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,
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 Vincent’s 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: email@example.com (L.P.L. Wulandari).
These authors contributed equally to this work.
The Lancet Regional
Health - Western Paciﬁc
Published online xxx
www.thelancet.com 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
Keywords: COVID-19 pandemic; Disease outbreak; Health system preparedness and response; Pharmacy; Drug-
Research in context
Evidence before this study
Pharmacies and drug stores play an important role in
serving the community as they are often the ﬁrst 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
Indonesia’s 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,
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 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 www.thelancet.com 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.
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)
to guide development of the study design.
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
The original questionnaire was developed in English,
translated into Indonesian, and then back-translated to
conﬁrm accuracy of the translation.
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 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,
www.thelancet.com 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-
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 ﬂowchart.
4 www.thelancet.com 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-
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.
www.thelancet.com 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,
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)
Bachelor’s 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 www.thelancet.com 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-
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)
Ofﬂine (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 ofﬂine** 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)
Don’t 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.
www.thelancet.com 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,
been reports that they have sparked patient anxiety and
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.
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 www.thelancet.com 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-
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
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
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.
www.thelancet.com 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 www.thelancet.com Vol 22 Month , 2022
Willingness to provide verbal advice on COVID-19 to the client (N=2353)
N (%; 95%CI) N (%; 95%CI) N (%; 95%CI)
<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)
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 leaﬂets on COVID-19 (N=2350)
<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)
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)
www.thelancet.com 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
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 leaﬂets on COVID-19 (N=2350)
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)
<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)
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: Respondents’willingness to engage in the COVID-19 response, by respondent and workplace characteristics.
12 www.thelancet.com 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,
Data curation: Yusuf Ari Mashuri, Luh Putu Lila
Wulandari, Astri Ferdiana, Ari Probandari, Tri Wibawa,
Marco Liverani, Matthew Law, Shunmay Yeung, Vir-
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 leaﬂets on
COVID-19 to clients
Willingness to participate in
COVID-19 related surveillance activities
*(95%CI) p-value AOR
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
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
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
Number of suspected COVID-19 client
Table 4: Correlates of willingness to participate in COVID-19 response.
AOR: Adjusted Odds Ratio.
* ‘very willing’ compared to ‘moderately willing’ and ‘unwilling’ combined.
www.thelancet.com 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 material associated with this article can
be found in the online version at doi:10.1016/j.
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