Assessing knowledge, attitude, practice, and preparedness of hospital pharmacists in Lebanon towards COVID-19 pandemic: a cross-sectional study

Background During the COVID-19 pandemic, the Lebanese government has taken the proactive anticipatory measure to minimize the infection rates. Despite the pivotal role of the pharmacists working in hospital settings, hospital pharmacists have not been engaged in the emergency preparedness for hospitals. The primary objective of this survey is to assess the knowledge, attitude, and practice of hospital pharmacists in Lebanon towards COVID-19 pandemic and explore the level of health emergency preparedness of Lebanese hospitals in response to this outbreak. Methods A standardized English-based, anonymous and online questionnaire was diffused via social media platforms to all Lebanese hospital pharmacists. The questionnaire consisted of 78 questions related to sociodemographic characteristics, knowledge-based, attitude-based, practice questions, and pandemic preparedness. Descriptive statistical analysis was used to summarize data. Results A total of 81 questionnaires were completed; the participants were able to know > 90% of the knowledge-based questions regarding COVID-19. Most of the respondents were concerned about getting infected and their families due to their professional exposure. Similarly, around 67% were following the safety recommendations. Most of the participants agreed that they are facing shortages, rising prices, and delays in supply of masks and sanitizers. In terms of COVID-19 readiness, about 50% of hospitals have taken practical steps. Conclusions Our findings revealed an appropriate level of knowledge and good practice towards COVID-19, among the respondents from Lebanese hospitals. National organizations may benefit in utilizing the expertise of the hospital pharmacists to be able to minimize/avoid future waves of COVID-19 if it emerges.


Background
The COVID-19 pandemic has posed a significant health and economic challenge for the global and development of the community [1]. In less than a month, the global number of confirmed COVID-19 cases doubled from about 75,000 cases on February 20 to more than 153,000 on March 15 to reach 6,400,000 on June 2 [1,2]. That infection rate, as scary as it sounds, hides just how much the out-of-control virus has spread, especially in the hardest-hit communities. Efforts to completely contain the new coronavirus, responsible for infecting people in 213 countries and territories [2], have failed. Although the profile of the disease suggests that 80% of cases are mild, some 15% of people react severely while 5% become severely ill (septic shock, respiratory, and organ failure) [3]. Severe cases affect patients with underlying conditions such as cardiovascular disease, hypertension, and diabetes or elderly; older age is a particular concern in many countries with aging populations [3]. Transmission can occur from person to person by droplets from an infected individual or contaminated surfaces or objects [4].
No known effective treatment for COVID-19 virus exists [5]; therefore, management is largely intensive supportive care [5]. Many experimental therapies including existing anti-infective agents, including antibiotics, antivirals, and antiparasitics, in addition to antibody therapy are being studied and may be useful in the future [5]. New molecules also continue to be evaluated and tested as potential future antiviral therapies against the COVID-19 virus and others [5]. The most impactful intervention would be the implementation of an effective vaccine during an outbreak event. Many COVID-19 vaccine candidates are currently being studied in early phase trials. As there is currently no vaccine or specific medication to treat COVID-19 [6], and because testing is so limited, the only way to flatten the curve [7] is through collective action. The US Centers for Disease Control and Prevention (CDC) has recommended that all Americans wash their hands frequently, self-isolate when they are sick or suspect they might be, and start "social distancing" (essentially, avoiding other people whenever possible) right away [8].
Governments across the world have responded to the pandemic with a set of actions including closures of schools and public attractions, implementation of travel bans, quarantines, and nationwide lockdowns [9]. Sequentially, the COVID-19 pandemic has created an unprecedented disruption of the economy [10].
In general, emergencies put health systems and their ability to deliver health care services under strain. Currently, health care services in the various regions around the world are being confronted with increased demand generated by the COVID-19 outbreak [11]. When health systems are overwhelmed, morbidity is exacerbated, disability intensifies, and both mortality from the outbreak and mortality from vaccine-preventable and treatable conditions increase [12]. Responding exclusively to COVID-19 cases, without considering how the delivery of essential health care services will be maintained across the continuum of care from prevention to palliation, comes with several risks [12]. Organizations fighting infectious diseases, supporting health workers and delivering social services, have become the center of attention. But their work is complicated by a set of challenges related to access, safety, supply chain logistics, and financial stress [13].
The COVID-19 pandemic is primarily a health shock [14]. Knowing that the primary objective is health emergency, countries have focused their attention on a set of critical interventions [15].
Several European countries have shared common concerns about the readiness and capacity of their health systems to respond to the novel coronavirus (SARS-CoV-2) COVID-19 pandemic [3].
The American Society of Health-System Pharmacists (ASHP) has highlighted the role of the pharmacist in emergency preparedness, including biological disasters [16], and has made available COVID-19 Pandemic Assessment tools intended to assist pandemic planning efforts in the department of pharmacy and to foster pharmacist involvement in preparedness at the institutional and community level [17]. Other pharmacy organizations such as the International Pharmaceutical Federation (FIP) have dedicated a set of resources to help pharmacists during this pandemic [18]. In fact, pharmacists have an important multifaceted role in disaster preparedness and disaster response. The American Pharmacists Association (APhA) mentioned in its Policy Manual disaster preparedness section published in 2015 that the APhA "encourages pharmacist involvement in surveillance, mitigation, preparedness, planning, response, and recovery related to bioterrorism and emerging infectious diseases" [19]. Pharmacists, being the medication experts [20], should lead in managing medication supply chains and distribution systems such as procurement, storage, compounding, and dispensing in emergencies [16,19,21]. Furthermore, pharmacist expertise will help in guiding treatment decisions and drug information questions for the most vulnerable individuals including children, elderly, pregnant women, and immunocompromised patients, as well as developing local treatment plans. Besides, pharmacists possess the ability to provide direct patient care by medication therapy management, adherence counseling, and monitoring (particularly for the long durations of PEP) [1,22]. This is particularly true for hospital pharmacists. In Lebanon, the government and the Ministry of Public Health (MOPH) have taken the proactive anticipatory decision of closure and were able to raise awareness to keep the numbers of patients infected with COVID-19 to the minimal [23]. As of June 2, 2020, the total number of confirmed cases is 1242 with 27 deaths overall. The majority of the cases are males (59%), while only 16.8% are above 60 years of age. Interestingly, 57.5% of the cases had mild/moderate presentation, 37% had no symptoms at all, in contrast to 5.5% who had severe conditions [23]. Luckily, the cases reported to date did not overwhelm the Lebanese health system, including private (12,749 beds, 1020 respirators) and public hospitals (2446 beds, 165 respirators) [24].
Despite the preventive measures taken on national levels, there has been no guidance or support or involvement in emergency preparedness for hospital pharmacists on how to deal with such a pandemic. The Order of Pharmacists of Lebanon has only issued minimal guidance for pharmacists working in a community setting [25]. Therefore, the main objective of this survey is to assess the knowledge, attitude, and practice of hospital pharmacists in Lebanon towards COVID-19 pandemic and explore the level of health emergency preparedness of Lebanese hospitals in response to this pandemic.

Study design and procedure
This was a descriptive cross-sectional observational study based on an online anonymous survey. It was conducted from March 29, 2020, through May 10, 2020. The voluntary survey was carried out on licensed pharmacists working in hospital pharmacies located in all Governorates of Lebanon (Beirut, Mount Lebanon, North, South, and Bekaa). To minimize interview risks as well as the lockdown restrictions enforced by the Lebanese Government, a snowball sampling method was used as an approach to the survey using online Google forms [26]. The survey was distributed via social applications including WhatsApp, LinkedIn, and Facebook. All invited participants were above 18 years of age. Licensed pharmacists practicing in other settings or not currently working in Lebanon were excluded from this survey.

Sample size
The sample size was determined by using Epi Info 7 Stat-Calc functions for a population survey. Considering that at the time of the survey, 320 licensed pharmacists were working in hospital settings, with an expected confidence level of 95%, a margin of error of 5%, and assuming that 90% of the hospital pharmacists were familiar with the recommendations of the ASHP [15] that were circulated on the hospital pharmacists group and were available online, the minimal sample size was found to be 75.

Survey development
A group of 5 pharmacists with extended experience in hospital pharmacy and academia developed the questionnaire based on a thorough review of the literature [3,4,8,18,23,25] and the latest recommendations of professional organizations. The preparedness questions were adapted from the ASHP COVID-19 pandemic assessment tool for health-system pharmacy departments [17]. The questionnaire was piloted and reviewed by another set of 5 hospital pharmacists. All questions were simplified for better understanding (Additional file 1). The final questionnaire required an average of 14 min to complete.

Data management and statistical analysis
Statistical analyses were performed using the Statistical Package for the Social Sciences for Windows, Version 23.0 (SPSS Inc. -IBM Corp., Armonk, NY, USA). Descriptive statistics were calculated. Means and standard deviations were reported for continuous variables. Categorical variables were assessed and described as frequency and percentage.

General characteristics of hospital pharmacists
A total of 81 hospital pharmacists were included in the survey (mean age 39.36 years ± SD 10.48, 85.2% females). The highest percentage of respondents was from Beirut. The great majority had a PharmD or Master's degree (80.2%), while only 19.8% had a BS in Pharmacy (Table 1).

Knowledge related to COVID-19
Knowledge of hospital pharmacists in Lebanon was appropriate for most simple questions (more than 90%), particularly regarding preventive measures, concentration of alcohol to kill viruses, and medication use ( Table 2).

Information about COVID-19
The majority of pharmacists reported getting information about COVID-19, mainly for 1-2 h per day (48%) and some for less than 1 h (25%). As for sources of information, the most trusted were World Health Organization-WHO (83%), MOPH (74%), and CDC  (Table 3).

Additional matters related to MOPH hotline and other comments
Very few pharmacists tried to reach the MOPH COVID-19 call center (12.3%), and 69.1% reported having attended an awareness session on COVID-19.
In the last open-ended question, some pharmacists expressed many needs, including information and clear recommendations.

Attitude of Lebanese hospital pharmacists towards COVID-19
The majority of pharmacists were concerned about getting infected and their families due to their professional exposure. More than half of them declared being exhausted because of the pandemic but claimed that their stress did not affect their professional duties nor  Correct answers in bold *More than one answer can be correct their family and staff relationships, and a few employees (29%) expressed their desire to quit their jobs. Less than 50% of pharmacies have implemented icebreaking or energizing actions to mitigate staff stress ( Table 4).

Practice of hospital pharmacists regarding safety
Two thirds of hospital pharmacists reported following appropriate safety recommendations. As for shifts management, around half of pharmacists are still operating as usual, with no reduction in timing and no change or rotation when shifts overlap. Nevertheless, 8.6% of staff were tested positive for COVID-19 till now. For those wearing masks, they would change it after a median of 5 h; for gloves, it would be after 2.5 h. Although more than 90% declared being able to frequently wash or rub their hands, and avoid touching their face, a lower percentage could keep a safe distance from their work colleagues (80%). About 22% do not stay home even if they are not feeling well, 26% do never wear gloves, and 30% rarely wear masks ( Table 5).

Provision of protective devices and supplements
The majority agreed that they had a shortage of masks, gloves, and hand sanitizers. Almost all pharmacists were facing supply delays, rising prices, and pressure from suppliers to pay in cash, and after short periods (Table 6).

Practice related to the hospital preparedness for COVID-19
At the time of the survey, almost half of the hospitals had taken practical steps in preparation for COVID-19 pandemic spreading in Lebanon; one quarter to one third were still working on their plans, but some were not taking any measures as institutions (Table 7).

Discussion
Pharmacists are front line responders for COVID-19 patient care [27]. In this study, the authors assessed the knowledge, attitude, practices, and preparedness of a representative sample of hospital pharmacists towards COVID-19 pandemic across Lebanon. Knowledge of  hospital pharmacists regarding COVID-19 is important. Hospital pharmacists are essential members of interprofessional health care teams especially during outbreaks, where they serve a vital role in infection control and in managing the medication therapies of patients hospitalized due to COVID-19 or related illnesses [28,29]. Moreover, providing drug information is one of the main professional responsibilities of all pharmacists [30].
As they are assuming their advisory role on the use of pharmaceutical products, hospital pharmacists should also be aware of the recommendations concerning masks for example [31]. The majority of our study respondents showed appropriate knowledge regarding COVID-19 methods of transmission, preventive measures, and medications used. This finding is consistent with many studies that surveyed hospital pharmacists in different countries (Turkey, Vietnam, and Pakistan) and showed adequate knowledge about COVID-19 [32][33][34].
In mid-February, the WHO announced that COVID-19 outbreak was accompanied by an "infodemic" defined as an overabundance of information, making it highly prone to falsehoods and misinformation [35]. Consequently, healthcare providers should carefully evaluate COVID-19 information sources and utilize trustable resources to seek information [36,37]. Most of the hospital pharmacists in our study reported using trusted resources from official websites including websites of MOPH, CDC, WHO, and Infectious Diseases Society of American (IDSA). Around half of the pharmacists also reported using television as a source of information. Different surveys in the USA and UK showed that television viewing during   March and April 2020 has remarkably surpassed previous years, where public service media are viewed as a trusted source of information on the COVID-19 crisis [38][39][40]. Around one-third of pharmacists reported using Facebook for COVID-19 information, which is an unsafe practice. A new report has found that dozens of popular Facebook pages are publishing, repeating, and sharing false stories about the new coronavirus, related to conspiracy theories and false cures [41].
Concerning the attitude of Lebanese hospital pharmacists during the COVID-19 pandemic, most of the respondents reported exhaustion and concerns about being infected due to their professional exposure. Respondents, however, claimed that their stress did not affect their professional duties. Fear and exhaustion are common complaints among healthcare providers across the globe as the COVID-19 pandemic has taken a heavy toll on them [42].
The majority of the hospital pharmacists surveyed reported positive practices regarding safety and protective measures from COVID-19 infection, but reported shortages or delays in the supply of masks, gloves, and hand gels. The provision of personal protective equipment items and other medical devices should be adequately ensured in hospitals as they are used every day to provide adequate protection for healthcare professionals and patients as needed [31,43]. The Chinese Pharmaceutical Association compiled a list of key facilities, equipment, and personal protective equipment of COVID-19 infections, particularly to hospital pharmacy settings [44]. As the number of affected countries and infected patients increased, the world faced a global shortage leading to disruption or delay of supplies [45]. In response to these threatening shortages, CDC and other non-official organizations recommended several strategies to optimize the supply and use of these equipment items and devices [43,45,46]. It is to note that the shortages in Lebanon were exacerbated by the harsh financial crisis and dollar shortage the country has been facing even before the COVID-19 pandemic [47,48]. Along the same line, the WHO and the CDC have developed preparedness tools and checklists to enhance the readiness of healthcare professionals and facilities responding to COVID-19 [49,50]. More specifically, the American Society of Health-System Pharmacists (ASHP) and the International Pharmaceutical Federation (FIP) has issued guides for health-system pharmacy departments and the pharmacy workforce respectively, to assist in planning efforts of the pharmacy department and to foster pharmacist involvement at the institutional and community levels in the fight of COVID-19 [17,31]. These guides mainly focused on the role of the hospital pharmacist in ensuring adequate stock of medications and supplies, planning proper staffing needs, and providing adequate professional education and training. In this study, we surveyed participants between March 29 and May 10, 2020, 2 weeks to 2 months after the WHO declared COVID-19 outbreak a global pandemic [51]. Around two thirds of the surveyed pharmacists reported taking practical steps in their departments in preparation for COVID-19 pandemic or progressively working on their plans. Around 30% of the respondents, however, reported not taking any measures. The lowest preparedness (around 55%) was reported for the designation of a pharmacy staff member to coordinate education and training on COVID-19. The unpreparedness of some hospitals could be attributed to the previously mentioned financial crisis in the country, which made it harder for Lebanese hospitals to cope [47,48]. Another potential reason is the fact that the local COVID-19 health strategic preparedness and response plan developed by the Lebanese MOPH did not include detailed measures or preparedness plans for pharmacy departments. It rather mentioned the importance of ensuring healthcare service continuity through maintaining adequate supplies of pharmaceuticals and medical devices [52].
At the time the investigators started this study, the number of infected people in the country was around 400 [23]. It was around a week after the country's prime minister declared a state of a medical emergency and announced the closure of the airport, seaports, and land entrances. As of June 1, the number of COVID-19 patients in the country reached around 1233 cases (around 180 cases per 1 million of the population) [2]. This makes Lebanon among the countries that successfully flattened the curve, as the numbers were much lower than previously projected [53,54]. Currently, Lebanon is preparing for a gradual exit from the lockdown [55]. This is happening amidst fears from a second wave, as the numbers of infected people per day are increasing again [23]. This requires continuous readiness for the healthcare system.
To our knowledge, this is the first study that has assessed the knowledge, attitude, practice, and preparedness of hospital pharmacists regarding COVID-19 in Lebanon. Potential limitations include the relatively small sample size. In addition, as the survey was in English language, Arabic/French speaking pharmacists may have refrained from filling it due to language barrier. This may have contributed to the relatively small sample size. Concerning the sample representability, the distribution of hospital pharmacists in Lebanon per geographical area is as follows: Bekaa (10.6%), South (13.4%), North (12%), Beirut (35.3%), and Mount Lebanon (28.6%). Therefore, we can conclude relatively lower representability of hospitals from the south area (a remote region from the capital), suggesting a probable overestimation of the results we obtained. Finally, there is a possibility of information bias, as surveys were self-administered and some pharmacists may have understood some questions differently. Further studies are suggested to take into account these weaknesses; nevertheless, we have no reason to believe that this would change the main results we obtained.

Conclusion
Our findings revealed an appropriate level of knowledge and good practices towards COVID-19 among respondents from Lebanese hospital pharmacists. However, hospital pharmacists have not been engaged by the ministry of public health in the health emergency plans. This translated on delaying hospitals preparedness as a whole. National officials and organizations may benefit in utilizing the expertise of the hospital pharmacists to be able to minimize/avoid future waves of COVID-19 and mitigate the risk if these waves emerge.