An Exploratory Study of Consumers’ Social Behavior Towards Role of Malaysian Community Pharmacists in Providing Healthcare

Background: Consumers awareness, perceptions, expectations and experiences are integral components of their satisfaction towards the quality of care provided by community pharmacists. The study aims to assess consumers’ awareness, perceptions, expectations and experiences about the role of community pharmacists in providing healthcare. Methods: The study was carried out in the state of Penang, in the north of Malaysia. A survey was carried out by conveniently selecting the consumers patronizing the community pharmacies. A pretested and validated survey tool with different domains (Cronbach’s alpha ranged from 0.577 to 0.774) was used. Descriptive and inferential statistics (Chi-Square, Mann-Whitney and Kruskal-Wallis tests) were used for analyzing the data using SPSS program, Version 26. Results: Of the total 424 questionnaires distributed, 195 (46%) were returned and usable. The median age of the consumers was 30 (IQR = 28-38). The majority of them were female, Chinese, living in urban area and having a bachelor degree. The mean awareness score was 8.39 (± 2.00), mean perception score was 2.95 (± 0.83), mean expectation score was 3.70 (± 0.13), and mean experience score was 3.17 (± 0.97). Trusting a pharmacist’s advice about medicines was signicantly associated with the consumer’s age (p= 0.030). age of the consumers was a signicant determinant in their perception of CP suggestions about the use of certain prescription medicines to patients and physicians (p = .001 and p = 0.014, successively). The strongly anticipated that CPs should monitor responses to drug therapy and be more concerned with the patient rather than being prot-oriented (medians = 5 and 4, respectively). Conclusions: The consumers in this study were aware of the role of community pharmacists in community pharmacies and healthcare settings. They were also showed high perception, expectation and positive experience with the community pharmacists.


Background
The rising contribution of pharmacists to public health will require changes in both pharmacist and consumer behaviors. Pharmacists are in a unique position to improve medication safety and they have the time and expertise to manage chronic conditions of the patients [1]. Many consumers have never been provided with public health services by their pharmacists and do not expect them to be an offer. Consumers consider a pharmacist to be a suitable public health counsellor but have ambivalent opinions on the involvement of pharmacists in this eld. Agreement with this role seems to be high among those who had experience with pharmaceutical public health [2]. The doctor-pharmacist relationship is crucial for consumer or patient satisfaction. Community pharmacists (CPs) can undertake a more active role in providing healthcare by creating partnerships with doctors so that patients can consult a pharmacist if they nd it impossible to visit the doctor. In addition, governments should encourage pharmacists to be involved in healthcare and should promote their role in patient education so that the public will have a chance to communicate with these professionals [3].
Generally, consumers accept community pharmacists as health educators but there are few barriers that hinder this task [4]. General Practitioners (GPs) and the public are similar in their negative perceptions of the pharmacist´s role in managing speci c minor symptoms [5]. In a study conducted, four important factors were found to in uence consumer satisfaction with the pharmacy and pharmacists in Malaysia [6]. These factors are convenient timing, over-the-counter (OTC) medicine availability and the diversity of products, pricing and attitudes towards the pharmacy and pharmacist. It was found that elderly and unemployed groups have a signi cant in uence on this satisfaction. Overall, they are underutilized [6].
There has been a growing need for community pharmacists around the world to have a greater professional role in the delivery of primary care for patients [1]. Pharmacists always occupy the position of the most trusted professionals, and they have a high ranking when people are asked to rate them [7].
The public´s understanding of community pharmacists' role in healthcare provision can assist in rendering consumers more aware of the abilities of CPs in improving care [8]. In the literature, there are few studies that highlight consumer perspectives towards community pharmacists' role as healthcare providers in Malaysia.
This study was conducted to evaluate the consumer awareness of CPs in the provision of healthcare, consumer perceptions of CPs in providing healthcare, consumer expectations of CPs in healthcare provision, and to evaluate consumer experiences with CPs during healthcare provision.

Study design
This study adopted a cross-sectional design using a questionnaire to determine Malaysian consumers' awareness, perceptions, expectations, and experience of the role of CPs in providing healthcare.

Ethical consideration
Ethical approval was obtained from the Joint Ethics Committee of the School of Pharmaceutical Sciences, USM-Hospital Lam Wah Ee on Clinical Studies. An explanatory statement for the general public (consumers) was attached to the questionnaire regarding the aims and objectives of the study. A verbal consent was approved by the committee as this is a survey design. Furthermore, the participants were provided assurance that responses would be kept con dential and used only for research purposes.

Study population and sample size
Due to nancial constraints, this study was restricted to Penang State. As noted earlier, Penang occupies an area of 1,048 km 2 and has a population of 1.5 million with a population density of 1,500/km 2 . The sample size was calculated using the same con dence interval approach developed by Cochran as follows: In making nite population corrections for proportions, the sample size (n 0 ) was adjusted using the second equation, where n 0 is the consumer sample size and N is the population size.
Due to the lack of population database and sampling frame, a convenient sampling method was applied to recruit the consumers. A sample of 385 was calculated with the addition of 10% for drop-outs. The total sample was thus 424 respondents who were selected according to the ease of data collection from pharmacy outlets by ve data collectors (undergraduate pharmacy students) who were recruited and trained to collect the data for a one-week period. Respondents under 21 years old were excluded.

Development and validation of the questionnaire
This questionnaire was developed after broadly reviewing an extensive range of literature and modi ed according to the Malaysian consumer context [9,10,11,12]. The questionnaire consisted of 36 questions divided into four sections, namely consumer awareness, perceptions, expectations, experiences with the pharmacist's role in healthcare provision, and demographic characteristics (see Appendix 1: Survey questionnaire). The rst section contained eleven questions grouped under the heading of consumer awareness of the CP's role in providing healthcare. This section was structured to include dichotomous questions with 'yes' or 'no' answers. The second section included nine items grouped under the heading of consumer perceptions of the CP's role. The third section consisted of nine items headed by consumer expectations and experiences with the CP's role. All the questions in the second and third sections were answered using a 4-point Likert scale, with strongly disagree = 1, disagree = 2, agree = 3 and strongly agree = 4. The fourth section included six demographic questions pertaining to patient gender, age, ethnic background, locality, education, and frequency of seeking information.
Supervisors, ethics expert and postgraduate students in the Discipline of Social and Administrative Pharmacy (DSAP) at the School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM) were asked to assess the content validity of this questionnaire. These individuals provided their general judgments by classifying and highlighting the questions according to their relevance and signi cance to the general aim of the study. The questionnaire was translated into the Malay language by the School of Languages, USM and again assessed for content validity by the same individuals in DSAP. To assess their face validity, 30 questionnaires were distributed by hand to 30 non-pharmacy Malaysian students in USM. All the students responded positively, and the questionnaires were collected after being answered fully, without making any comments. All of the students answered all the questions within 10 to 15 minutes and a rmed the clarity and simplicity of all the items. The questionnaire was then translated back into English by two experts from the School of Education and the Institute of Post Graduate Studies The coe cient alpha (i.e., Cronbach's alpha) was estimated for each of the three scales that had more than two categories in each scale. The highest coe cient (0.774) was found for the scale of consumer expectations towards the CP role in healthcare provision. The remaining two scales (perceptions and experiences) resulted in reliability estimates of 0.765 and 0.562, respectively. For dichotomous data (awareness), the coe cient alpha was 0.577. This result is equivalent to the Kuder-Richardson 20 (KR20) coe cient. For dichotomously scored items, KR20, and to some extent a computationally convenient approximation denoted KR21 (note that there were no computers in those days), gained notable fame, but they were gradually pushed aside as a misleading alpha [13]. Chi-Square test was used to determine the signi cance of differences between the consumer demographic characteristics (gender, age, ethnic background, locality, level of education and frequency of seeking information from community pharmacy) and dependent variables (consumer awareness, perceptions, expectations of a CP's role and consumer experiences with this role).
Mann-Whitney test was performed to look at the differences in the average scores for consumer awareness, perceptions, expectations of CP's role and GP's experiences with these roles based on the consumer demographic characteristics as sorted by gender. Kruskal-Wallis test was also used to determine the differences in the average scores for consumer awareness, perceptions, expectations and experiences of the CPs' roles among groups of consumers as sorted by age, ethnic background, locality, level of education and frequency of seeking information from the community pharmacy. Post hoc analyses using the Mann-Whitney test were further applied to determine where the differences occurred.
All the tests were run at an alpha level of 0.05.

Demographic characteristics of consumers
Of the total 424 questionnaires distributed by the members of the data collection team to consumers in Penang, 237 were returned, of which 42 questionnaires were not fully completed and were rejected. The total remaining useful number of questionnaires was 195, for a response rate of 46%. This response rate was adequate and found to be within the range quoted by researchers for self-administered questionnaires, namely from 5-70% [14]. All the demographic characteristics of the respondents are illustrated in Table 1. Consumer awareness of CPs' roles according to consumer's demographic characteristics Table 2 shows the results of descriptive and inferential analyses on consumers' awareness of CP's roles in providing healthcare. The results from the inferential analysis show that there were only two signi cant associations noticed in this part. Obtaining medicines without a prescription from a community pharmacy was found to be signi cantly associated with the consumer's locality of residence (p = 0.032). Trusting a pharmacist's advice about medicines was signi cantly associated with the consumer's age (p = 0.030). 10.Are you satis ed with the services provided by the community pharmacies?
11.Are you satis ed with the steps taken by the government to regulate the services provided by community pharmacies e.g., blood pressure monitoring, glucose and cholesterol levels assessments Consumer awareness of CPs' roles according to consumers' demographic characteristics The total average scores for consumer awareness of the CPs' roles and interpretations of the differences that emerged have been added up for the eleven items. The value of the mean awareness score was 8.39 (± 2.00) and the median score was 9.00 (IQR = 7.0-10.0). The minimum and maximum expected values were 0-11 and the midpoint was 5.5. A value above the midpoint was found to be a high awareness value. A Mann-Whitney test was performed to look at the differences in the average scores for consumer awareness of the CPs' roles according to a consumer demographic characteristic (gender). The Kruskal-Wallis test was also used to determine the differences in the average score for consumers awareness of the CPs' roles among groups of consumers as sorted by age, locality, and frequency of seeking information (FSI), ethnic background and level of education (Table 3).  Consumer perceptions of CPs' roles according to consumers' demographic characteristics As shown in Table 4, from the descriptive analysis, six of the median values equal 4, indicating that the consumers agree in their perceptions of the CPs' traditional role of providing patient education and suggesting the use of nonprescription medications to patients.  Table 5 shows that the age of the consumers was a signi cant determinant in their perception of CP suggestions about the use of certain prescription medicines to patients and physicians (p = .001 and p = 0.014, successively). The total average score for consumers' perceptions of the CPs' roles and interpretations of the associations that emerged were totaled for the nine items. The value of the mean perceptions score was 2.95 (± 0.83), and the median score was 3.00 (IQR = 2.22-3.67). The minimum and maximum expected values were (1-4), and the midpoint was 2.5; values above the midpoint were found to be high awareness values. Signi cant differences were found between the average score for the consumer perceptions of the CPs' roles and the consumer's age (p = 0.005), locality (p = 0.011), FSI (p = 0.042) and ethnic background (p = 0.026), as shown in Table 6.

Consumer expectations and experiences of CPs' roles
Contrary to the results for GPs, Tables 7 and 8 indicate that consumers have high levels of expectation for the CP as a healthcare provider. They expect CPs to take personal responsibility for resolving any drug-related problems they discover or to design drug therapy treatment plans, to be knowledgeable drug therapy experts and to educate them about the safe and appropriate use of medications (median = 4).
They also strongly anticipate that CPs will monitor responses to drug therapy and be more concerned with the patient rather than being pro t-oriented (medians = 5 and 4, respectively). Note. SD = Strongly disagree, D = Disagree, A = Agree, SA = Strongly agree 1. I expect pharmacists to take personal responsibility to solve any drug-related problem.
2. I expect pharmacists to be knowledgeable drug therapy experts.
3. I expect pharmacists to educate me on the safe and appropriate use of medicine.
4. I expect pharmacists to monitor responses to drug therapy.
5. I expect pharmacists to be more concerned about patients.

Discussion
This study was conducted to explore the consumers' awareness, perceptions, expectations and experiences with the community pharmacists' services. In summary, the study illustrated that the consumers were satisfactorily aware about the roles of community pharmacists in the country. The consumers also have high levels of perception, expectations and experiences toward pharmacists.

Consumer Awareness of CPs' Role in Healthcare Provision
Changes in the professional roles of the pharmacist such as the implementation of pharmaceutical care have resulted in a concentration of responsibilities within the pharmacist-patient collaborative relationship. If pharmacists and patients have the same opinion on the communicative relationship, then the usefulness and results of this relationship will be optimal [15]. Here, the role of the pharmacy institutions and academics comes into play in propagating community consumer awareness of the roles and value of the pharmacist in guaranteeing optimal therapeutic outcomes [16]. More than half of the consumers in this study were aware of the role of CPs in community pharmacies and healthcare settings, and they indicated this awareness by identifying the presence of the pharmacists during their visits to community pharmacies. Unfortunately, some consumers believed that personnel i.e. non-healthcare professionals who engage in dispensing tasks in GP clinics are pharmacists. This result is consistent with the nding of a study that identi ed 77.4% of the personnel who worked in medical clinics as pharmacists [17].
People must be aware of the need to treat OTC medicines with the same sense that they treat prescribed medicines since most pharmaceutical products can cause adverse events with low to moderate severities. The bene ts of increasing the circulation OTC medicines include increased ease for patients, greater control of minor illnesses and reduced national medicine expenditures. Health providers should also focus on the obvious criteria of these OTC products and their evident safety [18]. Our respondents indicated that they can obtain medicines from pharmacies without a prescription, they trust pharmacists to advise them regarding the use of medicines and other health issues and they feel comfortable when talking to a pharmacist regarding minor illnesses. Obtaining medicines without a prescription from a community pharmacy is in uenced by the consumer's locality of residence in this study. According to the locality of residence, consumers who live in the Penang city area were exceeding those from the suburbs and rural areas in obtaining medicines without a prescription from community pharmacies. This behavior may be due to the scarcity of private community pharmacies in rural areas where healthcare services are primarily delivered by the public sector.
Unless the healthcare system changes the way that it promotes trust in CPs, the public will not be expected to trust pharmacists to offer unfamiliar services that are perceived to have high risk. Public trust in this regard will be achieved by enhancing the pharmacist-patient relationship and by GPs supporting the pharmacists who are providing these services [19]. Although the GPs in this study did not support the CPs in providing these services, consumers are satis ed with the services provided by the community pharmacies and the steps taken by the government to regulate extended services such as the health screening services provided by the community pharmacies, such as blood pressure monitoring and glucose and cholesterol level assessments.
The awareness of our respondents is signi cantly associated with the consumer age as an important determinant in accepting a pharmacist's advice about medicines. Middle-aged consumers and older ones indicate more awareness of the advisory role of CPs regarding medicines than did younger consumers.
This result is consistent with the ndings from a study conducted in the Palestinian West Bank, in which older consumers (over 40 years old) were more likely to easily explain their opinions about asking a pharmacist for advice in comparison to younger consumers [20]. This result may have been found because the older consumers visited the same pharmacy frequently and thus established a good relationship with the CP, more than the younger group [21]. The ethnic background of consumers and their frequency in seeking information from the community pharmacy are the primary factors in uencing consumer awareness of the CP's roles in providing healthcare.

Consumer Perceptions of CPs' Role in Providing Healthcare
When studying the expansion of professional roles in healthcare, it is imperative to think about consumer perceptions and the impact of consumerism on the demand for health services [22]. Understanding how patients perceive and evaluate healthcare services should occur prior to measuring their satisfaction with these services [23]. The professional role of the pharmacist will not be fully used unless it is fully understood and perceived by the public. There is a scarcity of studies about consumer perceptions and their needs from CPs in Malaysia. One study consumer preferred to go to clinics and hospitals for minor illnesses and screening tests. Our respondents disagree in their perceptions of CPs' roles, which they believe to pertain to physicians only, such as suggesting the use of certain prescription medicines to patients, suggesting the use of certain prescription medicines to physicians, and diagnosing and treating minor illnesses [17]. This nding was also consistent with the ndings of a study conducted in Malta, where the respondents preferred to consult a doctor or treat themselves instead of consulting a pharmacist for their minor illnesses [24]. Although some pharmacists can provide these services, perhaps due to the lack of awareness of most consumers about the availability of the service, they prefer to visit a clinic or a hospital [17]. In Thailand, a country neighboring Malaysia, the situation is quite different in that consumers agree in their perception of the pharmacist's role in consultation activities, which are considered to be a vital part for the success of the pharmacy trade in that country [25]. On the other hand, a study conducted in Saudi Arabia found out that consumers perceived that there is lack of commitment from community pharmacists to dispense medications with prescriptions, and they do not give adequate counseling about medications. The professional performance in general is below expectation [26].
In the Malaysian study although the vast majority had heard the term "pharmacist", some consumers believed that pharmacists were working on farms, and the majority believed that pharmacists work in doctors' clinics [17]. In addition, the majority sought advice about the use of medicines from doctors and few went to pharmacists for this purpose. At present, a great improvement in consumer perceptions of pharmacists has taken place. Consumers in this study agreed in their perceptions of the CPs' roles regarding the educational and traditional roles of providing patient education and suggesting the use of nonprescription medications to patients. Certain clinical roles of CPs such as identifying and preventing prescription errors, designing and regulating medication regimens for patients, monitoring the outcomes of these regimens, and checking or preventing drug-related problems were also agreed upon by consumers. Trust in CPs was found to increase with age, and this is because the elderly are more extensive users of community pharmacies [27]. In the present study, consumer age was found to be a determinant in perceiving CPs as having a clinical role in providing healthcare. The majority of older respondents disagreed about the ability of CPs to perform these roles, more than middle-aged and young individuals. This nding may be attributed to the fact that in the past, pharmacists were perceived negatively by consumers, and older people now recall that past and stand as witnesses for the present era by still having the same perceptions towards pharmacists.
In India, rural residents have higher perceptions of pharmacists than urban inhabitants [28]. In this study, consumer perceptions of CPs' roles in monitoring drug regimens and checking and preventing drugrelated problems are correlated with the locality. The majority of the city inhabitants agreed that CPs monitor and prevent drug-related problems, more than those residing in the suburbs and rural areas. This nding may be attributed to the fact that there are no pharmacies and pharmacists in the rural areas of Malaysia, and nurses instead used to dispense medicines to patients [29]. Consumer FSI behavior is considered to be another determinant of their perceptions of the CP conducting extended pharmacy roles such as diagnosing and treating minor illnesses. Ethnic background was found to play an important role in tailoring consumer perceptions that the CP would suggest the use of certain prescription medicines to physicians and assist in checking and preventing drug-related problems. The age, locality, ethnic background of consumers and FSI from CPs are the primary factors in uencing consumer perceptions of the CPs' roles in providing healthcare.

Consumer Expectations of CPs and Experience in Healthcare Provision
In the present study, unlike GPs, consumers have high levels of expectations of the CP as a healthcare provider. They expect CPs to take personal responsibility for resolving any drug-related problems they discover and to design any drug therapy treatment plans. CPs are considered to be knowledgeable drug therapy experts who are able to educate patients on the safe and appropriate use of medications. They also strongly anticipated that CPs will monitor responses to drug therapy and be more concerned with patients rather than being pro t-oriented. In one study, consumers were interviewed had high expectations on community pharmacists to suggest the right medicines and advise them on the safe and effective use of medicines and recommend medicines with affordable price. The consumer's previous experiences with community pharmacists were not satisfactory [30].
Pharmacists should know the reliability of information, its accessibility and their abilities to evaluate the literature to assist patients and providers [31]. In their experiences with CPs, the consumers in this study also differed from the GP respondents in that they highly considered CPs as a reliable source of general drug information and as important professionals in healthcare provision. They also agreed that CPs always counsel them regarding the safe and appropriate use of medicines, and they denied the reversed statement that "Pharmacists appear reluctant to take personal responsibility for assisting them." In general, consumer expectations of the CPs in healthcare matched their experiences.
Locality is an important determinant for consumer expectations of CPs taking personal responsibility for solving any drug-related problem, with CPs being a reliable source of general drug information and knowledgeable drug therapy experts who are more concerned about patients than being pro t-oriented.
The level of education of the consumer and his or her locality of residence also had important impacts on consumers' experiences with the CP, especially urban citizens who utilized more educational and pharmaceutical services, to view the CP as an important healthcare provider and a counsellor of patients regarding the safe and appropriate use of medicines. Consumers who utilized the healthcare system expected to experience the highest quality of care services from con dent and experienced providers [32].
The response rate (46%) of the study was low and it was study only in one state, hence the ndings may or may not able to be generalized to the population. Secondly, due to the nature of the study, there is potential of social desirability bias i.e. there is tendency of the respondents to provide responses in a way to be more socially acceptable to the researchers.
In many countries, community pharmacies are more accessible to the general population. More evidencebased research related to the community pharmacists' role and contribution to public health needs to be carried out. Outcomes research also need to be done to focus on the effectiveness of community pharmacists' activities and practices versus general practitioners. From another perspective, research and practice model need be established to study the effectiveness of collaborative care between general practitioners and community pharmacists in disease management and outpatient patient care.

Conclusions
The Malaysian consumers in this study were aware of the role of CPs in community pharmacies and healthcare settings. Their opinions towards the pharmacy and pharmacists have progressed considerably when compared with past attitudes. They trust pharmacists and are satis ed with the services provided, such as advising them regarding the use of medicines and other health issues. The scarcity of private community pharmacies in rural areas shows clear evidence of depriving these areas of the services provided by CPs. A consumer's age is an important determinant in accepting the pharmacist's advice about medicine use and their communicative relationship, especially with older consumers. Malaysian consumers have high levels of expectations that the CP will be a knowledgeable healthcare advisor, educator and counsellor regarding the safe and appropriate use of medicines. Malaysian CPs, with their high trust from consumers, have an opportunity to prove their contribution in healthcare provision and improve their attitudes, practices and behaviors to achieve their goals apart from dispensing medication.