Discussion
To our best knowledge, this study is the first cross-sectional study conducted in Malaysia to seek to understand the coping strategies and innovative responses of community pharmacists for COVID-19 pandemic. We found that most community pharmacists were generally well prepared to cope with the pandemic and had a positive outlook towards keeping themselves and their customers safe, thereby further affirming the instrumental role of community pharmacists in implementing public health measures to control the spread of COVID-19. Whilst most community pharmacies had adapted their environment to reduce the risk of transmission, some community pharmacies went further in innovating new services, for instance, providing a drive-through or home delivery service to further minimize contacts among their customers. Interestingly, another key collaboration that was developed was referral services among other community pharmacies as well as with primary care doctors within the vicinity, which had been rarely practiced in Malaysia due to competing commercial interests.
However, we found that less than one in every five community pharmacists in the survey reported to have installed acrylic glass barriers or perspex in front of the counter for the collection of medicine and utilized baskets to receive payments at cashier. This might be due to limited floor space and lack of infrastructure feasibility for applying the physical distancing measures. Notwithstanding, the employees were protected with the complimentary use of gloves and hand sanitizers. Furthermore, there was a growing opportunity for community pharmacists to exploit technologies to facilitate remote consultations, as presently practiced by 31.1% of the respondents. Despite major investments have been insufficient in health technology industry of low-middle and middle-income countries, the COVID-19 pandemic has propelled the pursuit of convenient and inexpensive telehealth solutions to reduce population movements or physical and social interactions which help to curb the spread of the disease, while maintaining quality of clinical care. To realize a holistic telehealth-enabled future, novel engineering designs, products, and innovations such as smart phones, wearable devices, and instrumented (smart) homes can be accoutered with environmental and biological sensors that are interconnected using 5G networks to monitor patient health and send messages to assigned clinicians and pharmacists when emergency situations are detected.9-11
We observed an overall decrease in level of perception on the dimensions of safety, resilience, and support with increasing age of pharmacists. The majority of participants surveyed (74.7%) were mid-career pharmacists aged 30 to 49 years, while only 2.3% aged 60 years or older. It has been suggested that pharmacists’ reactions to work-related conditions and experiences is dependent on age, with middle-age pharmacists expressing less satisfaction compared to both younger and older practitioners.12 Our study resonated with a previous observation that pharmacists of 45 to 59 years old were more dissatisfied with their workload and attached more importance of their jobs to patients than did younger or older pharmacists.13 We believe that this could be because senior members of the profession had prior experience to coordinate the emergency response to past series of influenza outbreaks that were similarly characterized by novel virus subtypes, specifically SARS outbreak of 2003, H1N1 Influenza of 2009, and New Avian Influenza Viruses H7N9 and H10N8 of 2013.14 As such, they could acclimatize better to the policies and work environment for which they have served over numerous years.
Data from this study also found some evidence of gender disparity in organizational support. Albeit a tactful bit of literature found no evidence for gendered differences in ability, the variation in perceptions demonstrates a potential effect of local social norms and cultural influences in achieving supportive organizational culture which is governed by the shared values and beliefs that influence workplace and employee behaviors.15 As such, effective strategies involving legislation, allyship, leadership, and professional development of core competencies could transform organizational culture and climate towards gender equality in science, medicine, and global health, hence optimizing health, social, and economic gains.16  In many countries, the limited opportunities for hiring, merit, promotion, and access to productive resources of women in the fields of science and medicine warrant policy changes. This is indispensable for addressing and removing barriers to ensure full engagement and participation of women in the workforce, resulting in increased satisfaction and more diverse recruitment.15 
The surprising correlation between perceived workplace safety and occupational role could be plausibly explained by external covariates, including the availability of higher operating budget, business revenue, and staff education programs. Being the owner, partner, or executive officer of a community pharmacy generally has the ultimate responsibility and authority to decide on the company’s capital allocation, decision making, and operational management processes. Hence, the extent to which pharmaceutical care of patients and welfare of staff were distributed under the condition of a pandemic would stem from decisions and actions from the corporate boards.
Several limitations of this study should be noted. First, because the study design was cross-sectional, we could not elucidate the causality and temporal patterns between characteristics of community pharmacists and the way they responded to epidemic outbreaks. Second, the study faced challenges to timely repetition and longitudinal follow-up, limiting its utility for long term surveillance to examine the effects of different responses to public health crises on clinical outcomes and general infection control measures. The sample size was small in certain subgroups, particularly among male, those who were older as well as locum pharmacists, which could result in wide confidence intervals and point estimates. Similarly, due to the multiplicity of tests performed, there is a likelihood of occurrence of type 2 errors in the correlations between demographics and the safety, resilience, and organizational support received. As such, we urge caution in the interpretation of the results. In addition, the generalizability of the results might be limited because most of the participants were young women. However, this population is comparatively similar to the general community pharmacist population in Malaysia and many other countries.17-19  Our study findings were also restricted to items contained in the survey instrument which was not designed to quantify the magnitude of changes in coping strategies and provision of pharmaceutical services over the pandemic period.
As we did not perform a probability-based sampling method, our results may not be representative of the full diversity of the Malaysian population with respect to race and ethnicity. The questionnaire scope did not measure responses by race or ethnicity of the pharmacists, socioeconomic status of the communities surrounding the pharmacies, geographical locations, and presence of public health programs in the local settings. Nevertheless, we believe that a transdisciplinary, cross-sectoral, coherent approach to infectious disease control should embrace community pharmacies with public health agencies to address the social determinants of health. As such, community pharmacies represent an important infrastructure within the primary healthcare systems for combating the pandemic, contributing a part in patient education, disease surveillance, and dealing with medical supplies to be stockpiled or redirected in an emergency.20 The services that can be delivered in community pharmacy settings include medication dispensing for chronic and acute conditions, chronic disease management, recommendations for over-the-counter medications, medication management and adherence support, self-care recommendations, vaccinations, specimen collection, and point-of-care screening or testing services for rapid diagnosis and education of patients about results, lifestyle recommendations, and referral to specialty care if necessary.21-23 
There may be variations in responses regarding planning and preparedness of community pharmacies to disease outbreaks prior to stringent enforcement of lockdown measures by the authorities since March 18, 2020.24 Consequently, the results of this study cannot explicitly refute other ecological drivers of change which may have influenced the findings of this study. It is also noteworthy that the perceptions of pharmacists may change over time in response to social and physical environmental factors. Strict enforcement would improve compliance to rules and standard operating procedures introduced by the government and thus minimizing the risk of community transmission of COVID-19 in pharmacies and public areas.25 As compared to face-to-face interviews, our study was conducted through online survey which might lead to biased results because it could have dismissed those with high workload, scarce time, and limited connectivity.
The repercussions of lockdown are now being observed in the Malaysian society, where furloughs have turned into redundancies and economic recessions have taken place. As such, we believe it is reasonable to anticipate not only sustained distress and considerable deterioration in supply chain and affordability of long term personal protective equipment along with various businesses and profits downturn, but emergence of adverse health impacts of economic recessions due to the precarious job markets and weak social protection systems. The COVID-19 pandemic has engendered numerous daunting challenges for health service provision, especially with differing access to housing, food security as well as social connectivity, all of which are related to public health. Therefore, appropriate and proportionate clinical duties and response to mitigate or manage coronavirus crisis require multidisciplinary high-quality pharmaceutical care from the community pharmacies, alongside sufficiently resourced public health services supported by government policies and programs.