\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Pharmacists' Awareness of COVID-19 and Perceptions of their Roles,
Barriers, and Roles of Policymakers: exploring the Middle East and North
Africa (MENA)}



\author[1]{Iman Basheti}%
\author[1]{Feras Darwish El-Hajji}%
\author[1]{Razan  Nassar}%
\author[1]{Samar  Thiab}%
\author[1]{Muna Barakat}%
\author[2]{Mariam  Basheti}%
\author[1]{Alberto  Berardi}%
\author[2]{Bandana saini}%
\affil[1]{Applied Science Private University}%
\affil[2]{The University of Sydney}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Background: The coronavirus infection (COVID-19) was declared in January
2020 as a public health emergency of international concern. The Middle
East and North Africa (MENA), like other parts of the world, suffered
from several epidemics over the years. Pharmacists have vital roles to
play to prevent the spread of this virus. Objectives: To assess the
awareness of COVID-19 amongst pharmacists from countries located in the
MENA countries, and to assess their perspectives of their role,
barriers, and roles of the educational institutions and pharmaceutical
associations in preparing them for their roles during the pandemic.
Methods: An online survey was conducted to run a descriptive
cross-sectional study in Jordan from 12th to 22th April 2020. The
questionnaire was validated and put on Facebook for pharmacists'
recruitment and assessment of their awareness (20 questions with a score
out of 20) about epidemics/pandemics and COVID-19, their perceived roles
and barriers, and roles of the educational institutions and
pharmaceutical associations. Data were analyzed using Statistical
Package for the Social Science (SPSS). Results: Study participants (n=
2589) had a mean age of 29.3 (8.2) years and 1329 (51.5\%) were females.
Most of the participants were from Egypt 819 (40.8\%), Followed by
Jordan, Algeria, and Syria. As for the sources of information about
coronavirus treatment among the study participants, 60.8\% got their
information from the social media. Fear as a consequence was identified
by the majority of participants (87.7\%). The majority of pharmacists
identified positive roles for the pharmaceutical association and
pharmaceutical associations. Conclusion: Pharmacists from the MENA
countries believe they got enough education previously about
epidemics/pandemics, and the majority follow on the latest coronavirus
updates from social media. Fear was reported as the major barrier that
requires resolution by the policymakers. Certain gaps in the awareness
about COVID-19 were identified.%
\end{abstract}%



\sloppy


\textbf{What is already known about this topic?}

The coronavirus infection (COVID-19) was declared in January 2020 as a
public health emergency of international concern. The Middle East and
North Africa (MENA), like other parts of the world, suffered from
several epidemics over the years. Pharmacists have vital roles to play
to prevent the spread of this virus. To prepare globally uniform
pharmacy response directives for pandemics, pharmacists' awareness and
perspectives around roles during pandemics in different regions of the
world need to be assessed.

\textbf{What does this article add?}

This article adds that Pharmacists from the MENA countries (Egypt,
Jordan, Syria, Palestine, Lebanon, and Iraq) believe they got enough
education previously about epidemics/pandemics, and the majority follow
on the latest coronavirus updates from social media. Fear was reported
as the major barrier that requires resolution by the policymakers.
Certain gaps in the awareness about COVID-19 were identified. In
addition, a significant correlation between pharmacists' awareness
scores across the study countries with the COVID-19 international
mortality statistics was found.

\textbf{Keywords:} coronavirus; pandemics; pharmacists; educational
institutions; Pharmaceutical association; Middle East; North Africa;
MENA.

Abstract word count: 295; Manuscript word count: 3983

\textbf{Introduction}

According to the World Health Organization (WHO), a pandemic is the
worldwide spread of a new disease\textsuperscript{1}. Viral pandemics
are caused by viruses that possess a surface protein to which the
majority of people lack immunity, which then spreads between people
within the population extending beyond national
borders\textsuperscript{2}. Historically, many viral pandemics have been
documented. The most notorious of these is the Spanish influenza
pandemic of 1918--1920, which was caused by the H1N1 virus and was
responsible for about 40 million deaths worldwide\textsuperscript{3}.
Other pandemics include the Asian Influenza (1957) caused by the H2N2
virus, the Hong Kong Influenza (1968) caused by H3N2
virus\textsuperscript{2}, the Severe Acute Respiratory Syndrome (SARS)
which occurred in 2003 and was caused by SARS coronavirus
(SARS-CoV)\textsuperscript{4}, and the Middle East respiratory syndrome
(MERS) which occurred in 2012 and was caused by coronavirus
(MERS-CoV)\textsuperscript{4.} Recently, on the 31\textsuperscript{st}
of December 2019, a case of pneumonia of unknown cause in Wuhan was
reported to the WHO Country Office in China\textsuperscript{1}. It was
later identified as coronavirus disease-2019 (COVID-19) caused by the
novel coronavirus officially called SARS-CoV-2, belonging to the family
Coronaviridae\textsuperscript{5}. The Coronavirus genome consists of a
single strand positive sense ribonucleic acid (RNA) \textsuperscript{4}.
The virions~(virus particles\emph{)} ~ are enclosed in a lipid
envelope~characterized by the presence of crown-like spikes on the
surface which have led to the nomenclature -where `corona' implies the
crown like appearance created by these bulbous
spikes.\textsuperscript{4}. SARS-CoV-2 usually causes mild symptoms such
as fever, dry cough, and sore throat. However, it can sometimes lead to
fatal complications such as severe pneumonia, pulmonary edema, acute
respiratory distress syndrome (ARDS), organ failure and septic
shock\textsuperscript{6}. The spread of the virus to many countries
around the world in a short space of time with no clear treatment or
vaccine in sight as yet, is alarming and has resulted in high workload
for healthcare teams globally\textsuperscript{7-9}. Effective strategies
currently followed to slow the spread of the virus included hygiene
practices such as proper hand washing, hand sanitizing and wearing
facemasks and gloves (personal protective equipment), in addition to
social distancing and public quarantine measures\textsuperscript{10}.

The Middle East and North Africa (MENA), like other parts of the world,
have experienced several epidemics over the years. Outbreaks of
plague,~smallpox \textsuperscript{11}, cholera \textsuperscript{12}, and
meningococcal infection\textsuperscript{13} have all been documented,
especially in Saudi Arabia during the annual~Pilgrimage (\emph{Hajj} )
as Muslims from more than eighty countries convene together, which led
the Saudi authorities to require all visitors to immunize against
certain diseases\textsuperscript{11, 12}.

Community pharmacists (or retail pharmacists as they are known in some
countries) have a crucial role to play during
pandemics\textsuperscript{14}. One of the most important role of
community pharmacists is to ensure the availability of effective therapy
in addition to health education and health promotion activities and
vaccination provision \textsuperscript{15-17}. Moreover, community
pharmacists need to engage with patients, providing them with counseling
regarding the safety precautions to minimize exposure and infection
probabilities as well as psychological and mental health support during
a pandemic. Pharmacists would be expected to support general health care
teams in infection prevention, as well as alerting public health
officials of potential outbreaks/cases\textsuperscript{18, 19}. During
pandemics pharmacists' role in managing minor ailments increases as
doctors and hospitals become overwhelmed \textsuperscript{18, 19}. The
International Pharmaceutical Federation (FIP) released a guideline
during March 2020 stating the needed information for pharmacists and the
pharmacy workforce to help them in dealing with the COVID-19
outbreak\textsuperscript{20}, and acknowledging the responsibilities put
upon the pharmacists in the control of the COVID-19 outbreak
\textsuperscript{20}. This mandate highlights the clear need for
pharmacists to convey factual evidence based and up-to-date information
to the public\textsuperscript{21.} In a study conducted during the
pandemic outbreak of H1N1, it was found that patients rely on
information provided by pharmacists and considered them an effective
educational source regarding the pandemic in addition to trusting
pharmacists as immunizers\textsuperscript{22}. In previous `pandemic
preparedness testing studies', in the United States (US), community
pharmacists have expressed concerns that need to be considered by
policymakers, for example, about critical medicine shortages or managing
medicine hoarding\textsuperscript{17}. Collating published literature,
it appears that there are various research studies published to guide
pharmacists on how to improve patient care services and
outcome\textsuperscript{19, 23, 24}, however, pharmacists are still in
need for more tailored and extensive training to improve preparedness
for emergency situations\textsuperscript{18}. To prepare globally
uniform pharmacy response directives for pandemics, pharmacists'
awareness and perspectives around roles during pandemics in different
regions of the world need to be assessed. In light of the repeated
pandemic/epidemic experiences in the MENA region, the aim of this study,
therefore, was to assess awareness of COVID-19 amongst pharmacists from
countries located in the MENA and to assess their perspectives of their
role, barriers, and roles of the educational institutions and
pharmaceutical associations in preparing them to be able to deal with
the pandemic.

\textbf{Method}

\emph{Study design and participants}

This study was conducted from the 12\textsuperscript{th} of April to the
22\textsuperscript{th} of April 2020 over 10 days during the COVID-19
outbreak and public quarantine in most of the MENA countries. A
descriptive cross-sectional study design (an online survey) was used to
address the study objectives. The research team developed an online
survey (based on the current information regarding the COVID-19) in
order to meet the study objectives which included assessing MENA region
pharmacists':

a) readiness to combat any epidemic/pandemic with a focus on the
COVID-19 pandemic, assessing their clinical awareness, and b) views on
the role of the pharmacy educators/educational institutes/pharmaceutical
associations in preparing future pharmacists to deal with
epidemics/pandemics and the COVID-19 specifically.

Any licensed pharmacist or enrolled pharmacy student in the MENA
countries (community or hospital pharmacist, academic, industry based
pharmacist, etc.) was deemed eligible for participation in the study. No
risk was posed to the participants' and their participation was
voluntary. The research team considered completing the survey as
informed consent by pharmacists for participating in this study. Ethics
approval was obtained from the Faculty of Pharmacy, Applied Science
Private University, Jordan.

\emph{Survey Development}

An extensive review of the literature was conducted to inform the
development of items within this survey\textsuperscript{14}. The survey
was administered in the Arabic language (common across the MENA region).
A variety of questions relevant to the study objectives, were also
sourced from many avenues the research team had (e.g. FIP/WHO
documents). The research team revised the survey in order to eliminate
duplicates and refine question. The team further checked for local
context and the aptness of language (slight regional variations in
nuanced meanings of words).

In order to ensure survey face validity, six expert academics in
Pharmacy Practice and Education were requested to evaluate the first
draft. A pretest for the survey was conducted and necessary refinements
were made. The pretest included evaluating the survey from different
aspects such as the wording and the clarity of the questions and whether
each question is relevant for inclusion with respect to the study
objectives. As a final point in the survey development, the research
team re-examined each question and made sure that the survey was
suitable for online administration (relevance, clarity, context,
response categories,~format and layout).

The final version of the survey was organized into five main sections
that address several topics of interest. The \emph{first
section}included items aimed at collecting participant's demographic
data. The latter four sections included several items relevant to the
study objectives (Figure 1).

Countries of the participants were grouped into geographic clusters
(regions) that are: East Mediterranean countries and Iraq, Egypt, North
Africa, Gulf countries, and other Arab countries.

\emph{Survey Implementation}

Social media (Facebook and WhatsApp) was used to recruit the
participants. The survey questions could be completed within an average
of 10 minutes. Participants were able to view the ethics committee
approval and the information about the purpose of the survey and what
participation entailed before completing the survey.

\emph{Statistics of confirmed cases and deaths}

The COVID-19 statistics of cases and deaths announced at the beginning
and around the end of the study period (12\textsuperscript{th} to
22\textsuperscript{th} of April 2020) for the countries which had at
least one confirmed case at the beginning of the study were collected
from the WHO Coronavirus Disease (COVID-19)
Dashboard\textsuperscript{25}.

\textbf{Sample size}

Sample size calculation was performed using the following formula: n = P
\selectlanguage{ngerman}× (100 - P) × z2/d2. Where P is the anticipated awareness score percent,
d is the desired precision, z is the appropriate value from the normal
distribution for the desired confidence interval. Using 95\% confidence
levels, 5\% precision level and an anticipated 50\% proportion of
participants receiving an appropriate score (this conservative value
results in the highest possible sample size that can be used in this
study, as no previous studies in this area where found to indicate level
of awareness), a sample size of 385 was required.

\textbf{Statistical analysis}

Following data collection, the survey responses were coded and entered
into a customized database using the Statistical Package for the Social
Sciences (SPSS), Version 24.0 (IBM Corp., Armonk, New York, USA).
Descriptive results were presented as means and standard deviations for
continuous variables and percentages for qualitative variables. A one
way ANOVA test was performed to analyse regional differences in
perception scores. All tests were two-tailed. A P-value of
\textless{}0.05 was considered statistically significant.

Correlation between awareness score (out of 20) and the COVID-19
statistics of cases and deaths announced at the beginning and end of the
study period (12\textsuperscript{th} to 22\textsuperscript{th} of April
2020) for the countries which had at least one case at the beginning of
the study was also conducted.

Linear regression was used to screen for the factors affecting
participants' awareness score about coronavirus pandemic versus chosen
independent variables in the study , i.e. age, area of residency (city
and urban areas or rural areas), country, region, having children,
educational level, university type (the university where participants
had studied and/or are studying at; public versus private), years of
experience, number of professional education workshops attended during
the last year, work setting, source of previous knowledge about
epidemics and pandemics, source of updates about COVID-19 management,
and current satisfaction with knowledge about COVID-19. These predictor
measures (independent variables) were considered as candidates for
linear regression modelling if they had a significance value p \selectlanguage{english}[?]0.25 in
univariate analyses. The candidate variables were subjected to backward
linear regression, where finally only the significant variables (i.e. p
\selectlanguage{english}[?]0.05) were retained with the model equation constant. Variables were
selected after checking their independence, where tolerance values
\textgreater{} 0.1 and Variance Inflation Factor (VIF) values were
\textless{} 10 were selected to indicate the absence of
multicollinearity between the independent variables in regression
analysis. The homoscedasticity assumption for multiple linear regression
was checked using Breusch-Pagan test, with a p\selectlanguage{english}[?]0.05 indicating the
absence of heteroscedasticity.

\textbf{Results}

Study participants (n= 2,589) had a mean age of 29.3 years and more than
half (51.5\%) were females (Table 1). Most of the participants were from
Egypt (n=819 40.8\%), followed by East Mediterranean countries (Jordan,
Syria, Palestine, Lebanon) and Iraq. More than 80\% of the participants
lived in urban areas (including capital cities). About 75\% of the
participants had, as a highest level of pharmacy education, either a
bachelor degree in pharmacy or Pharm. D., while the rest were either
pharmacy students or technicians, or they had received other
post-graduate degrees. The majority were alumni of public universities
(75.7\%). More than half of the participants were practicing pharmacy
either in community pharmacy or in hospital, years of work-experience
tended to be short, i.e. less than and up to 5 years, and number of
attended professional development workshops was low on average.

While only 30\% of the participants had received enough education about
epidemics/ pandemics and updates about coronavirus treatment, 91.2\% of
them do follow the latest corona virus updates on the treatment. Results
were almost similar across all regions (Figure 2). As for the sources of
information about coronavirus treatment among the study participants,
60.8\% reported that they sourced their information from social media,
followed by WHO reports and published articles (Figure 3).

Awareness scores (out of 20) were very similar across regions (Table 2),
with a mean of 13.9 (out of a maximum of 20), no statistically
significant difference was found between the regions (n= 2589, p= 0.193,
one way ANOVA). A significant correlation between awareness scores
across study countries was found (p= 0.026, Pearson correlation= -0.054)
with the COVID-19 mortality statistics as they stood on the 15th of
March 2020 for the countries which had at least one case at the
beginning of the study\textsuperscript{25}. Awareness score was higher
in countries with lower mortality. No significant correlation was noted
with other statistics of COVID-19 cases and deaths as they stood 15th of
March, and 1st and 15th of April 2020.

Table 3 presents the total percentage and percentage of participants
from the participating countries answering each of the awareness
statements correctly. Interestingly, univariate analysis of the
awareness score versus chosen independent variables showed significant
association with many variables. This was reflected in the linear
regression results, where older age participants, graduates of public
universities versus private universities, higher annual attendance rates
at professional workshops yearly, participants who practice in community
pharmacy and hospital settings, participants who reported to have had
previous knowledge from their graduating institute, participants who
sourced their information about COVID-19from published studies, and
those who were highly satisfied with their knowledge after 4 months of
COVID-19 had higher knowledge scores (Table 4).

More than 90\% of participants agreed with the statements provided
regarding the role of the faculties/educational institutes expect for
the statement `your faculty has a role in preparing you to deal with any
epidemic/pandemic' (74.8\%). As for the role of the pharmaceutical
associations, more than 90\% of pharmacists agreed with the statements
provided except for `pharmacists associations and societies have a role
in preparing you to deal with epidemics/pandemics such as the
coronavirus'. More than 80\% of participants agreed with the statements
provided regarding their role as pharmacists with the highest percentage
being about the statement `you ensure your personal safety by wearing
gloves and masks and avoid close contact with patients'. Significant
differences were seen regarding the regional distribution of study
participants' perceptions about the current role of the faculties of
pharmacies/educational institutes with regards to dealing with
epidemics/pandemics and coronavirus specifically (n= 1998), while no
significant differences were seen with regards to perceptions about the
current role of pharmacists' associations and societies and current role
of pharmacists (Figure 4, Table 5).

Most pharmacists believed that working in the pharmacy increases their
fears about getting infected with coronavirus (n= 2131, 82.3\% strongly
agree/agree). Significant differences found between regions (p=0.009).
In addition, participants believed that they should receive training
programs on how to provide mental health support for people during
epidemic and pandemic outbreaks (n= 2257, 87.7\% strongly agree/agree)
with no significant difference found between the regions (p=0.426).

\textbf{Discussion}

Nowadays, the world is facing a predatory pandemic infection caused by
COVID-19 requiring a concerted effort by health care professionals and
public health experts to contain the rate of infection and the havoc it
wreaks. Pharmacists, as essential health service providers, are
important in the management and control of COVID-19. Hearteningly, the
results of this survey indicated that pharmacists in the MENA countries
have good awareness about the COVID-19 and acknowledge the different
roles they can play during these times. Further, this study revealed
that pharmacists are aware of the important responsibilities of the
different educational faculties/educational institutes and
pharmaceutical associations in preparing them to take on their roles
during pandemics. Barriers impeding pharmacists from acting to their
full potential were also explored, with fear from contracting the virus
while performing their duty emerging as an important barrier that
requires resolution.

The source of information gathered by healthcare professionals is
important as it can affect clinical practice. The results of this study
illustrated that more than 90\% of the pharmacists monitor closely
COVID-19 news, with the major sources of information being social media,
WHO reports, and published literature. The collective responses are
indicative of a well-informed group of pharmacists, possibly the high
proportion of students and early pharmacy graduates contributed to this
result. Although the pre-mentioned sources of information are important,
Garcia and Julvez reported that referring to websites prepared by
official public health organizations is important to ensure a trusted
and updated source of information about COVID-19\textsuperscript{26}.
Interestingly, the majority of respondents reported that they have good
awareness of COVID-19, and they have sufficient information about the
infection. Social media may not always be the best source of accurate
information although previous studies in the region indicate that this
has been an important source of information for pharmacists in the MENA
region through several epidemics earlier\textsuperscript{27}.

Many medications for the management and treatment of the coronavirus
have been discussed within the media/social media. Chloroquine and
hydroxychloroquine for example have been frequently mentioned as
potential treatments for the virus. In this study, 35\% of the
pharmacists reported that these medications can be used not only for
treatment but for the prevention of the virus. Given that there is no
evidence supporting their use, this belief is disturbing. Currently more
than 140 clinical trials to test the COVID-19 efficacy of these
medications alone or in combination with other medications, such as the
antibiotic azithromycin, have been registered worldwide to explore their
use as treatment/prevention options for COVID-19\textsuperscript{28}.
However, on the 24\textsuperscript{th} of April 2020, the United States
Food and Drug Administration (FDA)~issued a warning on the use of
chloroquine and hydroxychloroquine for treating
COVID-19\textsuperscript{29}. The warning was due to reports of serious
cardiac rhythm problems associated with the use of these medications
particularly in combination with azithromycin, causing QT interval
prolongation, a measure of delayed ventricular repolarization
\textsuperscript{30}. As another example, the majority of the study
participants concurred that the use of non-steroidal anti-inflammatory
medications (NSAIDs) such as ibuprofen would increase the risk of
COVID-19 complications. This probably was based on the fact that NSAIDs
use as antipyretics for acute viral infections may induce serious
complications such as empyema (presence of pleural effusion on chest
radiograph and acidic pleural fluid) \textsuperscript{31}. However,
Capuano and co-workers published a review on the effect of NSAIDs on
COVID-19 infection based on the available preclinical and clinical
published studies\textsuperscript{32}.~They reported that there is
conflicting data in the current literature, and there is no scientific
evidence correlating NSAIDs use to the deterioration of COVID-19
patients' symptoms\textsuperscript{32}. On March
18\textsuperscript{th}~2020, the European Medicines Agency (EMA)
declared the need for further epidemiological studies for this issue,
and urged health professionals to wait for formal results of an ongoing
revision by the Pharmacovigilance Risk Assessment Committee (PRAC) on
the association of Ibuprofen/Ketoprofen and worsening of
infections\textsuperscript{33}. Accordingly, NSAIDs usage by COVID-19
patients should be conducted with ultimate caution and under medical
supervision. This conflicting news lead to conflicting believes and
incorrect counseling provided by healthcare professionals all over the
world, not just the MENA countries. Unifying the source of information
for pharmacists worldwide and keeping it updated is vital to prevent
such undesirable consequences.

Fear is a normal consequence to pandemics and public
quarantine\textsuperscript{34}. Our study findings demonstrated that the
majority of pharmacists have fears about being infected with the
coronavirus during their work at the pharmacy. Such findings have been
acknowledged previously by pharmacists from other countries around the
world\textsuperscript{35}. Mental health is a priority for healthcare
workers during pandemics, and pharmacists are not an exception
\textsuperscript{35}. Training sessions and online workshops were
requested by the pharmacists in this study, as has been the case in
previously published findings. In this term, the FIP had published a
guideline for the pharmacists and pharmacy workforce, clarifying all the
required responsibilities and role of both the community and hospital
pharmacists\textsuperscript{36}. This guideline also demonstrates all
the preventive measures, tips on infection control and some
recommendations for outpatient care\textsuperscript{36}. Interestingly,
this study resonates with research investigating the experiences of
other healthcare professionals, which highlights the need for more
tailored and appropriate training to improve preparedness for
deployment\textsuperscript{18}.

Delivering medication to patients' homes can decrease infection spread
especially for elderly patients were the risk of infection is increased.
As an example, in Jordan, the Jordan Food and Drug Administration (JFDA)
allowed community pharmacists and hospitals to provide free delivery of
medications to patients' homes. Before the COVID-19, this practice was
not allowed by the local laws\textsuperscript{37}, which is the case in
most countries in the MENA region. The majority of participants in this
study were willing to deliver medicines to patients' homes. This
provides an example of an effective service that can be successfully
delivered everywhere if the safety of pharmacists from COVID-19 was
guaranteed.

Social media was employed in the conduct of this study, which
facilitated a large and rapid collection of sample size from numerous
countries in the MENA region. It is of note that a significant
correlation between pharmacists' awareness across the countries included
in this study and the COVID-19 statistics of cases and deaths was found.
This may indicate that countries with people (hence pharmacists) of
higher awareness are likely to end with lower numbers of COVID-19 cases.

\emph{Limitations}

The fact that this study was conducted via an online survey brings
limitations just as it brought strengths. Such sampling technique led to
a convenience sample which is a type of non-probability sampling that
allows for data collection from a group of people easy to contact and/or
reach \textsuperscript{38}. Such approach may introduce sampling bias,
as pharmacists who use social media more frequently had a better chance
to participate in this study, giving results which may not be
representative of all of the pharmacists groups in the MENA
countries\textsuperscript{39}. This might explain the relatively young
age of the study participants, as men and older individuals are
generally known to be underrepresented on social
media\textsuperscript{39}. Pharmacy students who participated in this
study did not report their year of study, which can unveil useful
information if indicated. Fifth-year students for example are expected
to have different awareness levels compared to first and second-year
students. Finally, although the survey was not completely validated, the
items incorporated in it were done in real-time, based on the literature
and reviews of a team of clinical pharmacy specialists.

\textbf{Conclusion}

Pharmacists from the MENA countries believed that they got enough
education previously about epidemics/pandemics, and the majority follow
on the latest coronavirus updates on treatments mostly from social media
followed by the World Health Organization reports and published
literature. The majority believed they have a major role in the
management of the COVID-19, identifying fear as a barrier that requires
resolutions by the policymakers. Certain gaps in the awareness about
COVID-19 were identified, mainly concerning the conflicting news about
Hydroxychloroquine and Ibuprofen use by infected patients. Such findings
highlighted areas of improvement, and indicated that a significant
association is found between higher awareness amongst pharmacists and
the number of cases of COVID-19 patients in the MENA countries involved
in the study. Results of this study have important international
applicability, as pharmacists all over the world share similar barriers,
responsibilities and engagements when it comes to the COVID-19 pandemic.
Countries in the MENA region and worldwide share similar undergraduate
pharmacy education and training, in addition to similar healthcare
systems \textsuperscript{40}, hence perspectives presented by the
thousands of pharmacists involved in this study are an important
springboard for further action.

\textbf{Funding:} This study was funded by the Deanship of Academic
Research at Applied Science Private University, Amman, Jordan.

\textbf{Conflicts of interest:} None.

\textbf{Specific contributions of each contributor to the paper:} All
authors were involved in all parts of study and manuscript preparation
including literature search, study design, analysis of data, manuscript
preparation, and review of manuscript.

\textbf{References}

\textbf{1.} World Health Organization (WHO): What is a pandemic?
Accessed on 2-2010). Found at:
https://www.who.int/csr/disease/swineflu/frequently\_asked\_questions/pandemic/en/.

\textbf{2.} Horimoto T, Kawaoka Y. Influenza: lessons from past
pandemics, warnings from current incidents.\emph{Nat Rev Microbiol.}
2005;3:591-600. doi: 510.1038/nrmicro1208.

\textbf{3.} Morens DM, Taubenberger JK. The Mother of All Pandemics Is
100 Years Old (and Going Strong)!\emph{Am J Public Health.}
2018;108:1449-1454. doi: 1410.2105/AJPH.2018.304631. Epub 302018 Sep
304625.

\textbf{4.} Yang Y, Peng F, Wang R, et al. The deadly coronaviruses: The
2003 SARS pandemic and the 2020 novel coronavirus epidemic in China.
\emph{J Autoimmun.}2020;109:102434.:10.1016/j.jaut.2020.102434. Epub
102020 Mar 102433.

\textbf{5.} World Health Organization (WHO): Rolling updates on
coronavirus disease (COVID-19). Accessed on 5-2020. Found at:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen.

\textbf{6.} Sohrabi C, Alsafi Z, O'Neill N, et al. Corrigendum to
''World Health Organization declares Global Emergency: A review of the
2019 Novel Coronavirus (COVID-19)'' {[}Int. J. Surg. 76 (2020) 71-76{]}.
\emph{Int J Surg.} 2020;15:036.

\textbf{7.} Huang C, Wang Y, Li X, et al. Clinical features of patients
infected with 2019 novel coronavirus in Wuhan, China. \emph{Lancet.}
2020;395:497-506.

\textbf{8.} Kandel N, Chungong S, Omaar A, Xing J. Health security
capacities in the context of COVID-19 outbreak: an analysis of
International Health Regulations annual report data from 182 countries.
\emph{The Lancet.}

\textbf{9.} Huang C, Wang Y, Li X, et al. Clinical features of patients
infected with 2019 novel coronavirus in Wuhan, China. \emph{The Lancet.}
2020;395:497-506.

\textbf{10.} World Health Organization. Coronavirus disease (COVID-19)
advice for the public. Accessed on 5-2020. Found at
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public.

\textbf{11.} Corkill NL. Epidemic smallpox in Jiddah; treatment with
antibiotics. \emph{Br Med J.}1951;2:663-667. doi:
610.1136/bmj.1132.4732.1663.

\textbf{12.} Scrimgeour EM. Epidemic infections and their relevance to
the Gulf and other Arabian Peninsula countries. \emph{J Sci Res Med
Sci.} 2003;5:1-4.

\textbf{13.} Memish ZA, Venkatesh S, Ahmed QA. Travel epidemiology: the
Saudi perspective. \emph{Int J Antimicrob Agents.} 2003;21:96-101. doi:
110.1016/s0924-8579(1002)00364-00363.

\textbf{14.} Basheti IA, Nassar R, Barakat M, et al. Pharmacists'
readiness to deal with the coronavirus pandemic: Assessing awareness and
perception of roles. \emph{Res Social Adm Pharm.} 2020;23:30418-30416.

\textbf{15.} Sokolow LZ, Patel A, Koonin LM, Graitcer SB. Scripted Surge
Pharmacy Pandemic Exercise: Testing Vaccine Administration and Antiviral
Dispensing. \emph{Health Secur.} 2018;16:262-273. doi:
210.1089/hs.2018.0031.

\textbf{16.} Rosenfeld LA, Etkind P, Grasso A, Adams AJ, Rothholz MC.
Extending the reach: local health department collaboration with
community pharmacies in Palm Beach County, Florida for H1N1 influenza
pandemic response. \emph{J Public Health Manag Pract.} 2011;17:439-448.
doi: 410.1097/PHH.1090b1013e31821138ae.

\textbf{17.} SteelFisher GK, Benson JM, Caporello H, et al. Pharmacist
Views on Alternative Methods for Antiviral Distribution and Dispensing
During an Influenza Pandemic.\emph{Health Secur.} 2018;16:108-118. doi:
110.1089/hs.2017.0068. Epub 2018 Mar 1023.

\textbf{18.} Nazar Z, Nazar H. Exploring the experiences and
preparedness of humanitarian pharmacists in responding to an
emergency-response situation. \emph{Res Social Adm Pharm.}
2020;16:90-95. doi: 10.1016/j.sapharm.2019.1003.1146. Epub 2019 Mar
1031.

\textbf{19.} Song Z, Hu Y, Zheng S, Yang L, Zhao R. Hospital
pharmacists' pharmaceutical care for hospitalized patients with
COVID-19: Recommendations and guidance from clinical experience.
\emph{Res Social Adm Pharm.} 2020;3:30314-30314.

\textbf{20.} Khan Z, Muhammad K, Ahmed A, Rahman H. Coronavirus
outbreaks: prevention and management recommendations. \emph{Drugs \&
Therapy Perspectives.} 2020:1-3.

\textbf{21.} Gross AE, MacDougall C. Roles of the clinical pharmacist
during the COVID\selectlanguage{english}-19 pandemic.\emph{Journal of the American colledge of
clinical pharmacy} 2020:1-3.

\textbf{22.} Miller S, Patel N, Vadala T, Abrons J, Cerulli J. Defining
the pharmacist role in the pandemic outbreak of novel H1N1 influenza.
\emph{J Am Pharm Assoc (2003).} 2012;52:763-767. doi:
710.1331/JAPhA.2012.11003.

\textbf{23.} McCourt E. Improving pharmacist involvement in pandemic
influenza planning and response in Australia. Found at
https://ahha.asn.au/system/files/docs/publications/summary\_deeble\_institute\_issues\_brief\_no.\_25.pdf.
Accessed 4, 2020. \emph{Australian Healthcare and Hospital
Association.}2018.

\textbf{24.} Zheng SQ, Yang L, Zhou PX, Li HB, Liu F, Zhao RS.
Recommendations and guidance for providing pharmaceutical care services
during COVID-19 pandemic: A China perspective. \emph{Res Social Adm
Pharm.} 2020;26:30284-30289.

\textbf{25.} WHO Coronavirus Disease (COVID-19) Dashboard. Accessed on
May-2020. Found at https://covid19.who.int/.

\textbf{26.} Hernandez-Garcia I, Gimenez-Julvez T. Assessment of Health
Information About COVID-19 Prevention on the Internet: Infodemiological
Study. \emph{JMIR Public Health Surveill.} 2020;6:e18717. doi:
18710.12196/18717.

\textbf{27.} Karasneh R, Al-Azzam S, Muflih S, Soudah O, Hawamdeh S,
Khader Y. Media's effect on shaping knowledge, awareness risk
perceptions and communication practices of pandemic COVID-19 among
pharmacists. \emph{Res Social Adm Pharm.}
:.10.1016/j.sapharm.2020.1004.1027.

\textbf{28.} Day M. Covid-19: ibuprofen should not be used for managing
symptoms, say doctors and scientists. 2020;368:m1086.

\textbf{29.} FDA cautions against use of hydroxychloroquine or
chloroquine for COVID-19 outside of the hospital setting or a clinical
trial due to risk of heart rhythm problems. Cited on 4-2020/ Available
from:
https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or.

\textbf{30.} Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB.
Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): A
Review. \emph{Jama.} 2020;13.

\textbf{31.} Le Bourgeois M, Ferroni A, Leruez-Ville M, et al.
Nonsteroidal Anti-Inflammatory Drug without Antibiotics for Acute Viral
Infection Increases the Empyema Risk in Children: A Matched Case-Control
Study. \emph{J
Pediatr.}2016;175:47-53.e3.:10.1016/j.jpeds.2016.1005.1025. Epub 2016
Jun 1020.

\textbf{32.} Capuano A, Scavone C, Racagni G, Scaglione F. NSAIDs in
patients with viral infections, including Covid-19: victims or
perpetrators? \emph{Pharmacol Res.}2020;29:104849.

\textbf{33.} Alobaedi OH, Talib WH, Basheti IA. Antitumor effect of
thymoquinone combined with resveratrol on mice transplanted with breast
cancer. \emph{Asian Pac J Trop Med.}2017;10:400-408. doi:
410.1016/j.apjtm.2017.1003.1026. Epub 2017 Apr 1017.

\textbf{34.} Lima CKT, Carvalho PMM, Lima I, et al. The emotional impact
of Coronavirus 2019-nCoV (new Coronavirus disease). \emph{Psychiatry
Res.}2020;287:112915.:10.1016/j.psychres.2020.112915.

\textbf{35.} Walton M, Murray E, Christian MD. Mental health care for
medical staff and affiliated healthcare workers during the COVID-19
pandemic. \emph{Eur Heart J Acute Cardiovasc Care.}
2020;28:2048872620922795.

\textbf{36.} FIP. Coronavirus SARS-CoV-2 / COVID-19 pandemic:
Information and Guidelines for Pharmacists and the Pharmacy Workforce
Vol 2020. The Netherlands: International Pharmaceutical Federation 2020.

\textbf{37.} Nazer LH, Tuffaha H. Health Care and Pharmacy Practice in
Jordan. \emph{Can J Hosp Pharm.}2017;70:150-155. doi:
110.4212/cjhp.v4270i4212.1649. Epub 2017 Apr 4228.

\textbf{38.} Tyrer S, Heyman B. Sampling in epidemiological research:
issues, hazards and pitfalls.\emph{BJPsych Bull.} 2016;40:57-60. doi:
10.1192/pb.bp.1114.050203.

\textbf{39.} Nelson LM, Simard JF, Oluyomi A, et al. US Public Concerns
About the COVID-19 Pandemic From Results of a Survey Given via Social
Media. \emph{JAMA Intern Med.}2020;7.

\textbf{40.} Bates I, Bader LR, Galbraith K. A global survey on trends
in advanced practice and specialisation in the pharmacy workforce.
\emph{Int J Pharm Pract.}2020;28:173-181. doi: 110.1111/ijpp.12611.

\textbf{Figure legends}

\textbf{Figure 1.} Study process showing the five sections of the online
survey used in this study.

\textbf{Figure 2.} Study participants (n=2589) awareness about
epidemics/pandemics and updates about coronavirus treatment based on
region.

\textbf{Figure 3.} Sources of information about coronavirus treatment
among the study participants (n=2589).

\textbf{Figure 4.} Study participants' perceptions about the current
role of the faculties of pharmacies/educational institutes, pharmacists'
associations and societies, and pharmacists' role to deal with
epidemics/pandemics and the coronavirus pandemic specifically (n=2589).

\textbf{Hosted file}

\verb`Tables.docx`  available at \url{https://authorea.com/users/310289/articles/458795-pharmacists-awareness-of-covid-19-and-perceptions-of-their-roles-barriers-and-roles-of-policymakers-exploring-the-middle-east-and-north-africa-mena}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Slide1/Slide1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Slide2/Slide2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Slide3/Slide3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Slide4/Slide4}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

