The present study found that almost all the respondents (99.5%) were providing some types of health screening and monitoring, mainly the measurement of blood pressure, blood glucose and cholesterol levels. This is higher than from a previous nationwide study (77.1%) by Chua et al . This may be attributed to an increase in awareness and demand by the general public  especially by those who could not afford home-used medical devices . Nevertheless, future studies should also examine the quality and effectiveness of such services in detecting and monitoring the prevalence of non-communicable diseases in the country. This is especially important as the Ministry of Health Malaysia is considering a public-private partnership  in which community pharmacists can play an important role in the screening of non-communicable diseases among lower-income population, as well as providing continuous health monitoring if the Transition of Care programme where patients can be referred to the community pharmacies to reduce the overload in the public health care system, is implemented.
Most of the respondents (90.5%) also advised their customers on the selection and use of health supplements for general health. This is in agreement with a study by Chua et al.  which reported that the general public in Malaysia approached community pharmacists mainly to purchase health supplements. However, only 15.8% of the respondents who provided such services were accredited with CMEd. In addition, the odds of providing such service among the community pharmacists with a basic pharmacy degree is almost 5.0 times more than those with a master’s degree. This raises the question of whether CMEd or a master’s degree is essential for providing such services. Further studies are required to assess whether those without such qualifications are also able to provide effective counselling on health supplements. In addition, pharmacy programmes in Malaysia should include topics on health supplements in their curriculum to better equip future pharmacists.
More than two-thirds of the respondents were conducting patient medications reviews in the pharmacies and this was 10 times higher than those who were conducting home medication reviews. This may be due to a shortage of pharmacists or staff as shown in the present study where more than half of the respondents (63.1%) cited the shortage of manpower and hence, community pharmacists were not able to leave their pharmacies to conduct home medication reviews. Another reason could be a lack of clinical knowledge and skills in providing home medication review as the present study found that the odds of providing such service among community pharmacists with a master’s degree were 3.7 times more than those with a basic degree. Further studies on the processes of medication review in the pharmacies or in the homes of patients by community pharmacists are also required to determine if these were carried out comprehensively or consistently as in Australia  or other countries [8, 34] which have incorporated the practice principles for pharmaceutical care in their medication review.
About half of the respondents (51.0%) were providing counselling on smoking cessation to assist the general public to quit smoking. This is similar to the findings by Chua et al. (49.1%) . The war against smoking will continue and the demand for advice to quit smoking may increase in future. In addition, the present study showed that only slightly more than half (53.7%) of those who were providing counselling on smoking cessation have undergone the CSCSP programme while the odds of providing smoking cessation service among those with CSCSPs was 8.2 times more than those without such certification. This shows that community pharmacists should be encouraged to attend the CSCSP programme to ensure that they are appropriately trained to provide such services. Further studies should also be conducted to determine the effectiveness of such service provided by community pharmacists.
Despite health care demand on weight management due to its association with an increased risk of non-communicable diseases and the national health care expenditure, the present study showed that only slightly more than half of the respondents (52.4%) were providing weight management service. In addition, the odds of such practice were almost 1.8 times higher among pharmacists aged below 40 years compared to those 40 years old and above. Such service is not widely available among community pharmacies probably because the general public in Malaysia preferred to seek advice from dietitians and fitness instructors than from community pharmacists for weight management services, as most people are not aware of such service by community pharmacists .
Waste management in community pharmacies involved the collection of expired, damaged, or unused medicines and used needles from customers, for proper disposal. In 2018, a pilot project was initiated in Malaysia by the Malaysian Community Pharmacy Guild to empower community pharmacists to educate and assist the general public on the proper disposal of used needles. This was followed by the Green Pharmacy campaign which expanded its services to community pharmacies nationwide and includes other forms of clinical waste . Despite the initiative taken through several campaigns, the present study found that only a small percentage (7.9%) of community pharmacies were providing waste management service. This is as expected since such service is still relatively new and may need some incentives for the community pharmacies as well as more public awareness campaigns.
Multiple medicine management involves the use of medicine dose administration aid that can be provided by community pharmacists. This is beneficial to patients who have complex or multiple medicine regimens and especially for elderly patients to improve their medication adherence . With the growing ageing population (aged 60 and older) in Malaysia, from 7.7% in 2010 to the estimated 14.7% in 2030 , community pharmacists can play a major role in assisting geriatric patients to manage their medications since they are most susceptible to polypharmacy. However, the present study showed that not many respondents were offering such service. Thus, community pharmacists should expand their services to geriatric nursing homes to optimise medication use and minimise medication errors .
Slightly more than half of the respondents (53.3%) reported that they were providing pharmaceutical care services in their community pharmacies, mainly for patients with diabetes, hypertension, hyperlipidaemia and asthma. However, whether these community pharmacists were familiar with the concept and were practising appropriate pharmaceutical care processes were not captured in this study. A study of community pharmacists in Brazil reported that those who were providing pharmaceutical care did not have adequate knowledge of this service and even lesser knowledge than those who did not provide such service .
The present study on pharmaceutical care practices found that more than two-thirds of the respondents reported that they were not able to access patients' medical information from the patients’ medical doctors. Besides a lack of co-operation from the patients' medical doctors, there was a lack of acceptance by patients to allow community pharmacists to access their medical conditions and to provide pharmaceutical care. These findings are similar to that of studies in many other developing countries where the general public’s awareness on the roles of community pharmacists’ is still very limited [40, 41].
The study also revealed that some of the respondents (14.3%) did not gather medical information from their patients or their caregivers before providing their recommendations. Community pharmacists should be more vigilant in responding to patients’ request for treatment as insufficient patients' medical information may lead to inappropriate treatment recommendation and subsequently, may lead to more harm than good to the patients.
Even though more than 80% of the respondents in the present study claimed that they evaluated the safety and effectiveness of the medicines the patients were taking and ensured that their patients understood their current health conditions, most did not document such evaluation and its outcomes. Community pharmacists should be more conscientious to carry out comprehensive documentation which is essential for the effective practice of pharmaceutical care where pharmacists should monitor the drug therapy plan, detect any undesirable outcomes and if required, to modify the therapy plan .
Most of the respondents (76.2%) reported that they identified, minimised and prevented potential medicine-related problems while formulating a drug therapy plan. Studies in China (93.1%) and Nigeria (91.1%) also showed that a majority of the pharmacists identified medicine-related problems when devising pharmaceutical care plans [41, 42].
The present study found that only about 25% of the respondents would recommend changes to the patient's medication regimen when required, compared to 55% of community pharmacists in Nigeria . Documentation of a change in medicine was also rarely done. This may be because community pharmacists in Malaysia do not receive many prescriptions with multiple medications since such prescriptions are usually filled in the hospitals or the clinics of general practitioners. Therefore, community pharmacists are not actively involved in the management of patients' medication regimens and in intervening medication-related problems. Similar situations were also observed in Indonesia .
Only 10% (42) of the respondents would contact their patients’ medical doctors to discuss the need to change the patients’ medication regimens when appropriate and only half of these respondents documented their interventions. These findings are similar to that of a study in India where a majority of the community pharmacists did not contact the patients’ medical doctors on prescription issues . A previous study in Malaysia also found that almost all (98.9%) the medical doctors in private clinics never had any interactions with community pharmacists . Factors that may have prevented community pharmacists from contacting the prescribers included poor relationship between the two health care professionals , and a lack of awareness or acceptance of pharmacists' roles by the prescribers [45–47].
Proper monitoring could be the most important component of pharmaceutical care to detect any undesirable outcomes, but this is usually the least practised . The present study found that less than 20% (77) of the respondents were monitoring and modifying the drug therapy plans for their patients. This finding is similar to studies in Jordan  and Saudi Arabia .
Community pharmacists in Malaysia rarely document their pharmaceutical care services including the outcomes of their interventions. Poor documentation was also observed in studies on community pharmacist services in Jordan  and Brazil . The reason for not documenting the drug therapy plan for monitoring purpose could be the absence of regulations to keep patients' medical records, and also most community pharmacists thought that it is not necessary or are too busy to maintain any document . Documentation of pharmaceutical services provided should be done for the proper practice of monitoring and modifying of a drug therapy plan.
Ethnicity, employment status and age seemed to determine whether the community pharmacists would conduct the various steps in the practice of pharmaceutical care. Self-employed community pharmacists were more proactive in contacting the patient's other health care providers and recommending changes to the medications. This is as expected since most self-employed individuals will be more enthusiastic and will spend more time talking to their customers . More in-depth studies such as qualitative studies will be useful to determine how ethnicity affects the provision of pharmaceutical care services.
The present study found that community pharmacists in Malaysia were not providing adequate pharmaceutical care services in the following areas: collaborating with patients' other health care providers to obtain their medical and medication information; managing the patient's medication regimen including the recommendation to change medication when required; having proper patient monitoring and follow-up mechanism, and; maintaining documentation of pharmaceutical care services.
The most common barriers that prevented community pharmacists from providing pharmaceutical care services in the present study were government or professional health care policies such as the absence of separation between prescribing and dispensing; government initiative for patients to obtain their prescribed medications from community pharmacies; strict enforcement on the dispensing of prescription-only-medicines with valid prescriptions and lack of standard guidelines on pharmaceutical care services. Lack of supportive health care policies had also been cited as one of the main barriers in other studies [41, 46] including in Malaysia  and even in South Korea which practices separation between prescribing and dispensing . The small number of prescriptions received by the community pharmacies in the present study did not provide much opportunity for community pharmacists to provide pharmaceutical care services as patients with chronic and multiple medications seldom visit these pharmacies to fill their prescriptions. The implementation of separation between prescribing and dispensing is a major health care reform which may require political will, time and resources. Perhaps, the authorities concerned can emulate the community pharmacy practice in Thailand where incentives are given to community pharmacists to provide the following services: prescription refill, health screening for patients with chronic disease, smoking cessation counselling and Medicine Management Therapy .
Another barrier reported was medicine price discrimination by pharmaceutical suppliers. Some medications were not available or were sold to community pharmacies at higher prices [51, 52] and hence, costs of prescribed medications may be higher compared to private hospitals or clinics. This may prevent patients from filling their prescriptions in community pharmacies and consequently less opportunity for prescription screening and for identifying any medication-related problems as well as to provide pharmaceutical care services.
Lack of acceptance by medical doctors for community pharmacists to provide pharmaceutical care services was commonly cited by studies in many developing countries [42, 43, 47]. The present study also found that many respondents (63.6%) reported a lack of acceptance by doctors on recommendation of medication regimens by the pharmacist. This could be due a lack of doctors’ understanding regarding the clinical knowledge of pharmacists. However, an Indonesia study showed that doctors who had worked closely with community pharmacists expressed their trusts on these healthcare professionals . This indicates the importance of open discussion to foster closer collaboration between both health care professionals in providing optimal care to the patients.
Other barrier statements stated by more than 50% of the respondents were: patient or customer had no time; shortage of manpower at the pharmacies; and lack of public awareness. These factors could be inter-related because if the general public is adequately informed about the roles of pharmacists, they will be more willing to trade their time for the benefits of pharmaceutical care. Subsequently, with increased demand from customers, the pharmacies will also increase their manpower. Creating public awareness of pharmaceutical care services provided by community pharmacies will increase the utilization of such service and hence, community pharmacists can also contribute to the healthcare system of the country.