Adaptive professionalism among rural primary care pharmacists: A qualitative study of stunting prevention practice in eastern Indonesia

Abstract

Background: In rural primary care, pharmacists are increasingly expected to support preventive and public health activities, yet their role adaptation in under-resourced systems remains insufficiently understood. In Eastern Indonesia, stunting prevention provides a relevant context for examining pharmacists' expanded responsibilities in medicine and micronutrient supply, counseling support for mothers and children, and community-based preventive services. Objective: This study examined how rural primary care pharmacists in East Nusa Tenggara adapt their professional roles in stunting prevention practice, using adaptive professionalism as an analytic lens. Methods: A qualitative case study was conducted in Ngada and East Manggarai districts. All eligible pharmacists working in Puskesmas in the selected districts were invited to participate, resulting in a final sample of ten participants. Semi-structured interviews were conducted between April and July 2024. Data were analyzed inductively using Braun and Clarke's thematic approach, supported by OpenCode version 4.03. Results: Five themes were identified: expanding professional boundaries, adapting to logistical and workforce constraints, negotiating interprofessional collaboration, responding to institutional dynamics, and sustaining community-oriented professional values. Pharmacists described roles in micronutrient and medicine supply coordination, posyandu outreach, counseling support, and maintaining program continuity when service gaps emerged. Conclusion: Adaptive professionalism was enacted through everyday adjustments to service needs, interprofessional expectations, and resource limitations. Pharmacists' adaptive practices reflected a negotiated response to the practical demands of stunting prevention in rural primary care. Clearer role recognition, institutional support, and integration into preventive health programs are needed to sustain these contributions.

1. Introduction

Globally, pharmacy practice has increasingly moved toward patient-centered and team-based care, expanding pharmacists' expected clinical, preventive, and collaborative roles within primary care.1., 2, 3. The International Pharmaceutical Federation has emphasized that integrating pharmacists into primary health care can strengthen preventive care, chronic disease management, medication optimization, health promotion, and access to essential services.¹ In this article, adaptive professionalism is used as an empirically derived interpretive concept developed from pharmacists' accounts of role adaptation in rural primary care. It describes how pharmacists maintained professional responsibility while adjusting their roles, practices, and interprofessional boundaries in response to local service needs, resource constraints, and organizational expectations. This concept differs from role expansion, which mainly describes the widening of pharmacists' tasks and responsibilities in response to primary health care reform, and from improvisation or flexibility, which emphasize situational adjustment.4, 5 It also differs from resilience, which focuses on the capacity to maintain professional functioning under pressure, and from task shifting, which is commonly defined as the rational redistribution of tasks among health workforce teams to make more efficient use of available human resources.⁶ Adaptive professionalism therefore captures not only what pharmacists do beyond their formal duties but also how they negotiate professional identity, ethical responsibility, and legitimacy within constrained primary care settings.7, 8

This form of professionalism becomes particularly visible in rural and resource-limited settings, where pharmacists often work amid workforce shortages, fragile supply chains, limited infrastructure, and unclear role boundaries.1., 9, 10 In such contexts, pharmacists may be required to combine clinical, administrative, logistical, and community-facing responsibilities to support essential services.1., 9 However, evidence on how pharmacists adapt their professional roles in low- and middle-income primary care systems remains limited, particularly where structural constraints strongly shape everyday professional practice.9, 10 Within this broader gap, pharmacists remain underrepresented as a specific professional group in studies of role adaptation in primary care.⁷ The most specific gap addressed by this study concerns how pharmacists' public health roles expand informally in rural primary care, particularly when involvement in preventive programs emerges through local service demands rather than formal regulatory mandates.9, 11, 12 Examining how pharmacists adapt their roles in rural low- and middle-income primary care can therefore clarify how professional practice is reshaped by the interaction between service needs, institutional limitations, and interprofessional expectations.7, 8, 9

Indonesia provides a salient low- and middle-income country context for examining adaptive professionalism. Puskesmas function as first-contact primary care facilities mandated to deliver comprehensive, team-based services, although implementation varies markedly across regions.13, 14., 15. Ongoing system constraints including workforce shortages, uneven personnel distribution, and inadequate infrastructure continue to limit service capacity and influence pharmacists' everyday operational conditions.13, 15., 16 Despite policy emphasis on promotive and preventive care, pharmacists' involvement remains concentrated in medicine management rather than integrated community health initiatives.16, 17., 18 These conditions make Indonesia an important setting for examining how pharmacists' professional roles are adapted, negotiated, and legitimized within resource-limited primary care structures.16, 18

Childhood stunting provides a relevant context for examining pharmacists' adaptive professionalism in rural primary care because stunting-prevention activities require sustained coordination across nutrition services, maternal and child health, medicine and micronutrient supply, counseling, growth monitoring, and community outreach.19., 20., 21. Stunting is commonly defined as impaired linear growth, reflected in low height-for-age, resulting from chronic undernutrition and repeated adverse conditions during early life.²⁰ In Indonesia, stunting reduction is framed as a multisectoral and convergent effort across national, regional, and village levels.¹⁹ At the Puskesmas and posyandu levels, stunting-prevention activities commonly include growth monitoring, maternal and child nutrition counseling, micronutrient and supplement distribution, community outreach, and follow-up monitoring for at-risk mothers and children.19., 21. In East Nusa Tenggara, where stunting remains a major public health concern, these activities rely heavily on the coordination of Puskesmas services and posyandu-based outreach.21., 22. Within this service arrangement, pharmacists' involvement is not always grounded in clearly defined professional mandates, but may emerge from technical and operational needs, including maintaining continuity of medicine and micronutrient supply, supporting outreach activities, and filling service gaps in under-resourced Puskesmas.16, 17. These conditions create an important empirical setting for examining how pharmacists' adaptive professionalism emerges through everyday efforts to meet local service needs while working within constrained rural health systems.

This study was conducted in Ngada and East Manggarai, two rural districts in East Nusa Tenggara, which were selected because they represented different stunting burdens within similarly resource-constrained primary care systems.²³ The inclusion of two districts was intended to capture contextual variation in rural primary care rather than to compare or evaluate district performance. This design enabled the study to examine how pharmacists' involvement in stunting prevention emerged across rural primary care contexts with shared resource constraints and varying local service demands. District context matters because pharmacists' involvement in stunting-prevention activities is shaped not only by national professional regulations but also by local program organization, interprofessional team arrangements, and how Puskesmas respond to resource limitations.16, 17., 19.

2. Methods

2.1. Research context and design

A qualitative case study design was employed to examine how primary care pharmacists enacted and adapted their professional roles in rural Puskesmas settings across two districts on Flores Island, East Nusa Tenggara, Indonesia.24, 25 All pharmacists meeting the eligibility criteria in the selected districts were invited to participate through a total population approach, rather than selecting a smaller purposive subsample.²⁶ Of the eleven pharmacists identified, one was excluded because the pharmacist had less than six months of involvement in stunting-prevention activities, resulting in a final sample of ten participants. Ngada and East Manggarai were selected to define the empirical boundaries of the case and to provide contextual variation, as the two districts represented different stunting burdens within similarly resource-constrained rural primary care systems. The study was not designed as a formal district-level comparison between Ngada and East Manggarai.23, 24, 25 These districts reflect the broader challenges of Indonesia's decentralized primary care system, where pharmacists' roles may extend beyond formal boundaries in response to local service needs, interprofessional arrangements, and resource limitations.13, 16, 18

The case was defined as the enactment of pharmacists' professional practice within Puskesmas settings.24, 25 The individual pharmacist's adaptive role was treated as the primary unit of analysis, bounded by organizational structures, interprofessional practices, and district-level health system characteristics.²⁴ Guided by an interpretivist, contextually grounded approach rooted in social constructivism, the study sought to understand how pharmacists made sense of and enacted their professional responsibilities within local primary care settings, particularly in relation to stunting prevention.27, 28

An inductive thematic analysis was used to identify patterns in pharmacists' accounts of professional role enactment, contextual constraints, and interprofessional boundary negotiation.29, 30 The detailed analytic process is described in Section 2.4. The study was guided by three overarching research questions: (1) How do rural primary care pharmacists understand and enact their professional roles within primary care? (2) How do institutional and contextual constraints shape their engagement in stunting prevention? (3) How do pharmacists negotiate professional boundaries through interprofessional collaboration? To enhance methodological rigor and reporting transparency, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ).³¹

2.2. Participant selection

Ten pharmacists participated, five from each district (eight women, two men, aged between 25 and 45 years). Their comparable professional backgrounds enabled in-depth exploration of adaptive practices and role negotiation within rural healthcare services. Pharmacists meeting the following criteria were included: (1) employment at a Puskesmas, (2) involvement in maternal-child health or nutrition programs for at least six months prior to data collection, (3) willingness to participate, and (4) ability to provide informed consent. Exclusion criteria comprised pharmacists on extended leave, those in primarily administrative positions, and individuals unable to participate in Bahasa Indonesia interviews. Recruitment continued until thematic saturation was reached, defined as the point at which no new conceptual insights emerged.32, 33, 34, 35, 36. Participant characteristics are presented in Table 1.

Table 1.

Distribution of participants by gender, age, and years of professional experience.

Participant ID	Gender	Age (Years)	Years of Professional Experience
P1	F	30	2
P2	F	28	2
P3	F	25	2
P4	F	42	5
P5	F	30	3
P6	F	29	2
P7	F	45	5
P8	M	34	4
P9	M	42	5
P10	F	31	5

2.3. Data collection

Data were collected between April and July 2024 through semi-structured, face-to-face interviews lasting approximately 45–60 min. All interviews were conducted in Bahasa Indonesia by the lead researcher, audio-recorded with participants' informed consent, and subsequently transcribed verbatim. Analysis was conducted on the original Bahasa Indonesia transcripts to preserve contextual meaning and interpretive nuance. Selected excerpts were translated into English for reporting purposes by a bilingual member of the research team and subsequently reviewed through team discussion to ensure semantic accuracy and contextual equivalence, consistent with recommendations for transparent reporting in cross-language qualitative research.37., 38

The interview guide was developed drawing on existing literature in pharmacy practice in primary care and community settings, public health roles, and barriers to pharmacy practice in low- and middle-income settings.10, 11, 12, 39 It was not formally piloted; however, the guide was reviewed and refined through research team discussion to improve clarity, domain sequencing, and contextual relevance to rural primary care settings prior to data collection. Interview domains were mapped to the study's research questions and encompassed pharmacists' understanding of their professional roles, involvement in stunting prevention, pharmaceutical and micronutrient supply management, interprofessional collaboration, institutional constraints, and strategies used to negotiate role boundaries.

Consistent with the interpretive orientation of this study, reflexivity was treated as an integral component of both data collection and analysis.30, 40., 41 The lead researcher's familiarity with the health system, language, and cultural context of East Nusa Tenggara supported rapport development and facilitated comprehension of locally specific practices, including Puskesmas operations, posyandu activities, and district-level program implementation. At the same time, this prior familiarity may have shaped participant responses and the researcher's interpretations, particularly through shared assumptions about resource limitations and structural constraints within the local primary health care system. To address this, the researcher used open-ended prompts and asked participants to provide concrete examples throughout each interview. Reflexive notes were maintained after each session to document emerging assumptions, situational observations, and potential interpretive influences, and were systematically revisited during analysis to help differentiate participants' situated accounts from the researcher's pre-existing knowledge of the local health system.30, 40., 41, 42

2.4. Data analysis

Interview transcripts were analyzed inductively using Braun and Clarke's thematic analysis procedures.29, 30, 43 The lead researcher first read each transcript repeatedly to become familiar with the data and wrote analytic memos to capture early impressions.29, 43 Initial codes were developed through line-by-line coding of participants' accounts, focusing on daily work practices, involvement in stunting-related activities, pharmaceutical and micronutrient supply management, interprofessional interactions, institutional constraints, and responses to service gaps.29, 43 Codes were systematically compared across participants and districts through iterative re-reading of transcripts, enabling identification of recurring patterns and contextual variations in role enactment.29, 43 Related codes were then grouped into preliminary categories and candidate themes based on conceptual similarity and shared meaning across participants' accounts.29, 30

Two researchers independently coded a subset of transcripts and discussed differences in coding interpretation. Where coding interpretations diverged, the researchers returned to the original transcript context, discussed the discrepancy, and refined code definitions collaboratively until consensus was reached.43, 44 Candidate themes were reviewed against coded extracts and the full dataset, and subsequently retained, merged, or collapsed based on their internal coherence, mutual distinctiveness, and relevance to the research questions.29, 30, 43 Participant member checking was conducted by summarizing key points during or after interviews and inviting participants to confirm, clarify, or correct the researchers' understanding.31., 43

The analysis moved from descriptive coding to interpretation by examining how pharmacists' reported activities reflected broader processes of role adaptation, boundary negotiation, professional responsibility, and legitimacy within constrained rural primary care settings.7, 8 Adaptive professionalism was not used as a theoretical framework, coding framework, or sensitizing concept during data collection, initial coding, or theme development. Rather, the concept was formulated after the empirical findings had been generated, as an interpretive synthesis of recurring patterns across participants' accounts, particularly how pharmacists maintained professional responsibility while adjusting their roles and interprofessional boundaries in response to local service needs, resource constraints, and organizational expectations. Literature on professionalism and professional jurisdiction was used after theme development to situate this empirically derived concept within broader scholarly debates.7, 8 OpenCode version 4.03 was used to organize transcripts, codes, categories, candidate subthemes, and final themes.

2.5. Ethical considerations and participant characteristics

This study received ethical approval from the Ethics Committee of the Faculty of Medicine and Veterinary Medicine, Universitas Nusa Cendana, Kupang, Indonesia (23/UN15.21.KEPK.2024). The research complied with the ethical principles outlined in the Declaration of Helsinki.⁴⁵ All participants received full information about the study and provided written informed consent before participation.

Participant codes (P₁ - P₁₀) were used to maintain confidentiality, and identifying data were removed during transcription. Participants were informed that anonymized quotations might be used in publications. The final sample of ten primary care pharmacists, five from each district, was considered sufficient to capture variation and achieve depth of insight across the two district contexts.

3. Results

Overall, participants from both Ngada and East Manggarai described broadly similar patterns of role adaptation in stunting prevention. Although the two districts differed in stunting burden, the interviews did not indicate a consistent district-level contrast across all themes. Instead, variation was more apparent in local implementation arrangements, Puskesmas-level workload, leadership support, interprofessional coordination, and the extent to which pharmacists were involved in outreach or program-support activities. The findings are therefore presented thematically, while indicating district-level similarities and contextual variation where these were evident in participants' accounts.

3.1. Participant characteristics

Ten primary care pharmacists participated in the study, eight females, two males, aged between 25 and 45 years of age. Most were in their late twenties or mid-thirties, reflecting an early- to mid-career profile. Professional experience ranged from two to five years, with the majority having two to three years of service in Puskesmas and a few up to five years in rural primary care.

This relatively young cohort with moderate professional experience provided a suitable context for examining adaptive role practices under constrained rural primary care conditions.

3.2. Theme 1: expanding professional boundaries in rural primary care

3.2.1. Sub-theme 1.1: extending responsibilities beyond dispensing

Pharmacists in both districts described responsibilities that extended beyond dispensing and inventory management. Their daily work included preparing supplements for posyandu activities, coordinating micronutrient distribution, developing educational materials, and occasionally accompanying midwives or nutritionists during home visits. Participants did not describe these activities as consistently included in their formal job descriptions. Instead, they explained that such tasks were often undertaken when program activities required pharmaceutical support, when other health workers were unavailable, or when community-based services needed logistical assistance.

One pharmacist explained:

“I'm not only dispensing. I also have to prepare supplements for posyandu, and sometimes join home visits when the midwife is busy.” (P₁).

Another participant described how pharmacists' involvement helped prevent delays in micronutrient distribution:

“If I don't help with the micronutrient programs, they'll be delayed because no one else manages the stock and distribution in the villages.” (P₈).

These accounts reflect how pharmacists positioned themselves as necessary actors in tasks such as supplement preparation, stock coordination, and field-level distribution, not because these tasks were formally assigned, but because no alternative personnel were available to perform them. The accounts from P₁ and P₈ particularly show that pharmacists' expanded involvement was framed as a practical necessity to prevent service disruption. In this way, their contributions remained situational and operationally grounded, arising from the day-to-day demands of maternal and child health services rather than from an explicitly defined program mandate.

3.2.2. Sub-theme 1.2: navigating ambiguous role expectations

Participants frequently described uncertainty regarding the scope and limits of their professional roles within the Puskesmas system. Although their formal responsibilities were mainly associated with pharmaceutical management, daily expectations from colleagues, program staff, and community activities were often broader. Pharmacists reported being asked to assist with counseling, program data, supplement preparation, and other activities that overlapped with the work of midwives, nutritionists, or program coordinators. This created situations in which pharmacists had to decide how far they could contribute while still maintaining their primary pharmaceutical responsibilities.

One pharmacist reflected:

“The guidelines say my job is medicine, but in reality, people expect me to help with everything related to programs.” (P₃).

Another participant described the blurred boundaries between professional roles:

“Sometimes the midwife asks me to join counseling, sometimes the nutritionist asks for help with data; it's not clear where my role starts or ends.” (P₇)

Both accounts point to a similar pattern: the official definition of the pharmacist's role, as understood through written guidelines, did not match the expectations encountered in daily practice. P₃ described this gap in terms of what “people expect,” while P₇ described it as an absence of clarity about where responsibilities began and ended. Together, these accounts show that pharmacists navigated role ambiguity not through formal renegotiation of their position, but through ongoing situational adjustments shaped by interprofessional requests and immediate service demands.

3.2.3. Sub-theme 1.3: bridging gaps in preventive and community health services

Limited staff, overlapping program schedules, and significant geographic barriers created gaps in preventive and health-promotion services, which often required pharmacists to support community-based activities within the Puskesmas system. Their participation in posyandu activities, nutrition counseling, and community outreach was described as a response to functional gaps rather than formal assignments. Pharmacists were often involved when midwives, nurses, or nutritionists were unavailable for field activities. This involvement remained closely connected to immediate service needs, particularly in remote posyandu settings where routine outreach required additional support.

Several pharmacists noted that their presence in community settings often determined whether routine outreach could continue. One participant described stepping in when other staff were unable to travel to the posyandu:

“If no one can go to the posyandu, I usually step in to support it so activities can continue.” (P₉).

Another pharmacist explained her role in ensuring the flow of essential nutrition supplies:

“Sometimes I coordinate with community-health officers in charge of the posyandu to ensure that supplements and micronutrients reach mothers, because the team is too limited.” (P₂).

P₉ described stepping in at the posyandu when no other staff member could travel there, while P₂ described coordinating with community-health officers to ensure that supplements and micronutrients reached mothers when the team was too small to manage distribution alone. Both accounts reflect involvement that was responsive and task-specific, tied to concrete logistical gaps rather than to any formal extension of the pharmacist's role. This involvement appeared to be situational in nature, emerging when routine outreach was constrained by staff limitations or field-level logistical demands.

3.2.4. Sub-theme 1.4: reinterpreting professional identity

Participants in this sub-theme described a gradual shift in how they spoke about their day-to-day work, moving from accounts centered on pharmaceutical tasks toward descriptions that included education, team support, and community engagement. This shift was not described as a deliberate decision, but as something that emerged through repeated involvement in program activities and regular interaction with other health workers.

One pharmacist explained:

“Working here, I realize being a pharmacist isn't only about medicines, it's also about educating mothers and supporting the team.” (P₆).

Another pharmacist reflected on this evolving role:

“I used to think my role was just technical. Now, I feel like I am part of the public health team as well. We go to the posyandu and provide nutrition education. I sometimes wonder whether I am capable, because we were not taught this during university, but now I study first before giving the education.” (P₇).

These accounts show that pharmacists' role understanding expanded through everyday work in rural Puskesmas. Their self-perception was shaped by repeated involvement in education, team support, posyandu activities, and nutrition-related counseling. This broader role was also accompanied by uncertainty about preparedness, particularly when pharmacists were expected to provide education beyond what they had formally learned during training. P7's account indicates that pharmacists could respond to this uncertainty through self-directed preparation before providing education. Across Theme 1, pharmacists' expanded professional boundaries were not experienced as a single formal change, but as a gradual and situational adjustment to service needs, interprofessional requests, and community-based program demands.

3.3. Theme 2: adaptive responses to systemic and logistical constraints

3.3.1. Sub-theme 2.1: improving workflow under resource shortages

Pharmacists described adjusting their daily workflows to manage shortages of staff, time, and operational resources. With limited personnel, they often handled several tasks in the same working day, including dispensing, stock management, documentation, counseling, and support for field activities. Participants described situations in which overlapping responsibilities led them to reorder tasks, combine activities, or extend working hours beyond the official schedule, especially when program schedules overlapped with routine pharmaceutical services.

One pharmacist explained:

“When programs overlap, I adjust the schedule myself. I combine tasks to ensure nothing is left undone despite staff shortages. I frequently cannot leave at the official closing time and often work overtime. Postponing work only causes tasks to accumulate, while new duties await the following day.” (P₅).

Another participant described the need to reorganize daily work when another health worker was unavailable:

“Sometimes the midwife suddenly has to go out, so I cover some tasks and rearrange my own work to keep the service running” (P₇).

These accounts show that workflow adjustment was a routine response to overlapping duties and limited staff availability. P₅ described combining tasks and working beyond official hours to prevent work from accumulating, while P₇ described rearranging pharmacy work when another health worker had to leave. Together, these accounts indicate that pharmacists' workflow changes were practical responses to immediate service pressures, rather than formally planned changes in task allocation.

3.3.2. Sub-theme 2.2: managing disruptions in medicine and micronutrients supply chains

Participants described disruptions in medicine and micronutrient supply as a recurring challenge in supporting maternal and child health activities. Delayed procurement, inconsistent distribution schedules, and limited stock availability required pharmacists to monitor supplies closely and make temporary adjustments when shortages occurred. These adjustments included calculating which posyandu to prioritize, coordinating informally with other Puskesmas, and, when district stocks were depleted, procuring items through available Puskesmas capitation funds.

One pharmacist reported:

“If stock from the district is late, I have to calculate which posyandu can wait and which cannot, so the programs still continue.” (P₁₀).

Another participant described informal coordination with other Puskesmas:

“Sometimes I ask other Puskesmas if they have spare micronutrients or deworming medicines. We exchange supplies so no posyandu is left without.” (P₇).

A further strategy described by one pharmacist involved using Puskesmas capitation funds to procure essential items when district warehouse stocks were depleted, though this approach required careful financial calculation given uncertainties in delivery time:

“If medicines or micronutrients run out at the district warehouse, we can purchase them using capitation funds. But it must be calculated carefully, because sometimes the items also take a long time to arrive.” (P₁).

These accounts show that pharmacists responded to supply disruptions through short-term and locally available solutions. P₁₀ described prioritizing distribution when stock from the district was delayed, P₇ described exchanging supplies with other Puskesmas, and P₁ described using capitation funds when district stocks were unavailable. These practices suggest that pharmacists' supply-related work involved continuous monitoring, calculation, and coordination to reduce interruptions in medicine and micronutrient availability, particularly for community-based maternal and child health activities.

3.3.3. Sub-theme 2.3: prioritizing tasks under workforce deficits

Participants frequently described situations in which program demands exceeded available staff. In these situations, pharmacists had to decide which activities required immediate attention and which could be postponed or supported by other health workers. Task prioritization was often shaped, as participants described, by program urgency, perceived impact on maternal and child health, and the limited number of personnel available to complete routine and field-based work.

One pharmacist reflected on the pressure of making these decisions:

“If I have to choose, I prioritize nutrition or maternal-child health (MCH) activities because the impact is direct on children. Other tasks can wait.” (P₄).

Another participant described the difficulty of choosing among competing responsibilities:

“Every day I have to decide what should be done first, but everything feels important. Still, we must choose because there is not enough staff.” (P₁₀).

These accounts show that prioritization was experienced as a daily practical challenge under workforce shortages. P₄ described giving priority to nutrition and maternal-child health activities because of their perceived direct impact on children, while P₁₀ described the difficulty of deciding among tasks that all felt important. Together, these accounts indicate that pharmacists' task prioritization was shaped by immediate workload pressures, perceived service urgency, and concern for child health outcomes, rather than by a stable or formally defined prioritization system.

3.3.4. Sub-theme 2.4: ethical decision-making in operational dilemmas and personal values

Resource limitations sometimes placed pharmacists in difficult decision-making situations, particularly when supplies or staff capacity were insufficient to meet all service needs at the same time. Participants described having to decide which posyandu should receive limited micronutrient stock first, which activities should be postponed, or how to respond when program delays affected community services. These decisions involved practical considerations such as urgency, expected benefit, and fairness, but participants also described emotional and moral discomfort when some needs could not be met immediately.

As one pharmacist recounted:

“When iron tablets are insufficient, I must decide which areas get them first. It is difficult because every posyandu needs them.” (P₄).

Another pharmacist expressed the moral tension involved:

“Sometimes I feel guilty when the program is delayed due to stock issues. I try to choose the option that benefits the most people.” (P₃).

Some participants also described personal values as a source of motivation in continuing their work under difficult conditions. One participant reflected on the emotional meaning of being recognized by mothers in the community:

“When the mothers call me ‘ibu’ and come to ask about medicines, I feel proud and happy. It reminds me why I am here” (P₃).

The same participant linked service in the stunting program to religious motivation:

“In the Catholic faith, we are taught compassion, what Pope Francis calls caring with love. For me, helping in the stunting program is a way to live out that faith.” (P₃).

P₄ described the difficulty of deciding which posyandu should receive limited iron tablets when all locations needed them, while P₃ described guilt when program delays occurred due to stock issues and the effort to choose options that would benefit the greatest number of people. P₃'s additional accounts, including the meaning derived from community recognition and the connection between professional service and religious conviction, suggest that, for some participants, personal values and faith provided an additional source of motivation when working under constrained conditions. These accounts indicate that decision-making under resource limitations involved not only operational calculation but also emotional and moral dimensions, though the character and sources of these dimensions varied across participants.

Across the four sub-themes, pharmacists' responses to systemic and logistical constraints were reflected in day-to-day decisions about workflow, supply management, task prioritization, and the allocation of limited resources, decisions that were practical in form but were also shaped, in varying ways, by perceived service urgency, concern for community health, and, for some participants, personal values.

3.4. Theme 3: interprofessional collaboration in practice

3.4.1. Sub-theme 3.1: negotiating legitimacy in interprofessional teams

Pharmacists described that their involvement in interprofessional activities was not always immediate or automatic. Although they had responsibilities related to medicines, micronutrients, and supply management, their participation in broader maternal-child health and stunting-related activities often depended on whether other team members recognized the relevance of their contribution. Participants described this recognition as developing gradually through everyday collaboration, particularly when pharmacists were able to assist with micronutrient management, logistics, or program-related tasks.

One pharmacist explained:

“At first, they did not involve me in MCH activities because they thought it was not my area. Only after they saw I could help with micronutrients did they start asking me to join.” (P₅).

Another highlighted how legitimacy was shaped through relational trust:

“When the team sees that I can handle logistics well, they trust me more and invite me to planning meetings.” (P₁₀).

These accounts show that pharmacists' participation in interprofessional activities was shaped by how their contributions were observed and valued by other health workers. P₅ described initial exclusion from MCH activities until the pharmacist's contribution to micronutrient-related work was recognized by other team members, while P₁₀ linked increased trust to the team's recognition of logistical competence. Together, these accounts suggest that pharmacists' inclusion in broader program activities often developed through contributions that became visible in daily work, rather than through formal recognition of their role from the outset.

3.4.2. Sub-theme 3.2: supporting nurses and midwives in community programs

Pharmacists described supporting nurses, midwives, and nutritionists when program demands exceeded available staff capacity. Their assistance included preparing micronutrients, joining posyandu sessions, helping with counseling, coordinating with program staff, and taking over selected tasks when other health workers were occupied with village visits or other field activities. Participants presented this collaboration as informal and need-based, rather than as a fixed division of responsibilities.

One participant described stepping in to assist when the nutritionist's workload across multiple programs became difficult to manage alone:

“The nutritionist handled many programs, and when she became overloaded, I helped with preparing micronutrients or joining the posyandu sessions.” (P₃).

Another participant described collaboration as something arranged according to immediate service needs:

“We work together based on need. If the nurse is out doing village visits, I take over some tasks so the service doesn't stop.” (P₁₀).

These accounts show that pharmacists' support for nurses, midwives, and nutritionists was closely tied to workload pressures in community programs. P₃ described assisting with micronutrient preparation and posyandu activities when the nutritionist's workload became heavy, while P₁₀ described taking over selected tasks when nurses were away for village visits. These forms of collaboration were practical and responsive, emerging from day-to-day service needs rather than from a clearly formalized interprofessional arrangement.

3.4.3. Sub-theme 3.3: navigating hierarchical structures in Puskesmas

Participants described interprofessional collaboration as taking place within a Puskesmas structure where program authority was often held by designated coordinators or other health professionals. Pharmacists reported that they could provide input on issues such as stock availability, scheduling, or service delivery, but they did not always have decision-making authority over program direction. In these situations, pharmacists described adjusting how they communicated suggestions and participated in team activities while respecting existing lines of authority.

One participant noted:

“Even when I see stock issues that affect the program, decisions are still made by the coordinator. I can only give input.” (P₄).

Another participant described the tension between wanting to contribute and following the established program structure:

“At times, I would like to suggest changes, but the organizational structure is clear. The midwife leads the programs, so I adhere to her direction.” (P₉).

These accounts show that pharmacists' participation in interprofessional collaboration was influenced by existing program authority within Puskesmas. P₄ described being able to identify stock issues and provide input, but not necessarily make program decisions, while P₉ described following the direction of the midwife who led the program. Together, these accounts indicate that pharmacists' participation in team activities was shaped by the authority structures already in place within Puskesmas, and that contributing within those structures involved adjusting when and how input was offered rather than formally renegotiating role boundaries.

Across Theme 3, pharmacists' collaboration with other health workers was described as informal and need-based, developing through repeated involvement in shared tasks rather than through formal interprofessional arrangements. Their participation in team activities was shaped by how their contributions were received by other health workers, by the workload pressures facing nurses and nutritionists, and by the program authority structures within Puskesmas. These accounts suggest that interprofessional working relationships were built gradually through day-to-day service activities, rather than established in advance through defined collaborative roles.

3.5. Theme 4: institutional dynamics shaping pharmacists' role enactment

3.5.1. Sub-theme 4.1: administrative pathways and governance differences

Participants described situations in which the timing of district instructions, the clarity of activity coordination, and the predictability of program schedules affected how they organized their daily work in stunting-related activities. When instructions arrived late or changed suddenly, pharmacists had to adjust their work plans, reorganize tasks, and respond to program needs with limited preparation time.

One pharmacist noted:

“Sometimes the district gives instruction late, so we adjust everything last minute. It makes our jobs harder.” (P₆).

Another participant described differences in coordination based on previous and current work experience:

“In my previous placement, coordination was smoother. Here, things often change suddenly.” (P₈).

These accounts show that administrative coordination influenced how pharmacists organized their daily work. P₆ described having to make last-minute adjustments when district instructions were delayed, while P₈ described differences in the predictability of coordination across work settings. Together, these accounts suggest that pharmacists' work was affected by the timing and clarity of program communication, rather than only by their own willingness or capacity to participate.

3.5.2. Sub-theme 4.2: fragmented program management and intersectoral coordination

Participants reported that administrative demands, including reporting, documentation, data entry, and procurement, took considerable time that ran alongside their clinical and community responsibilities. Multiple programs operating at the same time, each with different forms, reporting systems, and deadlines, created additional workload for pharmacists. Participants described this administrative work as affecting the time available for counseling, community engagement, and other direct service activities.

One pharmacist explained:

“Every program has a different form, a different system. We spend a lot of time just filling in reports.” (P₅).

Another participant described the difficulty of balancing counseling with reporting deadlines:

“Sometimes I want to focus on counseling, but reporting deadlines force me to prioritize paperwork.” (P₆).

These accounts show that fragmented reporting systems affected pharmacists' ability to allocate time to direct service activities. P₅ described the burden of multiple forms and systems, while P₆ described how reporting deadlines could shift attention away from counseling. Together, these accounts indicate that administrative fragmentation was experienced as a practical constraint in daily work, requiring pharmacists to balance documentation requirements with community-facing responsibilities.

3.5.3. Sub-theme 4.3: policy ambiguity and undefined professional roles

Pharmacists described a gap between formal responsibilities and the broader activities they carried out in rural Puskesmas. Formal expectations were commonly associated with medicine management, storage, and pharmacy services. In daily practice, however, participants reported involvement in public health outreach, health promotion, and nutrition-related activities, including stunting prevention. This broader involvement was not always described as a clearly written responsibility, but as something that occurred because pharmacists were part of the Puskesmas team and were expected to support program activities when needed.

One participant reflected on the gap between written responsibilities and field practice:

“The guidelines say my main role is managing medicines, but in reality, we do much more in the field.” (P₆).

Another participant described the lack of formal recognition for broader community work:

“Our work in the community is important, but it's not written anywhere, so sometimes it's not acknowledged. When community programs are conducted, we join the activities not necessarily because they're part of our core duties, but to share the workload and because the program provides an honorarium. It feels uncomfortable to receive it without participating.” (P₃).

These accounts show that pharmacists experienced a mismatch between written role expectations and the work they performed in community programs. P6 described field activities that extended beyond medicine management, while P3 described community work as important but not formally written or consistently acknowledged. P3 also showed that participation could be shaped by practical workload sharing and program-related incentives. Together, these accounts indicate that pharmacists' preventive involvement was often embedded in routine program participation, even when it was not clearly defined as part of their formal professional role.

3.5.4. Sub-theme 4.4: impact of organizational culture on collaboration and initiative

Pharmacists described the organizational environment within Puskesmas as influencing whether they felt able to share ideas, participate in planning, or become involved in activities beyond routine pharmacy tasks. Participants linked this environment to leadership openness, team responses, and how their contributions were received by other staff. Supportive leadership was described as enabling discussion and participation, while less open environments made pharmacists more likely to follow instructions without providing much input.

One pharmacist shared:

“If the head of the Puskesmas is open, we can discuss ideas. But if not, we just follow instructions without much input.” (P₆).

Another participant described how team recognition affected confidence:

“When the team values my contribution, I feel more confident to help in other programs.” (P₁).

These accounts show that pharmacists' initiative was influenced by how leadership and team members responded to their contributions. P₆ described openness from the head of Puskesmas as important for discussing ideas, while P₁ linked team recognition with confidence to support other programs. Together, these accounts suggest that pharmacists' participation beyond routine pharmacy tasks was shaped by the local working environment, particularly by whether leaders and team members responded to pharmacists' contributions in ways that enabled or limited their involvement in discussions and program activities.

Across Theme 4, pharmacists' accounts indicate that institutional conditions shaped their work through administrative communication, reporting systems, formal role expectations, and local organizational culture. These influences were experienced in practical ways, including last-minute schedule adjustments, time spent on documentation, uncertainty about whether community-based activities were formally recognized, and variation in whether pharmacists felt able to contribute ideas. Taken together, these accounts indicate that pharmacists' day-to-day involvement in community health activities was shaped not only by their own decisions and priorities, but also by the institutional, administrative, structural, and cultural arrangements within which Puskesmas services were organized and delivered.

3.6. Theme 5: professional values and motivations for community-oriented practice

3.6.1. Sub-theme 5.1: commitment to community wellbeing

Pharmacists described their work in rural Puskesmas as connected to responsibility toward the communities they served, particularly mothers and children in villages with limited access to health services. Participants explained that this sense of responsibility sometimes led them to join field activities, extend their working time, or provide support beyond routine pharmacy tasks when community services required additional personnel.

One pharmacist expressed this sense of obligation:

“I feel responsible because mothers depend on us. If we don't go to the village, no one will provide the service.” (P₆).

Another participant described helping despite heavy workload:

“Even if the workload is heavy, I try to help because the community needs us, especially for children's nutrition” (P₁).

These accounts show that pharmacists' motivation to support community-based activities was linked to their perception of community need. P₆ described responsibility in relation to mothers' dependence on available health workers, while P₁ described continuing to help because of the perceived importance of children's nutrition. Together, these accounts suggest that pharmacists' involvement in village-based activities was driven not only by operational service demands, but also by a perceived responsibility toward mothers, children, and communities with limited access to health care.

3.6.2. Sub-theme 5.2: professional pride in contributing to public health impact

Participants described pride and satisfaction when they felt that their work contributed to maternal and child health activities and stunting prevention. This sense of pride was linked to concrete activities such as ensuring supplement availability, supporting counseling, and participating in community programs. Rather than describing these activities only as additional workload, some pharmacists associated them with a broader sense of usefulness within the health service.

One pharmacist explained:

“When I ensure supplements are available and children's growth improves, I feel my work has real impact” (P₉).

Another participant described the satisfaction of being involved in community programs:

“I enjoy being involved in community programs. It makes me feel that pharmacists can make a difference beyond the pharmacy room.” (P₇).

These accounts show that pharmacists drew professional satisfaction from activities that connected pharmacy work with community health outcomes. P₉ linked supplement availability with perceived improvement in children's growth, while P₇ associated community program involvement with a sense that pharmacists could contribute beyond the pharmacy room. These accounts suggest that professional pride emerged when pharmacists could see their work as relevant to maternal-child health and community-based prevention.

3.6.3. Sub-theme 5.3 ethical orientation toward equity and service continuity

Participants described fairness and continuity of service as important considerations when responding to limited supplies, staff shortages, or competing program demands. Pharmacists expressed discomfort when some villages or service points experienced delays in receiving supplements or when tasks remained unfinished despite community dependence on the service. These concerns shaped how they described decisions about distribution, workload, and service completion.

One pharmacist described this ethical stance:

“I feel uneasy if one village receives supplements late. I try to make sure distribution is fair even when stock is limited.” (P₁₀).

Another participant linked responsibility to completing community-related tasks:

“Sometimes we work longer because it feels wrong to leave tasks unfinished when the community depends on us.” (P₇).

These accounts show that pharmacists' decisions were shaped by concerns about fairness, delayed services, and community dependence. P₁₀ described discomfort when supplement distribution was unequal across villages, while P₇ described working longer to avoid leaving tasks unfinished. Together, these accounts suggest that pharmacists' responses to supply and staffing constraints were shaped by discomfort with unequal distribution across villages and by concern that community-dependent tasks should not be left incomplete.

3.6.4. Sub-theme 5.4 motivation for continuous learning and role expansion

Several pharmacists described rural Puskesmas practice as a setting that required them to learn new skills beyond routine dispensing and medicine management. Their involvement in counseling, field activities, and coordination with community-health officers exposed them to tasks that were not limited to pharmacy-room activities. Participants described this learning as challenging, but also as a source of professional development and motivation.

One pharmacist reflected:

“Working here forces me to learn many new things, like counseling mothers or coordinating community health officers responsible for posyandu. It helps me grow professionally.” (P₂).

Another participant described the relationship between challenge and motivation:

“The challenges make the work interesting. I feel I develop more here than if I only dispensed medicines.” (P₅).

These accounts show that pharmacists' motivation was also linked to opportunities for learning and professional growth in rural practice. P₂ described learning through counseling mothers and coordinating with community-health officers, while P₅ described the challenges of rural work as making the role more interesting than dispensing alone. Together, these accounts suggest that expanded responsibilities were not experienced only as additional burden; for some pharmacists, involvement in counseling, field coordination, and community activities also created opportunities to develop competencies that routine dispensing alone would not have required.

Across Theme 5, pharmacists' accounts indicate that community-oriented practice was supported by a combination of responsibility toward mothers and children, pride in contributing to public health activities, concern for fairness and service continuity, and motivation to learn through expanded responsibilities. These motivations were described in relation to specific activities and situations, including joining village outreach, ensuring supplement distribution, completing unfinished tasks, and developing counseling or coordination skills, rather than as general statements about professional purpose.

4. Discussion

This study suggests that primary care pharmacists in rural East Nusa Tenggara enacted adaptive professionalism through situational role expansion, contextual problem-solving, interprofessional negotiation, and value-oriented practice. Their professional adaptation extended beyond medicine management to include public health outreach, nutrition counseling, and logistical coordination for stunting-prevention activities. Rather than being driven primarily by formal directives, these practices appeared to develop through everyday responses to resource shortages, fragmented administrative arrangements, and workforce gaps. Pharmacists' adaptive practices were therefore shaped as situated, relational, and value-informed responses within a resource-constrained primary care system.

4.1. Adaptive professionalism in resource-constrained contexts

The findings of this study suggest that rural primary care pharmacists in East Nusa Tenggara adapted their professional roles through a combination of situational role expansion, practical problem-solving, interprofessional negotiation, and community-oriented motivations. These adaptations were not described by participants as deliberate professional innovations or as responses to formal policy directives, but as adjustments that developed gradually through everyday service demands. Across the five themes, pharmacists' accounts indicated that role boundaries were fluid and that their involvement in maternal and child health and stunting-prevention activities often emerged from immediate operational needs rather than from an explicitly defined professional mandate.

This pattern of practice-driven role adaptation is consistent with conceptualizations of adaptive professionalism in resource-limited health systems, where frontline health workers have been shown to extend their functional responsibilities beyond formal role boundaries in response to local service conditions rather than regulatory guidance.46, 47, 48 Existing literature has also discussed pharmacists' adaptability in relation to changing service demands, workforce challenges, evolving pharmacy roles, and primary care development.18, 49, 50 The present findings suggest that, in rural Indonesian primary care, role adaptation was closely embedded in everyday service pressures and the practical demands of community-based health programs, rather than in a formal process of policy-led professional development.

Importantly, the adaptive practices described by participants should not be interpreted as signs of role dilution or professional inefficiency. Rather, they may be understood as expressions of professional agency and responsiveness within settings where formal institutional supports are limited and service continuity depends on frontline workers' capacity to reorganize, prioritize, and contribute beyond their nominal responsibilities.46, 47, 48 The following subsections examine the operational, interprofessional, institutional, and motivational dimensions through which this adaptive professionalism was shaped and sustained.

4.2. Organizational and resource constraints as drivers of adaptation

The operational constraints described in this study were most evident in pharmacists' accounts of workforce shortages, overlapping workloads, supply-chain disruptions, and the need to reorganize daily tasks. These constraints shaped how pharmacists allocated time, prioritized activities, and maintained medicine and micronutrient availability during routine and community-based services. Rather than treating these responses as isolated improvisations, the findings suggest that such adjustments became part of everyday work in resource-limited Puskesmas settings.

These findings are consistent with previous studies showing that pharmacists' work is often shaped by workforce pressures, stressful working conditions, retention challenges, and increasing service demands in community and primary care settings.51, 52, 53. In Indonesian primary health care, Yuliasih et al. (2025) also emphasized that optimizing pharmacists' roles in Puskesmas requires stronger information systems and better coordination of service data.¹⁸ In the present study, pharmacists responded to such pressures by combining tasks, extending working hours, coordinating supplies across service points, and deciding which program activities to prioritize when staff and time were insufficient. This pattern is consistent with literature on pharmacy workload and prioritization, which shows that pharmacists often need to decide which services or tasks can be delivered within limited time and resource conditions.52, 54, 55 These responses should be understood as operational adjustments to maintain service delivery under constrained conditions, rather than as evidence of a formally redesigned pharmacy role.

Supply-chain disruptions were also central to pharmacists' adaptive work. Participants described delayed district supplies, limited stock availability, and the need to calculate which posyandu should receive available micronutrients first. Similar challenges have been reported in studies on drug shortages and pharmaceutical supply systems, where medicine shortages, disrupted supply chains, and limited coordination can affect the continuity of pharmacy and health services.54, 56, 57 In the present study, pharmacists' responses included stock monitoring, informal coordination with other Puskesmas, and the use of available local mechanisms such as capitation funds when district stocks were depleted.

These operational adaptations also point to the need for stronger institutional support. Previous studies have suggested that integrated information systems, improved workflow design, and better allocation of daily activities can support pharmacy service delivery by reducing duplication and improving coordination.18, 58, 59 However, the findings of this study suggest that digital or administrative reforms alone are unlikely to be sufficient unless accompanied by adequate staffing, reliable supply systems, and realistic workload distribution. Strengthening these operational supports would help reduce pharmacists' dependence on informal and improvised adjustments as the primary means of sustaining routine and community-based services.

4.3. Interprofessional collaboration as a mechanism of adaptive practice

The findings of this study suggest that pharmacists' participation in maternal and child health and stunting-prevention activities was shaped by how their contributions were recognized within interprofessional teams. Rather than entering these activities with clearly established authority, pharmacists described being included gradually when other health workers saw the practical relevance of their work in micronutrient management, logistics, counseling, or program support. In this study, such recognition developed particularly through pharmacists' contributions to logistical coordination and supply management, which helped establish their relevance to other team members before broader program participation was offered.

This finding is consistent with studies showing that pharmacists' roles in primary care and multidisciplinary settings are often negotiated through everyday interactions and recognition by other professionals, rather than through formal role definition alone.60, 61, 62 Perceived usefulness, relational trust, and demonstrated competence have been identified as key pathways through which such recognition develops.63, 64 In the Indonesian primary care context, pharmacists' contribution to primary health care also depends not only on policy vision, but also on how their role is positioned within the wider primary care system.¹⁶

In this study, pharmacists' involvement in team activities was also shaped by workload pressures experienced by nurses, midwives, and nutritionists. Participants described supporting these colleagues through practical tasks such as preparing micronutrients, assisting with posyandu activities, helping with counseling, or taking over selected tasks when other staff were unavailable. This is consistent with collaborative models of pharmacy practice that emphasize responsiveness to service needs, task sharing, and the integration of pharmacists' contributions within wider healthcare teams.47, 65., 66 However, the present findings also show that such collaboration was often informal and need-based, rather than supported by clearly defined interprofessional arrangements.

The findings further suggest that interprofessional collaboration was shaped by hierarchy and program authority within Puskesmas. Pharmacists could identify supply problems, provide input, and support field activities, but they did not always have authority over program planning or decision-making. This is consistent with literature on pharmacists' professional and clinical identity, which shows that pharmacists working in expanded or multidisciplinary roles often need to navigate boundaries between technical, clinical, and team-based expectations.67, 68 In the present study, pharmacists' adaptive participation therefore depended not only on their willingness to contribute, but also on whether other health workers accepted their input and whether existing program structures allowed opportunities for their involvement.

Taken together, these findings indicate that interprofessional collaboration functioned as an important pathway through which pharmacists adapted their roles in rural primary care. However, this adaptation should not be interpreted as evidence of a fully institutionalized collaborative model. Rather, pharmacists' participation appeared to develop through repeated practical contributions, relational trust, and negotiated involvement within existing team hierarchies. This suggests that strengthening pharmacists' role in stunting prevention may require not only individual initiative, but also clearer interprofessional expectations, recognition of pharmacists' contributions, and more structured opportunities for participation in program planning.

4.4. Institutional dynamics as structural drivers of adaptive professionalism

The institutional context in which pharmacists worked shaped how they participated in stunting-prevention activities, particularly through administrative communication, reporting systems, policy clarity, and local organizational culture. Participants described how administrative arrangements, including the timing of district instructions, reporting requirements, and the recognition of pharmacists' community-based roles, affected their day-to-day work in Puskesmas. These institutional conditions did not determine pharmacists' involvement in a uniform way, but they shaped the extent to which pharmacists could plan activities, contribute to program implementation, and participate in team decision-making.

In relation to district-level administration, pharmacists' accounts suggested that the timing and clarity of instructions affected how predictable their work became. Rather than indicating a systematic comparison between Ngada and East Manggarai, these findings point to variation in how administrative coordination was experienced across work settings. This is consistent with analyses of decentralized health governance in Indonesia, which show that decentralization has shifted substantial responsibility to local governments and created variability in local governance and implementation capacity.⁶⁹ Similar challenges have also been discussed in South and Southeast Asian primary health care systems, where local administrative capacity, coordination, and implementation arrangements can affect how national health priorities are translated into frontline services.70, 71, 72 In this study, such variation was reflected less as a direct comparison of district performance and more as a practical issue in pharmacists' daily work, including last-minute schedule adjustments, delayed program communication, and uncertainty in planning outreach activities.

Administrative fragmentation also shaped pharmacists' participation in community-oriented work. Participants described multiple reporting systems, documentation requirements, and program-specific forms as tasks that competed with counseling, community engagement, and interprofessional collaboration. These findings suggest that administrative demands affected not only the efficiency of service delivery but also the time and attention available for pharmacists' preventive and community-facing roles. Rather than treating administrative work as a background burden, the accounts indicate that documentation and reporting systems were part of the institutional environment within which pharmacists had to organize their contribution to stunting-prevention activities.

Policy ambiguity was another important institutional condition. While national regulations formally position pharmacists primarily within pharmaceutical management and pharmacy service functions, participants' accounts suggest that rural Puskesmas practice often involved contributions to nutrition, maternal and child health, and stunting-prevention activities beyond their formal remit. This mismatch between formal mandates and everyday expectations may be interpreted as a form of street-level discretion, in which frontline health workers make practical adjustments to implement programs within local service constraints.73, 74, 75, 76 In this study, these adjustments appeared to arise from routine program expectations and institutional practice rather than from clearly defined professional mandates. This finding is consistent with Indonesian pharmacy policy literature, which suggests that pharmacists' contribution to primary health care remains shaped by how their role is positioned within the wider health system and by whether policy vision is translated into operational recognition.¹⁶ As a result, pharmacists' broader community-based contributions could be present in everyday practice while remaining incompletely reflected in formal role descriptions or regulatory frameworks.

Organizational culture further influenced how pharmacists participated in program activities. Participants described leadership openness, team responsiveness, and recognition from colleagues as factors that affected whether they felt able to share ideas, participate in planning, or contribute beyond routine pharmacy tasks. Supportive local environments appeared to encourage discussion and initiative, whereas more hierarchical team dynamics limited pharmacists' opportunities to provide input. This finding is consistent with broader evidence showing that organizational culture and leadership climate can influence staff initiative, innovative behavior, collaboration, and role development in health care organizations.77, 78 Evidence from rural health care settings also highlights that interprofessional education and collaborative practice are shaped by local organizational context, professional relationships, and the conditions under which health workers are able to learn and work together.79, 80 In this study, pharmacists' confidence and initiative appeared closely related to whether their contributions were acknowledged by colleagues and whether team interactions created conditions for input and participation.

Taken together, these findings suggest that institutional dynamics shaped pharmacists' involvement in stunting-prevention activities through administrative communication, reporting structures, policy ambiguity, and local organizational culture. These influences were experienced in practical ways, including last-minute schedule changes, time spent on documentation, uncertainty about whether community-based activities were formally recognized, and variation in whether pharmacists felt able to contribute ideas. Strengthening institutional coherence, clarifying pharmacists' community health contributions, streamlining reporting systems, and fostering supportive team cultures may help pharmacists participate more consistently in preventive and community-oriented services.

4.5. Moral orientations as drivers of adaptive professionalism

Findings indicate that pharmacists' adaptive practices in rural Puskesmas were also shaped by professional values and moral considerations that guide their responses to service gaps, equity issues, and the needs of vulnerable populations. Rather than viewing their work solely as technical execution of pharmaceutical duties, participants expressed a moral responsibility toward mothers and children in remote posyandu. This ethical stance shaped how they prioritized tasks, managed resource shortages, and responded to service needs under operational constraints. Their decisions to extend working hours, join outreach teams, or compensate for system delays were framed as moral commitments to ensure that communities, particularly underserved posyandu, did not experience avoidable inequities.81, 82

These patterns suggest that adaptive professionalism in a rural context was supported by an ethical orientation toward fairness and continuity of care. While deeply personal, these moral commitments were described as values shaped by upbringing, community norms, and broader beliefs about compassion and service. For one participant, religious belief was explicitly described as a source of motivation for involvement in stunting-prevention activities. This should be interpreted cautiously as an individual account rather than a general explanation for all pharmacists' motivation. More broadly, personal values, community recognition, and concern for vulnerable groups appeared to reinforce pharmacists' willingness to contribute beyond routine pharmacy tasks.

These moral considerations appeared to support pharmacists' adaptive practices by shaping how they interpreted their responsibilities toward mothers, children, and underserved communities. Their ethical decision-making, particularly when facing operational dilemmas such as stock shortages or uneven distribution, suggests that moral considerations were embedded in practical judgments about fairness, prioritization, and service continuity.81, 82 Adaptive professionalism therefore reflects not only technical responsiveness but also a sense of responsibility toward rural communities. However, these moral orientations should not be interpreted as replacing the need for structural support. Rather, they help explain how pharmacists made sense of their extended involvement in rural primary care while working within systems where formal role recognition and operational resources remained limited.

4.6. Implications for policy and practice

Rural primary care pharmacists appear to undertake preventive, logistical, and community-oriented roles that are not yet fully reflected in current regulatory and organizational arrangements. These roles may contribute to stunting-prevention activities by supporting micronutrient availability, outreach activities, counseling, and coordination with other health workers. Strengthening formal integration through inclusion in district and provincial planning, clearer job descriptions, protected time for outreach and counseling, and simplified digital reporting could help align pharmacists' responsibilities with national primary care and stunting-prevention priorities while reducing administrative strain.

Improved interprofessional coordination, standardized supply-chain procedures, and locally organized collaboration networks could also support more consistent pharmacist involvement in routine and community-based services. Complementary investment in capacity building, including public health practice, supply-chain management, counseling, digital literacy, and joint interprofessional training, would further strengthen pharmacists' contributions to maternal and child health programs. Further mixed-methods, longitudinal, and transparently reported research is needed to assess whether institutionalizing these roles improves micronutrient availability, outreach coverage, and child nutrition outcomes, while also clarifying implementation barriers across diverse rural settings.

4.7. Limitations

This study has several limitations. First, the findings reflect the perspectives of pharmacists only and do not include direct accounts from midwives, nurses, nutritionists, community health cadres, Puskesmas managers, district-level policymakers, or community members. This limits the extent to which the findings can represent wider interprofessional, managerial, policy, or community perspectives on pharmacists' roles in stunting prevention. Second, the study involved a small sample of pharmacists from two districts in East Nusa Tenggara. Although this sample was appropriate for the qualitative case study design and reflected the available pharmacists meeting the eligibility criteria in the selected districts, the findings should be interpreted within this bounded geographic and institutional context rather than generalized to all rural primary care settings in Indonesia.

Third, the study relied on self-reported interview data. Participants' accounts may have been influenced by recall limitations, selective emphasis, or social desirability, particularly when discussing professional commitment, collaboration, and contributions to community-based activities. Fourth, although the analysis was conducted systematically, the interpretation of qualitative data is inevitably shaped by the researchers' positionality, disciplinary background, and prior understanding of pharmacy practice and primary care systems. To strengthen credibility, the study used iterative analysis, reflexive discussion, and attention to participants' accounts, but the findings remain interpretive rather than definitive representations of all pharmacists' experiences.

5. Conclusion

This study suggests that primary care pharmacists in rural East Nusa Tenggara described adaptive professionalism as a context-responsive form of practice shaped by service demands, institutional conditions, interprofessional relationships, and professional values. Their accounts suggest that pharmacists' work in rural Puskesmas may extend beyond medicine management to include preventive, logistical, educational, and community-oriented contributions to stunting-prevention activities. These roles appeared to emerge through day-to-day adjustments to local service needs rather than through clearly defined formal mandates.

The findings also suggest that pharmacists' adaptive practices were shaped not only by individual initiative, but also by administrative communication, organizational culture, interprofessional recognition, and the extent to which local systems created opportunities for participation. Rather than demonstrating a systematic contrast between Ngada and East Manggarai, the study highlights how pharmacists' experiences varied across local work settings within a bounded rural primary care context. Strengthening institutional support, clarifying pharmacists' community health contributions, improving interprofessional coordination, and integrating adaptive and collaborative competencies into professional education may help pharmacists participate more consistently in preventive primary care. Further research involving multiple stakeholders, mixed-methods designs, longitudinal approaches, or comparative case studies is needed to examine how institutionalizing these roles may affect health program implementation, micronutrient availability, outreach coverage, and child nutrition outcomes over time.

Research team and reflexivity⁸³

Personal characteristics.

The research team consisted of members with diverse backgrounds:

• •Principal investigator (female, pharmacist, lecturer, doctoral candidate): investigation, writing: original draft, research interests in pharmacy practice, social pharmacy, community pharmacy, and public health.
• •Prof. Satibi (corresponding author, male, pharmacist, and professor): ensured methodological rigor, ethical compliance, supervision, writing: review and editing; research interests in community and social pharmacy.
• •Anna Wahyuni Widayanti, Ph.D. (female, pharmacist, and lecturer): contributed conceptualization, methodology, supervision, writing: review and editing, research interest in community pharmacy, health behavior, health promotion, and social pharmacy.
• •Prof. Gabriel Lele (male; professor of governance and public policy): provided institutional and policy perspectives and contributed to conceptualization, methodology, supervision, writing: review, and editing: research interests in conflict management, anti-corruption, and policymaking.

Relationship with participants

Reflexivity was maintained through regular supervision and discussions with supervisors to minimize bias, consider cultural sensitivity, and ensure transparency in data interpretation.

Trustworthiness⁸⁴

To ensure trustworthiness, several strategies were implemented. Credibility was maintained through member checking, in which selected participants reviewed the interpretations of their statements to confirm accuracy and meaning. Reflexivity was practised continuously by documenting the researcher's positionality, professional background, and assumptions that could influence data interpretation. Transferability was enhanced by providing a thick description of the study context, including detailed accounts of participant characteristics and socio-cultural conditions in both districts. Dependability and confirmability were strengthened through maintaining an audit trail that systematically documented the coding process, analytical decisions, and supervisory discussions. These strategies collectively ensured the rigor and transparency of the qualitative case study.

CRediT authorship contribution statement

Maria Agnes Etty Dedy: Writing – review & editing, Writing – original draft, Visualization, Validation, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation. Satibi Satibi: Writing – review & editing, Validation, Supervision, Methodology, Data curation, Conceptualization. Anna Wahyuni Widayanti: Writing – review & editing, Validation, Supervision, Methodology, Formal analysis, Conceptualization. Gabriel Lele: Writing – review & editing, Validation, Supervision, Methodology, Formal analysis, Conceptualization.

Consent for publication

Participants were informed that anonymized quotations might be used in publications and provided written informed consent before participation.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used Grammarly and QuillBot solely to improve grammar, clarity, and readability. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Funding

This study was funded by the Indonesian Endowment Fund for Education (Lembaga Pengelola Dana Pendidikan, LPDP) through the Indonesian Education Scholarship (Beasiswa Pendidikan Indonesia, BPI), administered by the Center for Higher Education Funding and Assessment, Ministry of Higher Education, Science, and Technology of the Republic of Indonesia (Decree No. 02589/BPPT/BPI.06/9/2024; Scholarship No. 202209091478).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

The interview transcripts are not publicly available due to participant confidentiality and the sensitive contextual nature of the qualitative data. Requests for access to de-identified excerpts supporting the findings may be directed to the corresponding author and will be considered subject to ethical approval and confidentiality requirements.