 to clients
Willingness to participate in
COVID-19 related surveillance activities
*(95%CI) p-value AOR
*(95%CI) p-value
Age (years)
30 1
31-40 1¢26 (1¢04 - 1¢52) 0¢018
41-50 1¢82 (1¢34 2¢48) <0¢001
>50 1¢58 (0¢88 2¢82) 0¢125
Female 1
Male 1¢31 (1¢04 1¢66) 0¢020
Rather not say 0¢46 (0¢24 0¢89) 0¢021
Type of drug retail outlet
Pharmacy 1
Drug store 1¢23 (0¢90 1¢70) 0¢187
Size of drug retail outlet
>3 staff members 1 1
3 staff members 1¢31 (1¢10 1¢56) 0¢003 1¢36 (1¢15 1¢61) <0¢001
Level of concern about getting COVID-19
Not worried
A little
Very worried
Number of suspected COVID-19 client
10 clients
>10 clients
Table 4: Correlates of willingness to participate in COVID-19 response.
AOR: Adjusted Odds Ratio.
* ‘very willing’ compared to ‘moderately willing’ and ‘unwilling’ combined.
Articles Vol 22 Month , 2022 13
Probandari, Tri Wibawa, Neha Batura, Marco Liverani,
Richard Day, Stephen Jan, Gill Schierhout,
Djoko Wahyono, Yulianto, John Kaldor, Rebecca
Guy, Matthew Law, Shunmay Yeung, Virginia Wise-
Data sharing statement
The data that underpin these findings may be released
following a written request to the last author.
Declaration of interests
All authors declare no competing interests.
The authors acknowledge the Department of Foreign
Affairs and Trade, Australia, under the Stronger Health
Systems for Health Security Scheme for supporting the
study. We also thank the Indonesian Ministry of Health,
Indonesian Pharmacist Association, Indonesian Phar-
macy Technician Association at the national and district
levels, and participants involved in this study.
Editor note: The Lancet Group takes a neutral posi-
tion with respect to territorial claims in published maps
and institutional affiliations.
Supplementary materials
Supplementary material associated with this article can
be found in the online version at doi:10.1016/j.
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Articles Vol 22 Month , 2022 15
... Be it global, national, state, regional, and institutional, the pharmacists have a responsibility to promote public health [66]. In this article review, several interventions have highlighted the emerging roles of community pharmacists on public health especially on smoking cessation [7][8][9][10][11][12][13][14], weight management [15][16][17][18]68], COVID-19 [58][59][60][61], chronic disease management [19][20][21][22][23][24][25]62], drug misuse prevention and management [26][27][28][29][30][31], and immunization and vaccination [32][33][34][35][36][37][38][39][40][41][42][43][44][45][46]. ...
This study's aim was to conduct a comprehensive review of previously published research publications related to the emerging roles of community pharmacists in public health in Asia. It aims to analyze the new roles that community pharmacists are being called upon to fill in Asian regions in public health with also a focus on maximizing the full capacity of pharmacist skills and development to public health, a continuing advocate, and first-line empowerment of providing pharmacy information queries. The written works of this study utilized a systematic search of existing literature, including articles reporting on the emerging roles of community pharmacists in public health, using the following databases: Cochrane, Google Scholar, Science Direct, PubMed/Medline, and Research Gate. Hand searching relevant articles on the research topic were employed to help ensure the confinement of all necessary existing literature/articles. The intervention or services types are classified based on the following: smoking cessation services, weight management services, alcohol reduction services, chronic disease management, drug misuse prevention and management services, and immunization and vaccination services; each comprises different major processes aiming to improve an individual's health status providing ways upon validation that are crucial for the betterment of public healthcare. In accordance with the studies, community pharmacist-led public-health programs markedly strengthened the efficiency, steadfastness, and cost-effectiveness of the allocation of public health resources whilst still optimizing the health of clients and patients, specifically whenever it arrives at assessing prospective issues and individuals who seek specialized care. Notwithstanding such, community pharmacy operations still necessitate modification to satisfy the evolving demands of consumers of modern medications. Training must attempt to boost pharmacists' confidence in supplying these services if community pharmacies are to elevate the public health services they serve. A proactive approach to the delivery of public health care by confident, well-trained pharmacists should have a favorable impact on client attitudes and health.
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The global COVID-19 pandemic has resulted in an upsurge in antimicrobial use. The increase in use is multifactorial, and is particularly related to the empirical treatment of SARS-CoV-2 and suspected coinfections with antimicrobials and the limited quality of diagnostics to differentiate viral and bacterial pneumonia. The lack of clear clinical guidelines across a wide range of settings, and the inadequacy of public health sectors in many countries, have contributed to this pattern. The increased use of antimicrobials has the potential to increase incidences of antimicrobial resistance, especially in low-resource countries such as Zimbabwe already grappling with multidrug-resistant micro-organism strains. By adopting the antimicrobial stewardship principles of the correct prescription and optimised use of antimicrobials, as well as diagnostic stewardship, revamping regulatory oversight of antimicrobial surveillance may help limit the occurrence of antimicrobial resistance during this pandemic.
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Introduction: The aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia. Methods: Standardised patients (SPs) made a total of 495 visits to 166 drug outlets (community pharmacies and drug stores) between July and August 2019. The SPs presented three clinical cases to drug outlet staff: parent of a child at home with diarrhoea; an adult with presumptive tuberculosis (TB); and an adult with upper respiratory tract infection (URTI). The primary outcome was the dispensing of an antibiotic without prescription, with or without the client requesting it. We used multivariable random effects logistic regression to assess factors associated with the primary outcome and conducted 31 interviews with drug outlet staff to explore these factors in greater depth. Results: Antibiotic dispensing without prescription occurred in 69% of SP visits. Dispensing antibiotics without a prescription was more likely in standalone pharmacies and pharmacies attached to clinics compared with drug stores, with an OR of 5.9 (95% CI 3.2 to 10.8) and OR of 2.2 (95% CI 1.2 to 3.9); and more likely for TB and URTI SP-performed cases compared with child diarrhoea cases, with an OR of 5.7 (95% CI 3.1 to 10.8) and OR of 5.2 (95% CI 2.7 to 9.8). Interviews revealed that inappropriate antibiotic dispensing was driven by strong patient demand for antibiotics, unqualified drug sellers dispensing medicines, competition between different types of drug outlets, drug outlet owners pushing their staff to sell medicines, and weak enforcement of regulations. Conclusion: This study shows that inappropriate dispensing of antibiotics by private drug retail outlets is widespread. Interventions will need to address not only the role of drug sellers, but also the demand for antibiotics among clients and the push from drug outlet owners to compete with other outlets.
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Background: We assessed the impact of the coronavirus disease 2019 (COVID-19) epidemic in India on the consumption of antibiotics and hydroxychloroquine (HCQ) in the private sector in 2020 compared to the expected level of use had the epidemic not occurred. Methods and findings: We performed interrupted time series (ITS) analyses of sales volumes reported in standard units (i.e., doses), collected at regular monthly intervals from January 2018 to December 2020 and obtained from IQVIA, India. As children are less prone to develop symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we hypothesized a predominant increase in non-child-appropriate formulation (non-CAF) sales. COVID-19-attributable changes in the level and trend of monthly sales of total antibiotics, azithromycin, and HCQ were estimated, accounting for seasonality and lockdown period where appropriate. A total of 16,290 million doses of antibiotics were sold in India in 2020, which is slightly less than the amount in 2018 and 2019. However, the proportion of non-CAF antibiotics increased from 72.5% (95% CI: 71.8% to 73.1%) in 2019 to 76.8% (95% CI: 76.2% to 77.5%) in 2020. Our ITS analyses estimated that COVID-19 likely contributed to 216.4 million (95% CI: 68.0 to 364.8 million; P = 0.008) excess doses of non-CAF antibiotics and 38.0 million (95% CI: 26.4 to 49.2 million; P < 0.001) excess doses of non-CAF azithromycin (equivalent to a minimum of 6.2 million azithromycin treatment courses) between June and September 2020, i.e., until the peak of the first epidemic wave, after which a negative change in trend was identified. In March 2020, we estimated a COVID-19-attributable change in level of +11.1 million doses (95% CI: 9.2 to 13.0 million; P < 0.001) for HCQ sales, whereas a weak negative change in monthly trend was found for this drug. Study limitations include the lack of coverage of the public healthcare sector, the inability to distinguish antibiotic and HCQ sales in inpatient versus outpatient care, and the suboptimal number of pre- and post-epidemic data points, which could have prevented an accurate adjustment for seasonal trends despite the robustness of our statistical approaches. Conclusions: A significant increase in non-CAF antibiotic sales, and particularly azithromycin, occurred during the peak phase of the first COVID-19 epidemic wave in India, indicating the need for urgent antibiotic stewardship measures.
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Antimicrobial resistance is a hidden threat lurking behind the COVID-19 pandemic which has claimed thousands of lives prior to the emergence of the global outbreak. With a pandemic on the scale of COVID-19, antimicrobial resistance has the potential to become a double-edged sword with the overuse of antibiotics having the potential of taking us back to the pre-antibiotic era. Antimicrobial resistance is majorly attributed to widespread and unnecessary use of antibiotics, among other causes, which has facilitated the emergence and spread of resistant pathogens. Our study aimed to conduct a rapid review of national treatment guidelines for COVID-19 in 10 African countries (Ghana, Kenya, Uganda, Nigeria, South Africa, Zimbabwe, Botswana, Liberia, Ethiopia, and Rwanda) and examined its implication for antimicrobial resistance response on the continent. Our findings revealed that various antibiotics, such as azithromycin, doxycycline, clarithromycin, ceftriaxone, erythromycin, amoxicillin, amoxicillin-clavulanic acid, ampicillin, gentamicin, benzylpenicillin, piperacillin/tazobactam, ciprofloxacin, ceftazidime, cefepime, vancomycin, meropenem, and cefuroxime among others, were recommended for use in the management of COVID-19. This is worrisome in that COVID-19 is a viral disease and only a few COVID-19 patients would have bacterial co-infection. Our study highlighted the need to emphasize prudent and judicious use of antibiotics in the management of COVID-19 in Africa.
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Background: Community pharmacists play a pivotal role in healthcare worldwide. Their role became more critical during the COVID-19 pandemic. This study aims to investigate the community pharmacists' preparedness and responses to the COVID-19 pandemic, and how efficiently they were prepared to contain and prevent the spread of infection. Methods: An online questionnaire was distributed to community pharmacists in Saudi Arabia, Lebanon, and Jordan through social media platforms. A scoring system was developed to measure their level of adherence to the preventive measures of the global infection. Results: The total included responses were 800. Around 44% of the pharmacists reported spending less than 15 minutes/day reading about COVID-19 updates. Although more than half of them were reviewing official sites, 73% of them were also retrieving information through non-official channels. Additionally, almost 35% of them were directly contacting customers without physical barriers, 81% reported encountering infected customers, and 12% wore the same facial masks for more than a day. Moreover, 58% of the pharmacies reported the absence of door signs requesting infected customers to declare the infection, 43% of the pharmacies were not limiting the number of simultaneous customers, and 70% were not measuring customers' temperatures prior to entry. Collectively, the mean total score of applied protective measures was 10.12 ± 2.77 (out of 17). Conclusion: The level of preparedness of the community pharmacies in these three Middle Eastern countries was not adequate for facing the COVID-19 pandemic. Health authorities in these countries should closely monitor their adherence to the protective guidelines.
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Background: COVID-19 has already claimed a considerable number of lives worldwide. However, there are concerns with treatment recommendations given the extent of conflicting results with suggested treatments and misinformation, some of which has resulted in increased prices and shortages alongside increasing use and prices of personal protective equipment (PPE). This is a concern in countries such as India where there have been high patient co-payments and an appreciable number of families going into poverty when members become ill. However, balanced against pricing controls. Community pharmacists play a significant role in disease management in India, and this will remain. Consequently, there is a need to review prices and availability of pertinent medicines during the early stages of the COVID-19 pandemic in India to provide future direction. Objective: Assess current utilisation and price changes as well as shortages of pertinent medicines and equipment during the early stages of the pandemic. Our Approach: Multiple approach involving a review of treatments and ongoing activities across India to reduce the spread of the virus alongside questioning pharmacies in selected cities from early March to end May 2020. Our Activities: 111 pharmacies took part, giving a response rate of 80%. Encouragingly, no change in utilisation of antimalarial medicines in 45% of pharmacies despite endorsements and for antibiotics in 57.7% of pharmacies, helped by increasing need for a prescription for dispensing. In addition, increased purchasing of PPE (over 98%). No price increases were seen for antimalarials and antibiotics in 83.8 and 91.9% of pharmacies respectively although shortages were seen for antimalarials in 70.3% of pharmacies, lower for antibiotics (9.9% of pharmacies). However, price increases were typically seen for PPE (over 90% of stores) as well as for analgesics (over 50% of pharmacies). Shortages were also seen for PPE (88.3%). Conclusion: The pandemic has impacted on utilisation and prices of pertinent medicines and PPE in India but moderated by increased scrutiny. Key stakeholder groups can play a role with enhancing evidenced-based approaches and reducing inappropriate purchasing in the future.
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Background: As the coronavirus disease pandemic continues to severely strain healthcare systems across the globe, there is need to determine whether every facet of the healthcare system is ready to respond. Purpose of the study: The study investigated whether community pharmacists in the Kingdom of Saudi Arabia are ready to play a supportive role in the fight against COVID-19. Methods: The study employed a descriptive cross-sectional survey. A descriptive analysis to capture the demographic characteristics of the sampled population, frequency tables and graphs were generated to capture community pharmacists' practice, readiness, attitudes and awareness. The means of the subset of knowledge on COVID-19 etiology, prognosis and management, and the practice, attitudes were compared in a one way analysis of variance to determine whether the difference was significant to predict preparedness towards playing a supportive role in the fight against COVID-19. Results: The practice of community pharmacist as reflected adherence to recommended guidelines by the ministry of health on COVID-19 management and control. About 74% always disinfected contact surfaces, 69% conducted basic temperature checks on staff members and customers. Community pharmacists in Saudi Arabia displayed positive attitudes towards fight against COVID-19 [m = 4.08 and a relatively narrow difference in percentage distribution between those who were not sure and those who claimed to be very satisfied 20%]. Community pharmacists in KSA displayed extensive knowledge on the subject of COVID-19 as all respondents were aware of the primary symptoms of COVID-19 (100%), 62% were aware of COVID-19 management strategies, 81% believed information supplied through the ministry was sufficient. A p value of 0.00 indicated that the results were significant to support the assumption that community pharmacists in KSA were prepared to play a supportive role in the fight against COVID-19. Conclusion: The result demonstrated readiness among Saudi Arabian community pharmacists to be integrated into COVID-19 pandemic planning and response.
Background: Globally, antibiotics misuse by the public has been reported in the era of COVID-19, despite the discouraging instructions of the World Health Organization, especially for mild cases. Objective: Is to describe this antibiotic misuse and its contributing factors. Also, to measure the pharmacists' application of infection preventive practices during the pandemic. Methods: A cross-sectional study was conducted among randomly selected Egyptian community pharmacists (Center, East, Delta, and Upper Egypt) using a questionnaire and direct interviews from 1 to 30 August 2020. The questionnaire consisted of 2 parts, the first covered pharmacist's demographic data and their application of basic infection preventive practices (e.g. wearing face masks, regular hand sanitization, etc.), and the other part was related to antibiotic dispensing patterns. Data were descriptively analyzed and the impact of participant experience on the responses was evaluated using the Chi-square test. Results: From 480 randomly selected Egyptian community pharmacists, 413 (87%) consented to participate in the study. 86.7% the participants were keen to wear face masks (n=358) and 86.2% kept regular hand sanitization (n=356); whereas, 46.9% (n=194) maintained adequate antibiotic stock supply during the pandemic. Nearly 67% (n=275) of the pharmacists reported that patients were more likely to be given antibiotics for showing any sign or symptom of COVID-19 infection, and 82% (n=74278) of the dispensed antibiotics were given upon physician recommendation. Azithromycin, Ceftriaxone, and Linezolid were the major antibiotics dispensed to COVID-19 presumptive patients Azithromycin was given to approximately 40 % of presumptive patients showing only mild or moderate symptoms for 5-10 days. Additionally, antibiotic combinations were given to 74% (n=62479) of home-isolated patients for a maximum of 2 weeks. Conclusions: Pharmacists applied suitable sanitation and infection control protocols. Meanwhile, antibiotics were dispensed heavily during this pandemic without proper clinical indication and for long durations supporting the idea of antibiotic misuse.
The aim of this paper is to review the roles that community pharmacists in the United States (US) can play to support public health measures during the current severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic (COVID-19). Community pharmacists in the US are highly visible and accessible to the public and have long been regarded as a source for immunization services as well as other public health activities. In the US, the scope of pharmacy practice continues to expand and incorporate various health services on a state-by-state level. For the purposes of this article, a PubMed literature search was undertaken to identify published articles on SARS-CoV-2, COVID-19, pharmacist- and pharmacy-based immunization and other public health care activities in the US in order to identify and discuss roles that community pharmacists can play during this pandemic including as vaccinators, screeners and testers. In conclusion, community pharmacists are knowledgeable and capable providers of public health services and are easily accessible and well regarded by the public. The incorporation of community pharmacists into this nation’s COVID-19 pandemic response plan can help aid recovery efforts in the US.