Which factors may inuence the implementation of drug dispensing in community pharmacies? A qualitative study

Background: Implementation of clinical pharmacy services, such as drug dispensing, is a complex process. It is necessary to understand the challenges associated with this practice from the perspective of the actors involved to help ensure optimal service provision. Thus, this study aimed to understand the factors that may inuence the implementation of drug dispensing in community pharmacies, according to the perceptions of pharmacists. Methods: This qualitative study was based on semi-structured, face-to-face interviews. The participants were pharmacists who worked in a chain of community pharmacies in Brazil, selected based on their direct participation in the implementation process. The interview recordings were transcribed full verbatim and were independently analyzed using thematic analysis, followed by consensus meetings between researchers. The factors identied by the participants were classied according to the Apoteca framework. This study was approved by the Committee of Ethics in Research and all participants signed an informed consent form. Results: We conducted 18 interviews, with 47 factors that may inuence the implementation of drug dispensing in community pharmacies being identied. These factors were allocated to seven categories: support from community pharmacy chain (4), pharmacy infrastructure (11), characteristics of the pharmacy, medicines and other health products (4), pharmacist (16), dispensing work process (2), pharmacy team (2), and patient (8). The classication of factors according to the Apoteca framework allocated most of them to administrative (14) and technical (14) domains, followed by attitudinal (13) and political (5) domains. Conclusions: This study identied several factors that can inuence the implementation of drug dispensing and classied them according to the domains of the Apoteca framework, highlighting the multifactorial nature of the implementation process. The results of this study can guide the planning of strategies aimed at providing ecient drug dispensing in community pharmacies.

practice and its implementation in relation to the actors involved. Thus, the aim of this study was to understand the factors that may in uence the implementation of drug dispensing in community pharmacies, according to the perceptions of pharmacists.

Study design
A qualitative study design was employed involving semi-structured interviews with pharmacists to provide a comprehensive understanding of factors that may in uence the implementation of drug dispensing in a chain of community pharmacies in Brazil. The interviews were conducted from November 2019 to January 2020.

Study context and setting
In Brazil, people have access to medicines through private community pharmacies and/or pharmacies belonging to the Brazilian Health System (SUS), free of charge. Nationally regulated licensure is needed to open and operate a community pharmacy in Brazil. Although pharmacy ownership is not restricted to pharmacists, a legally responsible pharmacist should be employed and be ever-present at the pharmacy during opening hours. There are no rules regarding the location of pharmacies in Brazil in relation to demographic and geographical criteria [19].
A private chain community pharmacy participated of the present study. The rst pharmacy belonging to this chain was installed in Brazil in 1935, with approximately 1,400 currently operating across the country. The speci c chain of pharmacies examined in this study was established in 2017, having 18 pharmacies located in the capital, which was the setting for the drug dispensing implementation process evaluated herein. The pharmacy team consisted of pharmacists, managers (not all of whom are pharmacists), and pharmacy assistants. In 2019, the Laboratory of Teaching and Research in Social Pharmacy (LEPFS) of the Federal University of Sergipe (UFS) established partnerships with this chain of community pharmacies aimed at implementing drug dispensing.
The implementation process will be based on the Methodology of Problematization with Maguerez Arc in association with the Apoteca framework [20,21]. This methodology has ve steps: observation of reality, key points, theorizing, solution hypotheses, and application to reality [22,23]. This study incorporated the rst stage of this methodology (observation of reality), through semi-structured interviews with pharmacists involved in the implementation process. It is worth mentioning that we intend on incorporating the other steps in future studies.
The research team in this study was composed of a general coordinator (DPLJ) with experience in CPS implementation, two senior researchers (ARM and GASJ), also with experience in the area, three research pharmacists (KSSR, SCS, and DCSAA), and two pharmacy students (JMS and PWSM).

Participants
One pharmacist from each of the 18 pharmacies, selected for convenience by managers, participated in this study. These 18 pharmacists were involved in the implementation process of drug dispensing.

Data collection
Semi-structured interviews were conducted with pharmacists using the recommendations proposed in the Consolidated Criteria for Reporting Qualitative Research (COREQ) [24]. This data collection method was chosen to include the varied experiences and perceptions of the participants. The interview guide was constructed during a brainstorming meeting between the research team (ARM, KSSR, and SCS), based on relevant literature [25,26,27] and their clinical experiences.
One of the researchers (SCS) subsequently conducted a pilot test interview with one of the authors of the study (DCSAA). The nal format of the interview guide was de ned by the research team through consensus discussions (Appendix 1). All interviews were audio recorded and conducted in the community pharmacies by prior appointment, according to the interviewees' choice, in a reserved room, guaranteeing the con dentiality and freedom of expression of the participants. At the time of the interview, only the moderators and the pharmacist being interviewed were present. The interviews were conducted by two female researchers from the research team (KSSR and SCS), who had master's degree and previous experience with this type of data collection. The researchers had no relationship with the interviewees prior to study commencement. At the beginning of the interview, the moderators explained the research objectives and the participants agreed to collaborate by signing an informed consent authorizing the researchers to use their audio recordings. The researchers took eld notes during the interviews.

Data analysis
The interviews were transcribed full verbatim and the data were initially analyzed independently by two researchers (KSSR and SCS), using thematic analysis [28], before a consensus meeting was held. The factors in uencing the implementation of drug dispensing were categorized using an inductive approach [29]. After the categories were de ned, the data were reviewed by two researchers (DCSAA and GASJ) and a careful review was subsequently carried out by two senior evaluators (ARM and DPLJ). After this process, critical analysis of the data was performed. All interviews were analyzed regardless of data saturation [30].
The factors identi ed in the study were classi ed by two researchers (KSSR and SCS), according to the Apoteca framework, which comprises the following domains: "attitudinal", "political", "technical", and "administrative". This conceptual framework emerged from systematic observation and immersion of our research group (LEPFS, UFS) in the implementation of CPS in various settings within the Brazilian Health System [20,21]. The aforementioned domains are de ned as follows: Attitudinal domain: related to behavior, action, or reaction, and motivated by a feeling or opinion toward or of a particular fact or person; including internal and external motivation.
Political domain: related to the relationships within a group or organization that allow particular individuals or groups to in uence others (support).
Technical domain: related to the CPS' own characteristics, as well as the skills and knowledge needed to perform them.
Administrative domain: related to the administrative processes (organization and management) that are required to perform CPS.

Concepts adopted in this study
The concept of drug dispensing adopted in this study is based on that of previous literature, which highlighted key complementary components of this service [31,32,33]. Thus, drug dispensing is a clinical pharmacy service that ensures the provision of medicines and other health products through the analysis of technical and legal aspects of prescription, assessment of individual health needs, and performance of interventions in the medicine use process, which includes pharmaceutical counseling and documentation of the interventions made. Implementation factors are de ned as elements that can moderate, either positively (facilitators) or negatively (barriers), the implementation of the services [11].
The characteristics of the pharmacists who participated in the implementation process are described in Table 1.
Factors that may in uence the implementation of drug dispensing Forty-seven factors that possibly in uence the implementation of drug dispensing were identi ed, and these were allocated to seven categories: support from the community pharmacy chain (4), pharmacy infrastructure (11), characteristics of the pharmacy, medicines and other health products (4), pharmacist (16), dispensing work process (2), pharmacy team (2), and patient (8). Table 2 presents the factors and categories that emerged from the interview, as well as the classi cations derived from the Apoteca framework.
i) Factors related to support from the community pharmacy chain Pharmacists reported that the institutional policy aimed at patient care, the support of managers, and the supply of training by the community pharmacy chain can be facilitators for implementing drug dispensing. In addition, they reported that managers guaranteed the autonomy of pharmacists to act clinically.

ii) Factors related to pharmacy infrastructure
Pharmacists reported that the presence of physical resources (adequate, wide, and air-conditioned pharmacy area) and materials (computers and internal systems for consulting information about medicines and about the patient, such as address, telephone, and purchase history) can facilitate the implementation of drug dispensing. However, the lack of a private area, internet access, and drug interaction programs can make patient care di cult.
Regarding human resources, the presence of a pharmacist throughout the pharmacy's opening hours was described as a positive factor. Most pharmacists reported that an insu cient number of pharmacy attendants can overwhelm the team and make it di cult to implement dispensing.
With regard to training and quali cation of human resources, pharmacists highlighted insu cient clinical training and the gap between what is learned during undergraduate studies and the reality of a community pharmacy as a barrier. In this sense, pharmacists reported the need to complement their academic education with specialization courses. "Undergraduate pharmacy courses do not teach us how to provide dispensing in the pharmacy, rather, we are only taught the most technical and theoretical aspects of drugs. When we begin working in the community pharmacy, we panic!" (Pharmacist A) iii) Characteristics of the pharmacy, medicines, and other health products The location of the community pharmacy was identi ed as a factor that could make it di cult to implement drug dispensing, in such cases where the pharmacy is located in a busy urban shopping mall, thereby having to accommodate a large number of patients and patient pro les. All pharmacists reinforced the di culty with performing drug dispensing when there was a high number of patients in the pharmacy at one time.
"When there is a large number of patients in the pharmacy, we can only deliver the medication to the patient or the shopper [without counseling them]." (Pharmacist J) Additionally, the type of dosage form has also been described as a factor that can in uence the counseling provided to the patient and, consequently, the implementation process. Typically, when medicines with complex dosage forms are dispensed, pharmacists have reported that they tend to provide more patient counseling. In addition, the range of medicines and health products in the market has been described as a factor that can hinder implementation, since pharmacists always need to be up to date on market innovations. iv) Factors related to the pharmacist The number of clinical and logistical activities was described as a factor that may compromise the implementation of drug dispensing, due to the associated di culty for pharmacists to perform all of their duties. However, the division of activities between the pharmacy team was reported as a positive point.
"Some days, I am checking the medicines that arrive at the community pharmacy and, at the same time, I am at the pharmacy counter. If a patient arrives and needs me, I will stop the checking [the medicines] and I will attend to the patient." (Pharmacist P) Pharmacists reported the need to develop and/or improve their knowledge (pharmaceutical legislation, pharmacotherapy, and foreign language), skills (communication with patients), and attitudes (interest, self-con dence, and initiative to provide the service) when dispensing drugs. These competencies have been reported as essential to identifying patients' health needs and making clinical decisions.
"Decision making depends on the situation of each patient. There are patients who don't need medication, they need referral to a physician. We have to make this assessment." (Pharmacist H) Finally, pharmacists declared that motivation generated by their interaction with the patient (positive feedback and a good therapeutic relationship), the team (recognition of leadership role), and the other pharmacists (professional satisfaction) can boost the implementation of the service.
"What motivates me is satisfaction. It is the patient really coming back to the community pharmacy to say that he or she has been feeling better and that I have made a difference in his or her life. I think this is very rewarding." (Pharmacist C) v) Factors related to the dispensing work process The lack of a structured and systematic model that helps pharmacists during drug dispensing was cited as a factor that can hinder the implementation of the service. In addition, interviewees alluded to the use of telephone contact to obtain patient feedback on the medicine use process can facilitate the implementation process. However, it was pointed out that this strategy was performed only for patients who used antimicrobials.

vi) Factors related to the pharmacy team
Pharmacists described how the implementation of drug dispensing is facilitated when each member of the pharmacy team understands their role. For example, when a patient requests an over-the-counter medicine, the pharmacy assistant forwards the request to the pharmacist. Another positive factor reported was having good relations within the pharmacy team.

vii) Factors related to the patient
The interviewees reported that patients had characteristics (previous knowledge about pharmacotherapy, literacy, and age) and behaviors (interest, active participation in the service, and opinions on dispensing) that can in uence the pharmacist's attitude when dispensing drugs and, consequently, in the service implementation. In addition, pharmacists pointed out that the expectations that patients have can generate negative feelings (shame, fear, and frustration), especially when the pharmacist's knowledge does not meet the patient's expectations. The pharmacists also stated that the implementation of drug dispensing can be in uenced by the person receiving the care, that is, the pharmacist will adapt the process depending on whether they are attending to the patient, a family member, a caregiver, or another person unrelated to the patient but collecting medication on their behalf.

Discussion
The literature based on qualitative studies that identify factors that may in uence the implementation of CPS is extensive [14,15,25,27,34] which begs the question, why carry out more studies on this topic? We believe that drug dispensing, as a basic and integrated service to health care networks, has great potential to promote the rational use of medicines and to screen patients who need additional, more complex, CPS. The factors identi ed in this study were speci c to drug dispensing, bringing to light new factors that can in uence the implementation of CPS. In addition, the classi cation of factors according to the Apoteca framework showed their applicability in other settings, such as community pharmacy, and reinforced the multifactorial nature of the CPS implementation process [11,35]. Thus, such ndings will assist in the development of speci c strategies for each Apoteca domain during the entire process of implementing drug dispensing.
Factors related to support from the community pharmacy chain were highlighted as facilitators of the implementation process. According to the literature, the support of the institution, the manager, and the supply of training, in uence the provision of CPS in different settings [15,26,27,36]. Regarding autonomy, studies have shown that this factor is in uenced by the market economy, often limiting the capacity for professionals, who are employed, to apply their own judgement when making decisions [37,38]. However, the fact that the community pharmacy supports patient care can empower pharmacists in their application of clinical activities and help improve patient care [14,36,39]. In this sense, all factors related to the support of the community pharmacy were related to the political domain of the Apoteca framework, which highlights the importance of strategies that engage managers throughout the CPS implementation process.
Factors related to the infrastructure of the community pharmacy were highlighted by the pharmacists. Studies indicate that the implementation of CPS must consider the presence of appropriate human, physical, and material resources conducive to professional practice [16,39,40,41,42]. Interestingly, the pharmacists reported de ciencies in their academic education in relation to drug dispensing. As in other low-and middle-income countries, these shortcomings may be related to an overemphasis of basic sciences during undergraduate studies and lack of specialized disciplines and internships for the development of clinical skills [43,44,45,46]. In addition, although there are government initiatives intent on modifying undergraduate degree programs related to health care, the excessive number of more than 600 pharmacy courses in Brazil can generate professional with different basic level needed to implement standard healthcare procedures [3,47,48]. These issues reinforce the need for curricular changes by educational institutions, speci cally the insertion of clinical science aimed at patient care, as well as continuing education for community pharmacists.
The pharmacists pointed out factors related to the characteristics of the pharmacy, medicines, and other health products. In particular, the high number of patients using community pharmacies can compromise the quality of the drug dispensing, since the pharmacist may feel pressured to provide a quick service without the adequate provision of pharmaceutical counseling [49,50]. This factor is more apparent in community pharmacies that are located in large urban centers, due to the large number of people in the region [51], and may be related to the nature of drug dispensing as a service designed to serve all patients upon arrival (i.e., spontaneous demand). Other CPS, such as medication review and comprehensive medication management, facilitate the establishment and scheduling of patient eligibility criteria [52,53]. This implies that the implementation process of drug dispensing may present different challenges compared with the implementation of other CPS, and this will require the design of speci c strategies for this service.
Factors related to pharmacists, such as knowledge, skills, and attitudes, were described by the interviewees. These competencies must form the foundation of high-quality work processes and have been widely discussed in previous studies related to the implementation of CPS [25,27,34,42]. Professions such as nursing, for example, which have well-de ned work processes, establish competencies conducive to consistent and high-quality practices [54,55]. Therefore, the development of patient-centered competences is essential for the establishment of performance standards for clinical activities and to strengthen pharmacists' professionalism in community pharmacies [56,57,58]. Thus, it is necessary to understand the individual and collective needs of pharmacists so that they may become competent in drug dispensing, by proposing interventions that optimize their performance.
The pharmacists reported the lack of structured work processes as a di culty to them dispensing drugs e ciently. Studies have shown that the absence of de ned, systematized, and reproducible work processes leads to varied pharmaceutical interventions in clinical practices, in uencing the measure of the dispensing results [59,60]. On the other hand, the pharmacists highlighted the patient's feedback by telephone as a facilitator of the implementation of drug dispensing. The literature shows that, as well as the patient returning to the community pharmacy, a telephone call can be a viable alternative for evaluating the results of pharmaceutical interventions performed during drug dispensing, as long as indicators that assess the quality of these results are utilized [18,61,62]. Therefore, the use of instruments that support drug dispensing, and the establishment of performance indicators, can be important for the systematization of the dispensing process and should be used to ensure the reproducibility of the service.
The understanding of each pharmacy team member regarding their role and the existence of good relationships with the pharmacist were identi ed as facilitators in this study. According to the literature, for clinical activities to be carried out properly, it is important that the entire pharmacy team understands their roles and responsibilities, so as to ensure safe practice for the patient [63,64]. Furthermore, trusting relationships, collaboration, and good communication between team members are key to obtaining positive and measurable results that favor the implementation and sustainability of pharmacy services [25,65,66]. In this context of collaborative practices, it is important to develop performance indicators to evaluate the effectiveness and e ciency of the pharmacy team in their provision of health care.
The different factors related to the patient that were identi ed in this study were also addressed in previous studies. The literature shows that knowledge, beliefs, interest, skills, active involvement of the patient in their own care, literacy, and age of the patient can affect the use of services provided in community pharmacies [67,68]. Among the factors related to the patient's behavior, their view of the pharmacy as a setting of quick service was an interesting nding. Studies show that patients often misunderstand the pharmacist's role and do not see community pharmacies as healthcare facilities [25,40,69]. In contrast, in England, for example, there are initiatives within the health system that encourage the public to view the pharmacist in the community pharmacy as a primary point of care, ensuring patient safety [70,71]. Thus, a patient-centered approach by the pharmacist and informing patients about all available pharmacy services can be an valuable strategy to promote the visibility of community pharmacies and pharmacists.
To the best of our knowledge, this is the rst study to identify factors that can in uence the implementation of CPS with a focus on the drug dispensing service in community pharmacies, in which new factors that can in uence this process were highlighted. As mentioned, the factors were categorized according to the Apoteca framework to allow for better planning of the strategies aimed at avoiding failures during the CPS implementation process. In addition, triangulation of data analysis methods was used to increase the reliability and quality of the results. However, there are certain limitations that must be mentioned. The perceptions of a single group of pharmacists are insu cient for comprehensively analyzing the complexity of a speci c implementation context, even more so in a country with as many differences as Brazil.

Conclusion
The pharmacists interviewed herein identi ed several factors that may in uence the implementation of drug dispensing in community pharmacies, such as a lack of systematization of the work process, de ciencies in their academic education, and the large number of patients using urban-based community pharmacies. Other factors such as support of the community pharmacy chain, adequate infrastructure, and good relationships within the pharmacy team and the pharmacist can positively in uence the implementation of drug dispensing. In addition, the factors raised were allocated according to the Apoteca framework, evidencing the multifactorial nature of the implementation process. Therefore, these results can guide the planning of strategies aimed at improving the provision of drug dispensing in community pharmacies.

Declarations
Ethics approval and consent to participate This study was approved by the Ethics Committee of the Federal University of Sergipe (CAAE: 15827719.4.0000.5546 and number 3.698.806).

Consent for publication
All participants signed a consent form that allowed voice recording and publication of interview data.

Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due the Committee of Ethics in Research precludes the data sharing due to the need to protect the con dentiality of the participants. The datasets used in this analysis during the current study are available from the corresponding author on reasonable request.