Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar

Marwa Elshazly; Sondus Jawad; Ayesha Ahmed; Hager ElGeed; Kazeem Babatunde Yusuff

doi:10.1371/journal.pone.0316363

. 2025 Jan 30;20(1):e0316363. doi: 10.1371/journal.pone.0316363

Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar

Marwa Elshazly ^1,^#, Sondus Jawad ^1,^#, Ayesha Ahmed ^1,^#, Hager ElGeed ¹, Kazeem Babatunde Yusuff ^1,^*

Editor: Jenny Wilkinson²

PMCID: PMC11781633 PMID: 39883709

Abstract

There is paucity of studies focused on the enablers and barriers to community pharmacists’ readiness to deprescribe inappropriate medications for older adults in developing settings. The current study assessed the enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults. A cross-sectional survey of 252 community pharmacists was conducted in Qatar with a pre-tested 24-item questionnaire developed with the theory of domain framework. Information about perceived enablers and barriers were elicited with a 5-point Likert-type scale. The response rate was 79.4% (200/252). The majority of the community pharmacists were females (54.5%), within the age range of 20–40 years (88.0%), had BSc / BPharm as the highest educational qualification (70.5%), were full-time employee (97.0%). The top-ranked enablers of community pharmacists’ readiness to implement deprescribing were exposure to CPD on the use of deprescribing toolkits and algorithm (66%), interprofessional collaboration with physicians (60.5%) and shared electronic patient record (59.5%), and improved remuneration / re-imbursement 58%). The top-ranked barriers were lack of access to patient records (70.5%), ineffective collaboration with physicians (66.5%), lack of time due to heavy workload (65%), regulatory framework that limit expansion of clinical roles (51%) and intense focus on sales target (49%). The top-ranked enablers of community pharmacists’ readiness to implement deprescribing were exposure to CPD on the use of deprescribing toolkits and algorithm, interprofessional collaboration with physicians and shared electronic patient record. These findings bode well for the implementation of community pharmacists-led deprescribing of inappropriate medications for older adults in Qatar. However, a number of critical barriers were identified, and these will require institutional, regulatory and organizational interventions to improve readiness.

Introduction

Deprescribing is an important clinical tool that gained ascendancy in the last decade and has become crucial to reducing potentially harmful medication-related adverse events, and promoting appropriate and rational prescribing and use of medicines [1,2]. Indeed, several studies have shown that deprescribing has proven to be particularly useful for older adults who are often diagnosed with multiple chronic medical conditions that are usually managed with chronic multiple drug therapy, and which puts them at higher risk of adverse and unnecessary clinical and financial burdens [3–5]. The most critical determinant of the risk of exposure to adverse outcomes in older adults is the number of medicines prescribed [6], and studies have shown that the elderly population are particularly at higher risk due to ageing-related altered pharmacokinetics and pharmacodynamics factors [6–10]. In addition, older adults are at risk of harms from medications that are considered inappropriate and potentially harmful due to an inherent risk of exposure to adverse effects [6]. Therefore, deprescribing is a useful clinical tool that provides an opportunity for a conscientious review of the relevance and utility of the medications prescribed to older adults with a view to identify the medications that are no longer required or harmful, and should be discontinued or replaced with safer and more effective alternatives [11].

Published studies done in developed settings continue to showcase the positive outcomes of community pharmacists’ participation in the deprescribing of inappropriate and potentially harmful medications for older adults. For instance, a systematic review by Buzancic et al, showed that community pharmacists’ effective collaboration with physicians and patients in the implementation of deprescribing results in optimal therapeutic outcomes [12]. Furthermore, Martin et al, in a cluster randomized controlled trial among older adults in Canada reported that community pharmacists-led deprescribing resulted in greater discontinuation of inappropriate medications compared to usual care at 6 months (risk difference: 31% (95%CI, 23%-38%) [13]. In addition, Tannebaum et al., reported that community pharmacists-led deprescribing intervention resulted in patients’ initiation of conversation with a physician or pharmacist about discontinuation or actual discontinuation of the use of benzodiazepine in older adults [14].

Despite the successful implementation of community pharmacists-led deprescribing intervention among older adults, a number of factors have been identified as enabling or militating against this intervention. The enabling factors include the use of tailored deprescribing guideline within a structured multidisciplinary framework, use of a multidisciplinary deprescribing model involving physicians, pharmacists and nurses, effective interprofessional collaboration and support, community pharmacists’ role expansion into implementing deprescribing at the primary and long term care settings, effective engagement and involvement of patients and / or their relatives, adequate education on deprescribing and availability of financial incentive or re-imbursement [15–17]. The identified barriers to the implementation of community pharmacists-led deprescribing include lack of expertise and deprescribing awareness, poor self-efficacy and fear of consequences of deprescribing, poor communication and collaboration with patients and healthcare professionals, fragmentation of the healthcare system and poor information exchange, lack of incentives, insufficient resources including time and finance, and perception of an “established hierarchy” where physicians are regarded as senior to pharmacists and nurses [15–20].

Studies focused on community pharmacists-led deprescribing intervention and the factors enabling and / or militating against it were conducted mainly in developed settings. Literature search revealed the paucity of such studies in developing settings, including Qatar. Indeed, only one such study focused on the assessment of community pharmacists’ knowledge of deprescribing and their self-perceived enablers and barriers to providing the service in the United Arab Emirates was identified [21]. The paucity of studies focused on community pharmacists-led deprescribing intervention in developing settings is unsurprising as the provision of a deprescribing service guided by a structured framework is currently not within the scope of practice for community pharmacists generally in developing settings including in the Middle Eastern Gulf countries. Hence, a baseline assessment of the enablers and barriers to community pharmacists’ implementation of deprescribing especially for a vulnerable group such as older adults seems like the appropriate starting point.

The current study was foregrounded by the Theoretical Domains Framework (TDF) V2 [21]. This is a theoretical framework that assesses the factors that may enable or militate against the successful implementation of an intervention focused on a specific desired practice change. The TDF consists of 14 domains developed from 128 theoretical constructs that were synthesized from varieties of behavioural change theories associated with implementation science and practice change [22–25]. The 14 domains of the TDF include knowledge; skills; social / professional identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; intentions; goals; Memory, attention and decision processes; environmental context and resources; and social influences.

Hence, the current study may provide new significant perspectives that will not only add to global knowledge in the research area but may also provide insights that can be used to develop an appropriate institutional framework to guide the implementation of community pharmacists-led deprescribing for older adults in Qatar and other similar developing settings. The objective of the study was to identify the enablers and barriers to community pharmacists’ readiness to implement the deprescribing inappropriate medication for older adults in Qatar.

Methods

Study design, setting and sampling

A cross-sectional survey of the enablers and barriers to community pharmacists’ readiness to implement deprescribing for older adults was conducted between 01 November, 2023 and 20 January 2024 in Qatar, a Middle Eastern Gulf country with an estimated population of 2.73 million [26].

The study participants include a purposive sample of community pharmacists who were drawn from a sampling frame of all licensed community pharmacists in practice for at least a year in Qatar, and who were fluent in oral and written English. The Raosoft online calculator was used to obtain a minimum sample of 252 community pharmacists and an extra 10% was added to adjust for non-response. The parameters used for the sample size calculation include: target population of community pharmacists (562), alpha level (5%), confidence level (95%), and response distribution (50%).

Questionnaire development and structure

The 14 domains of the TDF were grouped into 5 categories of deprescribing framework including ‘knowledge’, ‘professional role and identity’, ‘beliefs about capabilities’, ‘environmental context and resources’ and ‘social influence’. This grouping is inherent in the TDF and was also based on an Irish study conducted by Henrich et al, that assessed the perceptions of healthcare professional about the barriers and enablers to deprescribing in long-term care setting [16]. The 5 categories of deprescribing framework were used to develop the initial draft of 30 items that was identified by the research team after a thorough review of relevant literature in the research area [15–21]. This was, followed by an iterative process involving an in-depth discussion of the appropriateness, relevance and validity of the items, and their mapping to the deprescribing framework. This resulted in the final 23-item questionnaire comprising three sections including A (demographics = 10 items), B (Enablers = 7 items), and C (Barriers = 6 items). The questionnaire items were mapped to the deprescribing framework as follow: knowledge = 2, professional role and identity = 3, beliefs about capabilities = 2, environmental context and resources = 4 and social influence = 3. The content validity of the questionnaire was assessed by a panel of three experienced researchers in the research area. In addition, the internal consistency of the final questionnaire was determined with Cronbach alpha, and these were 0.82 and 0.75 for the sections B and C respectively. Lastly, the questionnaire was pre-tested to assess its clarity, completeness and relevance on a sample 10 community pharmacists, and minor modifications were made as necessary. The pre-test result was not included in the final results. The study participants were asked to rank their responses to the items in Section B and C on a 5-point Likert-type scale (highest = 5, high = 4, moderate = 3, low = 2, Lowest = 1). However, this response scale was re-coded into three categories of low (lowest + low), moderate and high (highest + high) to ease data analysis.

Ethics approval

Ethics approval was obtained from QUIRB (Qatar University Institutional Review Board) (QU-IRB 1906-E/23, August 30, 2023).

Data collection and analysis

Three research assistants (students) collected the data with the validated and pre-tested 23-item questionnaire. The data collection procedure was standardized to minimize variation. The questionnaires were delivered to the respondents at their workplace, and detailed information about the purpose and anticipated benefits of the study were provided in a separate informed consent form. The respondents who agreed to participate in the study signed the written informed consent form before the start of data collection, and they were all informed of their right to decline participation at any point in the study. Completed questionnaires were collected as soon as possible but not exceeding 5 days after distribution. Reminders were sent through telephone calls or emails to those who did not return completed questionnaires within one week. The IBM SPSS (Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp.) software was used for data analysis. Descriptive statistics such as median (IQR) was used for continuous data with non-normal distribution while frequency (%) was used for categorical data. The alpha level for significance was set at p ≤ 0.05.

Results

Of the 252 respondents who consented, two hundred completed the questionnaires (response rate, 79.4%). The demographic characteristics of the respondents showed that the majority were females (54.5%; 109/200), within the age range of 20–40 years (88.0%; 176/200), had BSc / BPharm as the highest educational qualification (70.5%; 141/200), were full-time employee (97.0%; 194/200), and consisted mainly of 5 nationalities (91.0%; 182/200) including Indian (40.5%), Egyptian (22.5%), Jordanian (22%) and Sudanese (6%). Furthermore, the majority of the community pharmacists had 1–5 years of practice experience (51.5%; 103/200) and previous hospital pharmacy experience (55%; 110/200) (Table 1). However, only 49% (98/200) reported exposure to deprescribing during undergraduate training. In addition, the majority of respondents reported not attending any CPD related to deprescribing in the past 5 years (54%; 108/200). However, the median (IQR) score for the willingness to complete a CPD program on deprescribing was 4 (2) (maximum = 5) (Table 1).

Table 1. Community pharmacists’ demographic and practice characteristics (N = 200).

Item	n (%)
Gender
Male	91 (45.5)
Female	109 (54.5)
Age group (years)
20–30	102 (51.0)
31–40	74 (37.0)
41–50	24 (12.0)
Nationality
Indian	81 (40.5)
Egyptian	45 (22.5)
Jordanian	44 (22.0)
Sudanese	12 (6.0)
Pakistani	7 (3.5)
Filipino	4 (2.0)
Syrian	3 (1.5)
Saudi	2 (1.0)
Palestinian	1 (0.5)
Ghana	1 (0.5)
Highest educational Level
BSc/BPharm	141 (70.5)
MSc / MPharm	33 (16.5)
PharmD	26 (13.0)
Employment status
Full time	194 (97.0)
Part time	6 (3.0)
Years of experience as a community pharmacist
1–5 years	103 (51.5)
6–10 years	57 (28.5)
>10 years	40 (20.0)
Previous hospital pharmacy experience
Yes	110 (55.0)
No	90 (45.0)
Exposure to deprescribing in undergraduate training
Yes	98 (49.0)
No	102 (51.0)
Attended CPD related to deprescribing in past 5 years
None	108 (54)
1–2	56 (28.0)
3–4	18 (9.0)
>4	18 9)
Willingness to complete CPD on deprescribing (Median (IQR))	4 (3, 5)

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The enablers and barriers to community pharmacists’ readiness to implement deprescribing for older adults in Qatar is shown in Table 2. The top-ranked enablers identified by the majority of respondents include continuous CPD on the use of deprescribing toolkits and algorithm (66%; 132/200), established forum for an effective interprofessional collaboration with physicians (60.5%; 121/200), availability of shared electronic patient record (59.5%; 119/200), improved remuneration for community pharmacists (58%; 116/200), opportunities to deprescribe inappropriate medications in practice (55.5%; 111/200), and public education on the benefits of deprescribing inappropriate medications (50.5%; 101/200) (Table 2).

Table 2. Enablers and barriers to the community pharmacists’ readiness to implement deprescribing for older adults in Qatar (N = 200).

No	Questionnaire items	Low n (%)	Moderate n (%)	High n (%)	Median (IQR)
	Enablers
1	CPD on deprescribing toolkits and algorithm and how to use them.	15 (7.5)	53 (26.5)	132 (66.0)	4 (3, 5) *
2	Established forum for effective interprofessional collaboration with physicians.	27 (13.5)	52 (26.0)	121 (60.5)	4 (3, 5) *
3	Availability of a shared electronic patient record for physicians and community pharmacists.	34 (17.0)	47 (23.5)	119 (59.5)	4 (3, 5) *
4	Regulatory permission to community pharmacists in Qatar to provide clinically-oriented services such as deprescribing	41 (20.5)	62 (31.0)	97 (48.5)	3 (3, 4)
5	Improved remuneration for community pharmacists to provide clinically-oriented services including deprescribing.	30 (15.0)	54 (27.0)	116 (58.0)	4 (3, 5) *
6	Public education for patients to know the benefits of deprescribing.	44 (22.0)	55 (27.5)	101 (50.5)	4 (3, 5) *
7	Opportunities exist to deprescribe inappropriate medications in my practice environment.	21 (10.5)	68 (34.0)	111 (55.5)	4 (3, 5) *
	Barriers
1	Lack of access to a detailed patient medical / medication history.	21 910.5)	38 (19.0)	141 (70.5)	4 (3, 5) *
2	Workload pressure leading to lack of time to review prescription for deprescribing opportunities.	32 (16.0)	38 (19.0)	130 (65.0)	4 (3, 5) *
3	Limited knowledge of the deprescribing toolkits and algorithm and how to use them.	35 (17.5)	70 (35.0)	95 (47.5)	3 (3, 4)
4	Lack of effective collaborative working relationship with physicians.	32 (16.0)	35 (17.5)	133 (66.5)	4 (3, 5) *
5	Intense focus on meeting given organizational sales / financial target	34 (17.0)	68 (34.0)	98 (49.0)	3 (3, 4)
6	Detailed medication usage review is not currently a key part of community pharmacists’ job description in Qatar.	57 (28.5)	49 (24.5)	94 (47.0)	3 (3, 4)
7	Current pharmacy regulatory framework limits the range of clinically-related services that could be provided by community pharmacists in Qatar.	40 (20.0)	58 (29.0)	102 (51.0)	4 (3, 5) *

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The top-ranked barriers by the majority of community pharmacists were lack of access to patient records (70.5%; 141/200), lack of an effective interprofessional collaboration (66.5%; 133/200), lack of time due to heavy workload (65%; 130/200) and current regulatory framework for community pharmacy practice in Qatar (51%; 102/200) and intense focus on meeting given sales target (49%; 98/200).

Discussion

The identification of opportunities to attend CPD programs focused on the effective use of deprescribing toolkits and algorithm as one of the top-ranked enablers seems unsurprising as only about half of the respondents reported exposure to deprescribing in their undergraduate training, and attendance of CPD program related to deprescribing in the past five years. This finding is consistent with that of Cheong et al, and Heinrich et al, who reported education about deprescribing resources and how to use them in practice as a top-ranked facilitator of initiative to enhance community pharmacists’ capacity to provide deprescribing service [27,28]. Therefore, the identification of attendance of CPD programs focused on the effective used of deprescribing toolkits and algorithm bodes well for enhancing community pharmacists’ readiness for this role expansion within the healthcare system. This is a plausible proposition as the majority of respondents in the current study reported a high willingness to complete a CPD program focused on deprescribing of inappropriate medications for older adults in Qatar.

Furthermore, the identification of the availability of a forum for an effective interprofessional collaboration with physicians and a shared patient electronic record and improved remunerations for community pharmacists as top-ranked enablers align with trends reported by published studies from developed settings [15,16,27]. These are propositions that will enhance community pharmacists’ readiness to effectively implement a clinical service such a deprescribing in Qatar. Several studies have documented the benefits associated with the use of an effective interprofessional collaborative model in enhancing effective provision of deprescribing service by community pharmacists [29,30]. In addition, the availability of a shared electronic patient record will improve community pharmacists’ access to critical information needed to identify and deprescribe inappropriate medications for older adults [31,32]. The identification of improved remuneration package for community pharmacists as one of the top-ranked is similar to the findings reported by Heinrich et al, [27] and Jokanovic et al. [33] This is unsurprising as the positive impact of an improved remuneration package on productivity, job satisfaction and readiness to complete assigned task are well documented [34,35].

The identification of existing opportunities to deprescribe inappropriate medications in practice by a majority of respondents is probably a good pointer of the current burden of the inappropriate medications that older adults are exposed to in Qatar. In addition, community pharmacists’ identification of public education of the benefit of providing deprescribing service especially at the community level as an enabler is probably an indicator of their commitment to provide this service. Perhaps, such a public enlightenment program may enhance the demand for such a service at the community level where community pharmacies abound [36].

Furthermore, it was unsurprising that lack of access to patient record was one of the top-ranked barriers identify by the respondents. The critical roles that access to detailed medical and medication history play in enhancing the ability to analyze, identify and resolve clinical problems are well documented [32]. In addition, the identification of lack of existing effective interprofessional collaboration and lack of time due to heavy workload as key barriers to the implementation of community pharmacists-led deprescribing are well documented [21,27,31]. Therefore, a holistic intervention targeted towards mitigating these barriers are warranted. Furthermore, the identification of the regulatory framework currently guiding community pharmacy practice in Qatar as a key barrier to the implementation of deprescribing in practice is being reported for the first time. This is because the range of clinically-oriented services that community pharmacists are legally permitted to provide are limited and not in tandem with the expanding needs at the community level. Therefore, there is a clear need for a review of the community pharmacy regulatory framework to ensure that it is in tandem with the expanding roles of community pharmacists, and meet the changing societal needs in the contemporary times. Indeed, the review of the regulatory framework is the crucial first step that must be undertaken in developing a scheme to expand the range of clinically-oriented services, including deprescribing, that community pharmacists will be able to provide to patients in Qatar.

Lastly, the identification of community pharmacists’ focus on meeting organizational sales target as a top-ranked barrier to readiness to implement deprescribing is being reported for the first time, and seems to suggest a dominant focus on the business side rather clinical practice in the community pharmacy sector in Qatar. This is unsurprising as organizational policies and goals, which are often shaped by organizational vision, are crucial determinants of job-related behavior, and seem to be an important factor to consider in developing an institutional framework for the implementation of community pharmacists-led deprescribing. This seems plausible as previous studies have reported that re-imbursement or remuneration of community pharmacists based on the number of prescriptions filled or medications dispensed or sold could be become a financial disincentive for implementing deprescribing in practice [16,20,37].

Strengths and limitations

To best of our knowledge, the current study is the first from a developing setting to foreground the assessment of enablers and barriers to the readiness of community pharmacists to implement deprescribing with the TDF, a widely used theoretical framework in implementation research. However, the study findings may be limited by a few factors including the use of a non-probability sampling as the participants were drawn mainly from the chain pharmacies. However, chain pharmacies constitute about 75% of the community pharmacies in Qatar [38]. Hence, the reported findings probably approximate the reality on the ground. Furthermore, the use quantitative survey design may have increased the risk of social desirability bias as the participants who responded may have done so in a favorable manner. However, this appeared not be the case as a sizeable proportion of top-ranked barriers were identified by the respondents.

Conclusions

The top-ranked enablers of community pharmacists’ readiness to implement deprescribing in practice were exposure to CPD on the use of deprescribing toolkits and algorithm, interprofessional collaboration with physicians and shared electronic patient record, and improved remuneration / re-imbursement. These findings bode well for the implementation of community pharmacists-led deprescribing of inappropriate medications for older adults in Qatar. However, a number of critical barriers were identified, and these will require institutional, regulatory and organizational interventions to improve readiness. The top-ranked barriers were lack of access to patient records, ineffective collaboration with physicians, lack of time due to heavy workload, regulatory framework that limit expansion of clinical roles, and intense focus on sales target.

Data Availability

All relevant data are within the manuscript.

Funding Statement

The study was funded with an Undergraduate Research Experience Program (UREP) award [UREP29-092-3-029] from the Qatar National Research Fund (a member of The Qatar Foundation). Open access funding was provided by the Qatar National Library. The contents of the manuscript are solely the responsibility of the authors, and the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0316363.r001

Decision Letter 0

Jenny Wilkinson

20 Sep 2024

PONE-D-24-26224Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in a developing settingPLOS ONE

Dear Dr. Yusuff,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Both reviewers have provided comments to improve the clarity of your work particularly regarding the decision making rationale for the study and data presentation.

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We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

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KBY

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Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript as presented could benefit from additional information, rationale to support decision-making and clarity. These follow in summary and more detail in peer review report.

1. Amend title to include Qatar

2. Offer definition of deprescribing for this study Lines 57-59. Deprescribing is identified as “… an important clinical tool…” but for clarity, it would be helpful to offer a definition or detailed description of deprescribing as used in this study.

3.Lines 85-88 would benefit from each key assertion being individually referenced

4. Lines 102-104 It can be helpful to identify the search criteria utilised

5. Lines 112-117 It could assist readers to identify additional information such as the fourteen domains and those especially relevant to this study, for example

6.Lines 140-144 ? Please explain the research team’s decision-making on this point. Please describe the fourteen domains and the theoretical background as it informs this study.

7. Lines 170-173 This section could be enhanced by some details about the research assistants since they seem to be the “face” of this study to pharmacist participants.

8. Analysis section - In a manuscript, it is beneficial to identify those functions within SPSS that were used to analyse the data, similarly any recoding of values such as for negatively phrased items. More detailed information is needed to understand the results obtained and the conclusions drawn.

9.study participants were asked to rank their responses to the items in Section B and C on a 5-point Likert-type scale (highest =5, high = 4, moderate = 3, low = 2, Lowest = 1). However, in Results section Table 2, the columns are labelled,

Low

n (%) Moderate

n (%) High

n (%) Median (IQR)

If additional analyses or re-coding were undertaken to result in these three categories, that needs to be clearly detailed.

10. Apparent repetition Lines 173-176 AND Lines 165-167 - Both state “The respondents who agreed to participate in the study signed the written informed consent form before the start of data collection, and they were all informed of their right to decline participation at any point in the study.”

11. Results Additional detail would be helpful to understand the results of the study and its outcomes.

12. Additional guidance is available in this article, “A Consensus-Based Checklist for Reporting of Survey Studies (CROSS)” in which the reporting guidelines are found in the supplementary material – supplement 3

13.The discussion benefits from being better contextualised by discussing recent publications centred on Qatar

14. Limitations - it was not evident in the manuscript which locations were sampling towns or regions as differences in perceptions, experiences and resources might be anticipated in various locations

15. The the link between methodology (survey) and favourable responses is not clearly explained but benefits from being so.

16.This reference (number 36) appears to be inconsistent with Vancouver referencing:

Gerlach N, Michiels-Corsten M, Viniol A, et al. Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing—a qualitative study. BMC Fam Pract. 2020/09/06 ed. 2020 Sep 4; 21(1):183.

17. Please review all references for consistency with Vancouver format.

Reviewer #2: The manuscript is good but I think the following points should be addressed:

1- rewrite the title as the title is not clear such using facilitators instead of enablers

2- I prefer to attach the developed questionnaire in the appendix or supplement file

3- I think also mention how did you summarize answers from five choices to three choice (table 2) in the methodology section after line 161-162

4- I think mention the current practice in Qatar, it is manly traditional practice or there is/are some advance practice such as reviewing medication, providing vaccination, prescribing authorizes, etc... will be beneficial and strengthen the study

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Reviewer #1: No

Reviewer #2: Yes: Mohammed Abdullah Kubas

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Attachment

Submitted filename: PLOS ONE ReviewFINAL Author Editor.pdf

pone.0316363.s001.pdf^{(109.9KB, pdf)}

PLoS One. 2025 Jan 30;20(1):e0316363. doi: 10.1371/journal.pone.0316363.r002

Author response to Decision Letter 0

29 Oct 2024

29 October 2024

The Editor-In-Chief

PLOS ONE

Dear Sir,

Re: Manuscript #PONE-D-24-26224 – “Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in a developing setting”

Our sincere thanks for the opportunity to revise the manuscript #PONE-D-24-26224, titled “Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in a developing setting” which is under your consideration for publication in the PLOS ONE. We thank the reviewers for the insightful comments and useful suggestions and we have revised the manuscript accordingly. Please find stated below our point-by-point response to the reviewers’ comments. We have also revised the manuscript in accordance with the editor’s comments.

EDITOR’S COMMENTS

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: The corrections have been done in accordance with specifications stated in the PLOS ONE style template

2. Thank you for stating the following financial disclosure:

KBY

Undergraduate Research Experience Program (UREP) award [UREP29-092-3-029] from the Qatar National Research Fund (a member of The Qatar Foundation). The contents are solely the responsibility of the authors. Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

Response: The financial disclosure statement has been amended as recommended, and also included in the revised cover letter.

3. Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical.

Response: The abstract has been amended as recommended.

REVIEWER’S COMMENTS

Reviewer #1: The manuscript as presented could benefit from additional information, rationale to support decision-making and clarity. These follow in summary and more detail in peer review report.

Response: We are truly grateful for the valuable comments offered by the reviewer and the time spent to provide these useful feedback. We value the suggested corrections proposed by the reviewer and we are convinced it can only improve the scholarly value of the manuscript.

• Comment-1: Amend title to include Qatar.

Response-1: We thank the reviewer for this suggestion and we totally concur with the premise of the suggested correction. The title has been revised to include “Qatar” [Pg 1, line 2].

• Comment-2: Currently those in Qatar older than sixty years of age constitute 3.6% of the population though that is predicted to increase to approximately 20.3% by 2050, which is in 26 years’ time, so lacking apparent immediate urgency. So, seek to identify the significance or implications of undertaking this study now in 2024. There is time available to review and amend pre-registration qualifications offered in Qatar by adding or increasing medicines simplification, quality use of medicines and de-prescribing content. In addition, there is time to develop continuing professional development materials, and propose credentialing or recognized qualifications to registering authorities.

• Response-2: We thank the reviewer for the important observation and we see the points raised. However, we are of the opinion that the potential clinical and financial burden associated with the harms inherent in the use of inappropriate medications in elderly population is better avoided by provision of a clinical service such as deprescribing especially at the primary care level where community pharmacists are easily accessible. In addition, 3.6% of the current population translates to about 120,000 elderly patients in Qatar (Estimated pop is about 3million). Hence, there is a lot of potential inherent benefits associated with the deployment of a care-enhancing clinical service such as deprescribing of inappropriate medications in one of the most vulnerable patient group such as the elderly. In addition, it is generally well established that early deployment of interventions focused improving patient outcomes and strengthening the health system often result lasting positive impact on public health.

• Comment-3: KEY WORDS: Currently- Community pharmacists, deprescribing, older adults, enablers, barriers. There is mention of training needs, education enhancement in the manuscript so perhaps adding : curriculum review, continuing professional development.

Response-3: This is an excellent suggestion and we sincerely thank the reviewer. The revision has been done as recommended [Pg 3, line 47-48].

• Comment-4: Line 31 The current study assessed determined… It is possible to use one or other word.

• Response-4: Heartfelt thanks to the reviewer. This was an unintended error and it has been corrected [Pg 2, line 24].

• Comment-5: Lines 35-36 “Enablers and barriers were assessed with a 5-point Likert-type scale” . Something such as - Information about perceptions of enablers and barriers were elicited using a 5-point Likert scale - This provides additional clarity as to the purpose and what was disclosed by respondents.

• Response-5: Many thanks to the reviewer for the suggestion. The corrections have been done [Pg 2, line 28].

• Comment-6: Lines 57-59. Deprescribing is identified as “… an important clinical tool…” but for clarity, it would be helpful to offer a definition or detailed description of deprescribing as used in this study. Although deprescribing as a term was stated to be first used in the English language health literature in 2003 in an Australian hospital pharmacy journal, over subsequent years the term has been customised, for example in patients taking cardiovascular medicines only, and the process to some extent modified(Reeve, E., Gnjidic, D., Long, J., & Hilmer, S. (2015). A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. British journal of clinical pharmacology, 80(6), 1254–1268. https://doi.org/10.1111/bcp.12732) , so clarity in this study’s use is beneficial

• Response-6: Heartfelt thanks to the reviewer for this valuable comment. We agree that a definition of deprescribing will further enhance clarity. In fact, we respectfully submit that we have already done this in the last sentence of the first paragraph of the Introduction section. However, this sentence has been revised to enhance its clarity as recommended by the reviewer. In addition, we have also added one of the references kindly suggested by the reviewer because we think its definition of deprescribing seems to have been captured in line 61-65 [Pg 3-4]

• Comment-7: Lines 63-65 assert that the greatest risk to the elderly from medication lies in the number of medicines, and certainly, the more medicines taken, the more there can be a risk of drug-drug, drug-herb, drug-disease state interactions, but there are also some medicines that have an inherent risk of adverse effects in the elderly, even with a lesser number of medications taken. These include NSAIDS, medicines with an anticholinergic effect, some diuretics, antihypertensives and others (https://www.msdmanuals.com/en au/professional/geriatrics/drug-therapy-in-older-adults/drug-categories-of-concern-in-older-adults).

• Response-7: Sincere thanks to the reviewer for this excellent comment. We concur with the reviewer point and we think this assertion has already been captured in the manuscript [Line 61-65]. We were conscious of balancing comprehensiveness with conciseness to minimize redundancies.

• Comment-8 Lines 76-78- Currently, “Furthermore, Martin et al, in a cluster randomized controlled trial among older adults in Canada reported that community pharmacists-led deprescribing resulted in greater discontinuation of inappropriate medications.” So, what is the comparator- Greater than prescribers? Greater than the patient’s requests? This benefits from additional clarity as to the insights relevant to or which informed this study.

Response-8: Sincere thanks for this important comment. The correction has been done to enhance clarity [Line 73-74].

• Comment-9: Lines 85-88. – Currently, “The enabling factors include the use of tailored deprescribing guideline within a structured multidisciplinary framework, use of a multidisciplinary deprescribing model involving physicians, pharmacists and nurses, effective interprofessional collaboration…”. These statements are referenced in the paragraph with references 14-16. Readers seeking more information perhaps of an unfamiliar term such as “a structured multidisciplinary framework” or an unfamiliar procedure such as “… use of a multidisciplinary deprescribing model…” would benefit from each key assertion being individually referenced, especially as these are identified as enabling factors.

Response-9: Many thanks to the reviewer and we see the point. However, for the sake of brevity, we cited the references at the end of the sentence. We think this is appropriate and consistent with the established norm in the scholarly world.

Comment-10 - Lines 92-98. Likewise, the benefit of additional clarity for the barriers.

Response-10 - Many thanks to the reviewer and we see the point. However, for the sake of brevity, we cited the references at the end of the sentence. We think this is appropriate and consistent with the established norm in the scholarly world.

• Comment-11: Lines 102-104. The manuscript states, “Indeed, only one such study focused on the assessment of community pharmacists’ knowledge of deprescribing and their self perceived enablers and barriers to providing the service in the United Arab Emirates was identified.” It can be helpful to identify the search criteria utilised as a quick search identified four studies that may have been helpful, two studies in 2024 in Nigeria (exploring barriers and enablers), one in Malaysia in 2023(deprescribing) and also in 2023 the study cited in reference 20 (key to promoting deprescribing).

• Response-11: Many thanks for the interesting suggestion. The studies alluded to in the review comments that were conducted in Nigeria and Malaysia were done among HCPs including physicians, hospital pharmacists, nurses practicing in secondary and tertiary care settings. Our study was focused mainly on community pharmacists.

• Comment-12: Lines 112-117. The manuscript states, “The current study was foregrounded by the Theoretical Domains Framework (TDF) V2 [21]. This is a theoretical framework that assesses the factors that may enable or militate against the successful implementation of an intervention focused on a specific desired practice change. The TDF consists of fourteen domains developed from 128 theoretical constructs that were synthesized from varieties of behavioural change theories associated with implementation science and practice change…” It could assist readers to identify additional information such as the fourteen domains and those especially relevant to this study, for example.

• Response-12: Great comment by the reviewer and we are thankful for this. However. We respectfully submit that the TDF was adequately referenced. However, the mansucript has been revised to provide a summary of the 14 domains of the framework [line 112-116]. We thought this suffices for any interested readers who desire more detailed information about the framework. However

Atkins L, Francis J, Islam R, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.

Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. HealPsychol Rev. 2015;9:323–344.

Cadogan C, Ryan C, Francis J, et al. Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing. Implement Sci. 2015;10:161.

Alqubaisi M, Tonna A, Strath A, Stewart D. Quantifying behavioural determinants relating to health professional reporting of medication errors: a cross-sectional survey using the theoretical domains framework. Eur J Clin Pharmacol. 2016;72:1401–1411.

• Comment-13: Lines 140-144. Please see comment above seeking the fourteen domains and those most relevant to this study. It is stated the fourteen domains were grouped into 5 categories, were these grouped by the research team or is this grouping inherent in the TDF? It goes on to say this grouping was influenced by an Irish study but would an Irish study and a Qatari study benefit from the same/similar categorisation? Please explain the research team’s decision-making on this point. Please describe the fourteen domains and the theoretical background as it informs this study. In which geographical region was the framework developed? How does it apply to Qatar.

Response-13: Many thanks for this suggestion. The grouping into 5 domains is inherent in the TDF and it was also based on a published Irish study, and we have revised the manuscript to clarify this. The TDF framework is a validated and well documented theoretical framework that has been in several published studies focused on understanding factors associated with behavioral change and implementation science. Relevant references regarding the details of how the framework was developed and validated have been provided in the manuscript. The grouping into 5 domains is inherent in the TDF and it was also based on a published Irish study. The research team adopted these domains because of their well-documented impact on behavioral change irrespective of settings. Additional details regarding the research team decision-making have been provided in line 142-163.

• Comment -14: Lines 159-160. For clarity please, does this mean that the responses from the pre-test sample were not included in the dataset of the study for analysis? What happened to them?

• Response-14: The pre-test results were discarded and this is in accordance with the established standard in Quantitative survey research.

• Comment-15: Lines 170-173. The three research assistants, were these individuals, students, administrative support people or pharmacists? This section could be enhanced by some details about the research assistants since they seem to be the “face” of this study to pharmacist participants. This is a concern because response rates for participation and completion can vary with the characteristics of the person providing the questionnaire. Back in 2002, it was established that even the colour of the paper a printed questionnaire was printed on made a difference, Etter and colleagues, for example, established that pink paper increased response rates by 12%, so provision of detail is important.

• Response-15: Many thanks for this important observation. The research assistants were students [3] and the data collection procedure was standardized to minimize any potential bias alluded to in the review comment [line 169-173].

• Comment-16: Line 173. The detailed “information about the purpose and anticipated benefits of the study,” how was the information provided? Verbally, written, link to study website? Additional information will assist readers as they consider their own studies.

• Response-16: Heartfelt thanks to the reviewer for this comment. The information about the purpose and anticipated benefits of the study was iincluded in the participant consent form given to the respondents to read and sign before the start of data collection. The manuscript has been revi

Attachment

Submitted filename: Response to Reviewers.docx

pone.0316363.s002.docx^{(44.3KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0316363.r003

Decision Letter 1

Jenny Wilkinson

21 Nov 2024

PONE-D-24-26224R1Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in QatarPLOS ONE

Dear Dr. Yusuff,

Thank you for your responses and revisions. The original reviewers have evaluated your responses and have asked for some further minor revisions to improve clarity of your work.

Please submit your revised manuscript by Jan 05 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Reviewer #1: Thank you for submitting your revised manuscript. To my perception the changes made have enhanced the clarity and communication of the manuscript. There are also opportunities for additional clarity and enhanced communication of your research, the decision-making inherent to the research and the outcomes. In particular, it is important to meet the journal's expectations for key sections such as the introduction which provides sufficient context and background for readers unfamiliar with the study site to understand the setting, professional practice in that setting, and, issues that may benefit from exploration and dissemination. Then the next key component - the methodology which benefits from sufficient information and justification for decisions made such as the choice of function within a data analysis program to inform the reader why and for which purpose that analysis plan has been effected. Lastly, the discussion provides some context within which the results of the study can be situated and considered - so it may be what is specific about pharmacy and pharmacy practice in Qatar.

PLOS ONE Review 2

TITLE: Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar.

RELEVANCE OR SIGNIFICANCE: Currently those in Qatar older than sixty years of age constitute 3.6% of the population though that is predicted to increase to approximately 20.3% by 2050, which is in 26 year’s time, so lacking apparent immediate urgency. So,please seek to firmly and clearly identify the significance or implications of undertaking this study now in 2024 - Why is it needed? Why now? What has to change and what else has to happen for the activity on which this research is focussed to come into effect. In my experience, often authors may be well aware of what is happening in their setting, what could be desirable and will of the pharmacist population to provide a proposed service or modify a standard procedure, for example. However, readers from outside the setting are often quite unfamiliar with a study's setting, and in lieu of more information may wonder if it is much the same as in t he reader's setting. In my experience providing context, information, including some statistics will assist the reader the view the study within the actual study setting.

INTRODUCTION: PLOS ONE expectations for introductory material is for: provision of sufficient background and context of the manuscript such that readers are able to understand the purpose and significance of the study; clarity in identifying the issue addressed and why it is problematic or necessary; concluding with a brief description of the overall aim and whether/how that was/was not achieved. Comments on this section of this manuscript follow.

Some were requested previously but not clarified or reviewed to reflect the information/request:

Issue Lines 57-59. Deprescribing is identified as “… an important clinical tool…” but for clarity, it would be helpful to offer a definition or detailed description of deprescribing as used in this study.

Authors response:

Response-6: Heartfelt thanks to the reviewer for this valuable comment. We agree that a definition of deprescribing will further enhance clarity. In fact, we respectfully submit that we have already done this in the last sentence of the first paragraph of the Introduction section. However, this sentence has been revised to enhance its clarity as recommended by the reviewer. In addition, we have also added one of the references kindly suggested by the reviewer because we think its definition of deprescribing seems to have been captured in line 61-65 [Pg 3-4]

The lines referred to have content as follows:

provides an opportunity for a dispassionate review of the relevance and utility of the medications prescribed to older adults with a view to identify the medications that are no longer required or harmful, and should be discontinued or replaced with safer and more effective alternatives.

Issue - A little more clarity would beneficial - what is a dispassionate review? What benefit arises from a dispassionate view? Why not a standard protocol? Why not take into consideration the patient’s perceptions of their medications or issues they may be having? Further, the key is to identify medications that are no longer required - for which reasons? duplication of therapy? continuation of medication to manage an acute condition? removal of a medication that manages an adverse effect of another medication taken by the patient?

Issue- benefit of additional clarity as to why deprescribing needs to be added, legally, to community pharmacists scope, and why the timing since hospital pharmacists have and are trialling a deprescribing initiative- how is it that deprescribing is within scope for hospital pharmacists in Qatar but not community pharmacists?

Response-2: We thank the reviewer for the important observation and we see the points raised. However, we are of the opinion that the potential clinical and financial burden associated with the harms inherent in the use of inappropriate medications in elderly population is better avoided by provision of a clinical service such as easily accessible. In addition, 3.6% of the current population translates to about120,000 elderly patients in Qatar (Estimated pop is about 3million). Hence, there is a lot of potential inherent benefits associated with the deployment of a care-enhancing clinical service such as deprescribing of inappropriate medications in one of the most vulnerable patient group such as the elderly. In addition, it is generally well established that early deployment of interventions focused improving patient outcomes and strengthening the health system often result lasting positive impact on public health.

This sort of explanation benefits from being included in the manuscript. Further, currently it would appear to be illegal for community pharmacists to do unless and until legislative change is effected, so how quickly can community deprescribing be instituted legally and effectively?. Further, in the 3.6% of the population, how many may be managed by hospital pharmacists who are trialling deprescribing already?

Lines 63-65 assert that the greatest risk to the elderly from medication lies in the number of medicines, and certainly, the more medicines taken, the more there can be a risk of drug-drug, drug-herb, drug-disease state interactions, but there are also some medicines that have an inherent risk of adverse effects in the elderly, even with a lesser number of medications taken. These include NSAIDS, medicines with an anticholinergic effect, some diuretics, antihypertensives and others (https://www.msdmanuals.com/en-au/professional/geriatrics/drug-therapy-in-older-adults/drug-categories-of-concern-in-older-adults).

So some additional clarity in the definition about how medicines may be harmful as medicines have many different perceptions to lay people, to various health professionals such as doctors, specialist doctors, nurses, pharmacists.

Lines 102-104. The manuscript states, “Indeed, only one such study focused on the assessment of community pharmacists’ knowledge of deprescribing and their self-perceived enablers and barriers to providing the service in the United Arab Emirates was identified.”

It can be helpful to identify the search criteria utilised as the databases, the search terms (e.g. whether words were used or truncation was included) and the timeframe as search engines often give different outcomes at different times, so when the search occurred also matters.

METHODS: The requested information in PLOS ONE is detailed and clear – the journal requires sufficient detail to allow suitably skilled researchers to fully replicate this study. When the methods are well established, authors may cite articles where those are described in detail, but even so THIS manuscript should include sufficient information to be understood independent of those references.

Please provide a copy of the survey in an appendix so format, item wording, response sets, item order can be considered.

ANALYSIS: The manuscript identifies that IBM SPSS (Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp.) software was used for data analysis. Descriptive statistics such as median (IQR) was used for continuous data with non-normal distribution while frequency (%) was used for categorical data, with significance set at p ≤ 0.05.

Additional clarity sought: In a manuscript, it is beneficial to identify those functions within SPSS that were used to analyse the data. In survey research, it usually matters both what you ask and how you ask it. So, for example, the manuscript data was stated to have been analysed to yield descriptive statistics such as median (IQR) for continuous, non-normal data and frequency for categorical data.

The SPSS Descriptive function data analysis can yield mean, sum, standard deviation, variance, minimum, maximum, range, skewness, kurtosis and standard error of the mean.

The SPSS Frequencies function yields mean, standard deviation, variance, minimum, maximum, range, skewness, kurtosis, valid & missing responses, median, mode quartiles, percentiles.

It is beneficial to identify the SPSS function actually used as that assists a reader to see whether that data analysis could yield the results of the study or whether a different analysis may have yielded more relevant or more useful result.

Words discussing the analysis can also assist readers as can the actual wording of items, order of items, response set and format of the survey, the study instrument.

The manuscript identified that it elicited responses on a Likert-like response set. Most commonly Likert scales have two extreme responses, two moderate responses and a neutral response per item (strongly disagree, disagree, neutral, agree, strongly agree or reverse order).

Subsequently, the responses were described as ranked, “Further, study participants were asked to rank their responses to the items in Section B and C on a 5-point Likert-type scale (highest =5, high = 4, moderate= 3, low = 2, Lowest = 1)”. The difference between rating and ranking lies in the information elicited. Rating scale questions such as Likert scales seek to elicit respondents’ attitude(s) towards something ( how much do you agree with this statement, for example). A ranking question seeks a respondent’s preference order.

More detailed information is needed to properly understand the results obtained and the conclusions drawn, so please provide additional information, and in particular, more detail.

RESULTS: PLOS ONE accepts single categories across Results/Discussion/Conclusions or merged categories such as Results/Discussion or Discussion/ Conclusions. This manuscript presents all three sections separately. Only Results will be addressed for review in this section.

The Results section starts with a presentation of the characteristics of the respondents noting for example, that “… [they] consisted mainly of 5 nationalities (91.0%; 182/200) including Indian (40.5%), Egyptian (22.5%), Jordanian (22%) and Sudanese (6%). Since only 182/200 may have responded to this item the absence of Qatari respondents was of interest as in 2024 it might be expected that there could be perhaps some 12 cohorts of graduating students from Qatar University since the course is listed as commencing in 2007 with full accreditation in 2011 (https://www.qu.edu.qa/static_file/qu/colleges/pharmacy/documents/Pharmacy%20A4%20Magazine-compressed%2019AY.pdf).

Additional detail and context would be helpful to fully understand the results of the study and its outcomes. It would be beneficial to understand where Qatari educated pharmacists work – data were elicited from chain pharmacies and none were identified as Qatari, so perhaps Independent pharmacies? Industrial pharmacy? Hospital pharmacy? Further, in a 2021 study which included independent and chain pharmacies differences were noted such as a preponderance of males rather than the females majority identified in the current study.

Response-22: We respectfully submit that the results obtained are as presented in the manuscript and the observed trend is consistent with published reports from several studies from Qatar. The community pharmacy sector in Qatar is dominated mainly by foreigners.

Firstly, then please provide the context using the published reports from several studies in Qatar cited in your reply as response 22. Irrespective, pharmacists working in Qatar would seem to be bound by the Law irrespective of nation of initial education and registration/authorisation to practice. Further, it is of interest to pharmacists/researchers globally where Qatari educated pharmacists work and WHY community pharmacy is run by foreigners, which may often be considered an issue in some nations. PLOS is an international journal and while pharmacy has a role in most if not all nations, in my experience, the roles, ownership, ability to practice as an out-of-nation educated pharmacist vary, sometimes greatly.

DISCUSSION: The discussion identified that the community pharmacist respondents would find continuing professional development, the availability of a shared electronic patient record and an improved remuneration package to be key enabling factors in deprescribing in older adults in Qatar who currently reported to be 3.6% of the population. However, there are already reports of an initiative in outpatient pharmacies at Rumailah Hospital, Qatar (Alyazeedi, A., Sherbash, M., Algendy, A. F., Stewart, C., Soiza, R. L., Alhail, M., Aldarwish, A., Stewart, D., Awaisu, A., Ryan, C., & Myint, P. K. (2024). Enhancing Medication Safety through Implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults. Healthcare (Basel, Switzerland), 12(12), 1186. https://doi.org/10.3390/healthcare12121186). If hospital outpatient pharmacies in 2022-23 are using, and others perhaps intending to use Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults i.e. community dwelling, what is the rationale for community pharmacists to also undertake deprescribing? This considers the significance of the outcomes of the manuscript study compared to an existing tool and implementation in outpatient pharmacies.

Please discuss and contextualise.For example, how many elderly people see only community pharmacists, how many or what proportion see both a hospital pharmacist and a community pharmacist and how many or what proportion see only a hospital pharmacist? Some of the reasons that detail and information is important to understanding is what others say about pharmacy practice in Qatar. For example, Nadir Kheir in a book chapter in December 2016 entitled "Pharmacy Practice in Qatar" identified that pharmacy services in Qatar are rapidly developing and pharmacists are rapidly changing, committing to lifelong learning, self leadership and self development. Further, within that chapter it was observed that one of the strongest drivers of the change and development in pharmacy practice is Qatar's National Health Strategy which a further on community pharmacy. It was envisioned that community pharmacy could contribute to a primary health care model of practice and care. So, from 2016 to 2024, what has happened?

LIMITATIONS: Limitations section identifies those characteristics of the study methodology or design that impact the research outcomes or interpretations. As such the limitations are addressed in the section from lines 294 to 301. The limitations identified were firstly, non-probability sampling as participants were drawn predominantly from chain or banner group pharmacies which represent 75% approximately of the community pharmacies in Qatar.

So, this is a valid issue and benefits from discussion as to any ameliorating factors or processes that the research team may have applied. It was also not known how community pharmacies are owned as the owners’ views and actions may also influence employed pharmacists’ perceptions. Context is important as there is not one single vision and practice of pharmacy, or even community pharmacy, world-wide. How different might community pharmacy be in New Zealand, in Thailand, in Japan, in Spain, in Sweden, in Brazil, for example? In some countries, pharmacies may only be owned by registered pharmacists, sometimes with limits imposed on the number of pharmacies owned by a registered pharmacist, in some countries companies can own pharmacies and employ pharmacists to provide services, so context benefits from greater clarity about the situation in Qatar.

The second limitation noted was that a quantitative survey design may have triggered social desirability bias or social acquiescence though the link between methodology (survey) and favourable responses is not clearly explained but benefits from being so.

To my perception, this is a well published area - there are a number of approaches such as published articles that consider this and also social desirability scales which could be included in the study instrument, and other options that can be explored such as Lechner and colleagues 2019; Bergen and Labonte 2020; Larson 2019; Primi and colleagues 2019; Kreitchmann and colleagues 2019; Tan and colleagues 2022 . Which approaches did the researchers use? If none of the approaches were used what was the rationale for not doing so?

So please, provide the critical analyses, the detail, the context that enhance understanding of your study, its results and proposed outcomes.

Reviewer #2: The manuscript looks good and I agree with proceeding for publication, but small comment; the sentence in the line 99-101, I did not any references of the studies that were mentioned

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Reviewer #1: No

Reviewer #2: Yes: MOHAMMED ABDULLAH KUBAS

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PLoS One. 2025 Jan 30;20(1):e0316363. doi: 10.1371/journal.pone.0316363.r004

Author response to Decision Letter 1

7 Dec 2024

07 December 2024

The Editor-In-Chief

PLOS ONE

Dear Sir,

Re: Manuscript #PONE-D-24-26224R1 – “Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in a developing setting”

We are sincerely grateful for the opportunity to revise, for the second time, the manuscript #PONE-D-24-26224R1, titled “Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in a developing setting” which is under your consideration for publication in the PLOS ONE. We thankful for the additional comments and useful suggestions provided by the reviewers. Please find stated below our point-by-point response to the reviewers’ comments.

REVIEWER’S COMMENTS

Reviewer #1:

• Comment-1: Currently those in Qatar older than sixty years of age constitute 3.6% of the population though that is predicted to increase to approximately 20.3% by 2050, which is in 26 years’ time, so lacking apparent immediate urgency. So, please seek to firmly and clearly identify the significance or implications of undertaking this study now in 2024 - Why is it needed? Why now? What has to change and what else has to happen for the activity on which this research is focused to come into effect. In my experience, often authors may be well aware of what is happening in their setting, what could be desirable and will of the pharmacist population to provide a proposed service or modify a standard procedure, for example. However, readers from outside the setting are often quite unfamiliar with a study's setting, and in lieu of more information may wonder if it is much the same as in the reader's setting. In my experience providing context, information, including some statistics will assist the reader the view the study within the actual study setting.

• Response-1: We are thankful once again for this important observation and we see the points raised by the reviewer. However, we thought we have addressed this concerns in our previous response. It is generally well-documented that prevention is not only better but it is more cost-effective than cure. Hence, we are of the opinion that the potential clinical and financial burden associated with the harms inherent in the use of inappropriate medications in elderly population is better avoided by provision of deprescribing service especially at the primary care level where community pharmacists are easily accessible. In addition, 3.6% of the current population translates to about 120,000 elderly patients in Qatar (Estimated pop is about 3million). Hence, there is a lot of potential inherent benefits associated with the deployment of deprescribing of inappropriate medications in one of the most vulnerable patient group such as the elderly without having to wait unnecessarily until 2050. In addition, it is generally well established that early deployment of interventions focused improving patient outcomes and strengthening the health system often result lasting positive impact on public health.

• Comment-2: Issue - A little more clarity would beneficial - what is a dispassionate review? What benefit arises from a dispassionate view? Why not a standard protocol? Why not take into consideration the patient’s perceptions of their medications or issues they may be having? Further, the key is to identify medications that are no longer required - for which reasons? duplication of therapy? continuation of medication to manage an acute condition? removal of a medication that manages an adverse effect of another medication taken by the patient? Issue- benefit of additional clarity as to why deprescribing needs to be added, legally, to community pharmacists’ scope, and why the timing since hospital pharmacists have and are trialing a deprescribing initiative- how is it that deprescribing is within scope for hospital pharmacists in Qatar but not community pharmacists?

Response-2: Heartfelt thanks to the reviewer for this additional comment. We submit with all due respect that the word “dispassionate” is self-explanatory. However, we have replaced this word with a more appropriate one as suggested [Pg 4, line 64]. In addition, we thank the reviewer for all the other issues that was raised in the review comment. However, we submit with all due respect these issues are outside the scope of the objectives of the current study. However, we believe that they are good leads for further research, and we are thankful to the reviewer.

Comment-3: Lines 63-65 assert that the greatest risk to the elderly from medication lies in the number of medicines, and certainly, the more medicines taken, the more there can be a risk of drug-drug, drug-herb, drug-disease state interactions, but there are also some medicines that have an inherent risk of adverse effects in the elderly, even with a lesser number of medications taken. These include NSAIDS, medicines with an anticholinergic effect, some diuretics, antihypertensives and others (https://www.msdmanuals.com/en-au/professional/geriatrics/drug-therapy-in-older-adults/drug-categories-of-concern-in-older-adults). So some additional clarity in the definition about how medicines may be harmful as medicines have many different perceptions to lay people, to various health professionals such as doctors, specialist doctors, nurses, pharmacists.

Response-3: Heartfelt thanks to the reviewer for this excellent suggestion. We concur and the manuscript has been revised accordingly [Pg 3, line 61-63].

• Comment-4: Lines 102-104. The manuscript states, “Indeed, only one such study focused on the assessment of community pharmacists’ knowledge of deprescribing and their self-perceived enablers and barriers to providing the service in the United Arab Emirates was identified.”

Response-4: Many thanks to the reviewer for the suggestion. However, the study was not a systematic review and hence we are of the opinion that the information presented about the procedure used for the literature review suffices.

• Comment-5: METHODS: The requested information in PLOS ONE is detailed and clear – the journal requires sufficient detail to allow suitably skilled researchers to fully replicate this study. When the methods are well established, authors may cite articles where those are described in detail, but even so THIS manuscript should include sufficient information to be understood independent of those references. Please provide a copy of the survey in an appendix so format, item wording, response sets, item order can be considered., so clarity in this study’s use is beneficial

• Response-5: Heartfelt thanks to the reviewer for this comment. Adequate information has been provided in the methods sections regarding all the procedures used at the various stage of the study, including the development and validation of the data collection tool. The data collection tool is available upon reasonable request.

• Comment-6: Lines 63-65 assert that the greatest risk to the elderly from medication lies in the number of medicines, and certainly, the more medicines taken, the more there can be a risk of drug-drug, drug-herb, drug-disease state interactions, but there are also some medicines that have an inherent risk of adverse effects in the elderly, even with a lesser number of medications taken. These include NSAIDS, medicines with an anticholinergic effect, some diuretics, antihypertensives and others (https://www.msdmanuals.com/enau/professional/geriatrics/drug-therapy-in-older-adults/drug-categories-of-concern-in-older-adults).

• Response-6: Sincere thanks to the reviewer for this excellent comment. We concur with the reviewer point and we think this assertion has already been captured in the manuscript [Line 61-65]. We were conscious of balancing comprehensiveness with conciseness to minimize redundancies.

• Comment-7 ANALYSIS: The manuscript identifies that IBM SPSS (Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp.) software was used for data analysis. Descriptive statistics such as median (IQR) was used for continuous data with non-normal distribution while frequency (%) was used for categorical data, with significance set at p ≤0.05. Additional clarity sought: In a manuscript, it is beneficial to identify those functions within SPSS that were used to analyse the data. In survey research, it usually matters both what you ask and how you ask it. So, for example, the manuscript data was stated to have been analysed to yield descriptive statistics such as median (IQR) for continuous, non-normal data and frequency for categorical data. The SPSS Descriptive function data analysis can yield mean, sum, standard deviation, variance, minimum, maximum, range, skewness, kurtosis and standard error of the mean. The SPSS Frequencies function yields mean, standard deviation, variance, minimum, maximum, range, skewness, kurtosis, valid & missing responses, median, mode quartiles, percentiles. It is beneficial to identify the SPSS function actually used as that assists a reader to see whether that data analysis could yield the results of the study or whether a different analysis may have yielded more relevant or more useful result. Words discussing the analysis can also assist readers as can the actual wording of items, order of items, response set and format of the survey, the study instrument. The manuscript identified that it elicited responses on a Likert-like response set. Most commonly Likert scales have two extreme responses, two moderate responses and a neutral response per item (strongly disagree, disagree, neutral, agree, strongly agree or reverse order). Subsequently, the responses were described as ranked, “Further, study participants were asked to rank their responses to the items in Section B and C on a 5-point Likert-type scale (highest =5, high = 4, moderate= 3, low = 2, Lowest = 1)”. The difference between rating and ranking lies in the information elicited. Rating scale questions such as Likert scales seek to elicit respondents’ attitude(s) towards something (how much do you agree with this statement, for example). A ranking question seeks a respondent’s preference order. More detailed information is needed to properly understand the results obtained and the conclusions drawn, so please provide additional information, and in particular, more detail.

Response-7: We thank the reviewer for these comments. We respectfully submit that adequate information has been provided with sufficient clarity in the methods sections regarding the data analyses conducted in the study [Line 141-184]. We are of the opinion that this suffices and it is consistent with the established norm in the scholarly world.

• Comment-8: RESULTS: PLOS ONE accepts single categories across Results/Discussion/Conclusions or merged categories such as Results/Discussion or Discussion/ Conclusions. This manuscript presents all three sections separately. Only Results will be addressed for review in this section. The Results section starts with a presentation of the characteristics of the respondents noting for example, that “… [they] consisted mainly of 5 nationalities (91.0%; 182/200) including Indian (40.5%), Egyptian (22.5%), Jordanian (22%) and Sudanese (6%). Since only 182/200 may have responded to this item the absence of Qatari respondents was of interest as in 2024 it might be expected that there could be perhaps some 12 cohorts of graduating students from Qatar University since the course is listed as commencing in 2007 with full accreditation in 2011 (https://www.qu.edu.qa/static_file/qu/colleges/pharmacy/documents/Pharmacy%20A4%20Magazine-compressed%2019AY.pdf). Additional detail and context would be helpful to fully understand the results of the study and its outcomes. It would be beneficial to understand where Qatari educated pharmacists work – data were elicited from chain pharmacies and none were identified as Qatari, so perhaps Independent pharmacies? Industrial pharmacy? Hospital pharmacy? Further, in a 2021 study which included independent and chain pharmacies differences were noted such as a preponderance of males rather than the females majority identified in the current study. Response-22: We respectfully submit that the results obtained are as presented in the manuscript and the observed trend is consistent with published reports from several studies from Qatar. The community pharmacy sector in Qatar is dominated mainly by foreigners. Firstly, then please provide the context using the published reports from several studies in Qatar cited in your reply as response 22. Irrespective, pharmacists working in Qatar would seem to be bound by the Law irrespective of nation of initial education and registration/authorisation to practice. Further, it is of interest to pharmacists/researchers globally where Qatari educated pharmacists work and WHY community pharmacy is run by foreigners, which may often be considered an issue in some nations. PLOS is an international journal and while pharmacy has a role in most if not all nations, in my experience, the roles, ownership, ability to practice as an out-of-nation educated pharmacist vary, sometimes greatly.

• Response-8: We are thankful to the reviewer for this comment and we see the point. However, we thought we have addressed this in our previous response. In addition, we respectfully submit that some of the suggested corrections are outside the scope of the stated study objectives. We sincerely appreciated the reviewer’s generosity in identifying these potential leads for further research but we desirous of ensuring that the manuscript is laser-focused on the stated objectives.

Comment-9 - DISCUSSION: The discussion identified that the community pharmacist respondents would find continuing professional development, the availability of a shared electronic patient record and an improved remuneration package to be key enabling factors in deprescribing in older adults in Qatar who currently reported to be 3.6% of the population. However, there are already reports of an initiative in outpatient pharmacies at Rumailah Hospital, Qatar (Alyazeedi, A., Sherbash, M., Algendy, A. F., Stewart, C., Soiza, R. L., Alhail, M., Aldarwish, A., Stewart, D., Awaisu, A., Ryan, C., & Myint, P. K. (2024). Enhancing Medication Safety through Implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults. Healthcare (Basel, Switzerland), 12(12), 1186. https://doi.org/10.3390/healthcare12121186). If hospital outpatient pharmacies in 2022-23 are using, and others perhaps intending to use Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults i.e. community dwelling, what is the rationale for community pharmacists to also undertake deprescribing? This considers the significance of the outcomes of the manuscript study compared to an existing tool and implementation in outpatient pharmacies. Please discuss and contextualize.

Response-9 - Many thanks to the reviewer for this comment. This comment has been addressed in our previous response as stated below, and we believe that this suffices:

“The study alluded to was focused on ambulatory patients in a hospital setting, while the current study is focused on community pharmacists in the community setting. The rationale for community pharmacist to undertake deprescribing is well-documented and has been alluded to in the manuscript [Line 68-79].

Comment-10: For example, how many elderly people see only community pharmacists, how many or what proportion see both a hospital pharmacist and a community pharmacist and how many or what proportion see only a hospital pharmacist? Some of the reasons that detail and information is important to understanding is what others say about pharmacy practice in Qatar. For example, Nadir Kheir in a book chapter in December 2016 entitled "Pharmacy Practice in Qatar" identified that pharmacy services in Qatar are rapidly developing and pharmacists are rapidly changing, committing to l

Attachment

Submitted filename: Response_2 to Reviewers_2nd Revision.docx

pone.0316363.s003.docx^{(37.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0316363.r005

Decision Letter 2

Jenny Wilkinson

10 Dec 2024

Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar

PONE-D-24-26224R2

Dear Dr. Yusuff,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0316363.r006

Acceptance letter

Jenny Wilkinson

9 Jan 2025

PONE-D-24-26224R2

PLOS ONE

Dear Dr. Yusuff,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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on behalf of

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PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Attachment

Submitted filename: PLOS ONE ReviewFINAL Author Editor.pdf

pone.0316363.s001.pdf^{(109.9KB, pdf)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0316363.s002.docx^{(44.3KB, docx)}

Attachment

Submitted filename: Response_2 to Reviewers_2nd Revision.docx

pone.0316363.s003.docx^{(37.7KB, docx)}

Data Availability Statement

All relevant data are within the manuscript.

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Enablers and barriers to community pharmacists’ readiness to implement deprescribing of inappropriate medications for older adults in Qatar

Marwa Elshazly

Sondus Jawad

Ayesha Ahmed

Hager ElGeed

Kazeem Babatunde Yusuff

Roles

Abstract

Introduction

Methods

Study design, setting and sampling

Questionnaire development and structure

Ethics approval

Data collection and analysis

Results

Table 1. Community pharmacists’ demographic and practice characteristics (N = 200).

Table 2. Enablers and barriers to the community pharmacists’ readiness to implement deprescribing for older adults in Qatar (N = 200).

Discussion

Strengths and limitations

Conclusions

Data Availability

Funding Statement

References

Decision Letter 0

Jenny Wilkinson

Roles

Author response to Decision Letter 0

Decision Letter 1

Jenny Wilkinson

Roles

Author response to Decision Letter 1

Decision Letter 2

Jenny Wilkinson

Roles

Acceptance letter

Jenny Wilkinson

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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