Table 1.

The included articles in the systematic review with their information. .

Author (Year)	Country	Study Design/Type	Population	Exposure	Outcomes of Interest (PPRR)	Main Findings
Ford et al. (2013)	USA	Review article	Articles on pharmacists’ role in disasters in peer-reviewed pharmacy journals	• Cold War-era disasters (1960–December 1991) • Post-Cold War/Preterrorism era (January 01, 1992–September 30, 2001) • Terrorism era disasters (October 01, 2001–present)	Response	The review stated that pharmaceutical supply outweighs other roles among role reports Certain natural disasters, from regression modeling, significantly elucidate pharmacists assuming disaster roles. Pharmacists assuming roles in patient management is significantly explained by tornados and hurricanes (P = 0.0403, P = 0.0281, respectively). Decreases of 14 and 13% were noted in patient management role references for every tornado and hurricane reference, respectively (Incident rate ratios (IRR) = 0.86, IRR = 0.97, respectively). Pharmacists assuming roles in response integration significantly explained by hurricane reports (IRR = 0.96, P = 0.0138). A decrease of 4% was noted in response integration role references for every hurricane reference. Pharmacists assuming roles in policy coordination or pharmaceutical supply was not significantly explained by natural disasters. Pharmacists’ roles were also significantly explained by chemical, biological, radiological, nuclear, and explosive (CBRNE) disasters. Two categories of CBRNE disasters, radiologic dispersal devices (RDD) and nuclear terrorism, significantly explained pharmacists assuming roles in policy coordination (IRR = 0.63, P = 0.1015, IRR = 2.1, P = 0.0052, respectively). A decrease of 37% was noted in policy coordination role references for every one RDD reference increase and an increase of 110% in policy coordination references for every one nuclear terrorism reference increase.
Alkhalili et al. (2017)	Canada	Descriptive	Published literature describing pharmacists’ experiences in responding to or preparing for both natural and manmade disasters	(1) Planning and preparation (2) Early/acute response (3) Recovery	Preparedness, Response, Recovery	Phase 1: The study composed a framework from a total of 505 work activities to defining the role of pharmacists in response to and in preparedness for disasters. Of work activities extracted, medical supply functions accounted for 41.2% of activities, and the remaining (n = 297) were categorized in 5 thematic areas: professional practice, population health planning, direct patient care, legislation, and communications. Phase 2: Development of a classification scheme for pharmacy personnel. By using this scheme, four categories of pharmacy personnel were defined. Distinctions between the different types of personnel were made by considering the 5 characteristics; 1) level of education; 2) experience/practical training; 3) skills not related to pharmacy; 4) dispensary tasks; and 5) level of self-government and autonomy in conducting pharmacy-related activities. Phase 3: Defining Roles and Responsibilities (Role-Mapping) The number of activities was relatively balanced through preparation for disaster, response during disasters and recovery from disasters. Personnel with primary responsibility in categories 1 and 2, carried out over the period of the emergency’s response phase, had a smaller number of activities. Conversely, personnel in category 3, during the course of the emergency response, carried out more activities, whereas personnel in category 4 carried out specialized, narrow roles.
Watson et al. (2019b)	Canada	Cross-sectional	222 participants at the World Association for Disaster and Emergency Medicine’s 20th Congress in Toronto, Canada	Emerging roles of pharmacists in disasters	Preparedness, Response	Most of the respondents deemed pharmacists to have an additional role other than logistical support and supply management in disasters (96.8%, n = 122/126). A total of 87.9% believed that pharmacists’ current range of practice involved providing support in disasters. Almost half of respondents were aware of pharmacists participating in roles such as CPR, first aid/wound care roles, triaging and screening (57.1%, 68/119). Themes Identified for Pharmacists’ Roles in Preparing and Responding to Disasters Preparing for a Disaster Education, inventory management, logistical support, and vaccinations Responding to a Disaster Logistical support, medication supply, medication management, participation in disaster teams, vaccinations, education. The two main barrier themes to pharmacists being involved in disasters identified by the respondents (n = 95) were lack of comprehension of pharmacists’ value in disasters and other healthcare professionals’ biases.
Watson et al. (2019a)	Australia	Cross-sectional, a Delphi study	Expert panel of key opinion leaders within the field of disaster health	Pharmacists’ roles in disasters	PPRR	The study (Watson et al., 2019a) prioritized the top five pharmacists’ roles during each phase in disasters by reaching a consensus by panel of experts (n = 15). Prevention phase: enhancing chronic disease management through accommodating point of care and ensuring medication supplies, vaccination, public education on infection control and disasters’ influence on increasing the risk of adverse health outcomes Preparedness phase: ensuring essential medications procurement, having an approach to secure cold chain lines, participating in local community disaster management teams, knowledge about national stockpiles, and participating in local/state/national disaster preparedness efforts. However, consensus was not reached on developing CBRN (chemical, biological, radiological and nuclear) weapons preparedness educational tools, including signs and symptoms and drug treatments for health professionals. Response phase: dispensing, counseling, logistical support of supplies for patients with chronic diseases, medication emergency supply refills, and national stockpiles issuing and distribution. However, consensus was not reached on the following roles: altering existing therapeutic regimens where clinically necessary and offering psychological health support following a disaster. Recovery phase: restoring normal stock levels and discarding contaminated stock properly, emergency/disaster kit refills, promoting local community health, detecting and prioritizing at-risk populations, and retrieving patients and drug records if compromised
Jiménez-Mangual et al. (2019)	Puerto Rico	Cross-sectional	Community pharmacy patients	Hurricane Maria in Puerto Rico	Response	The study reported patients’ thoughts on the role of community pharmacists (n = 65). Access to medications from the pharmacy was the topmost medication need among participants (35.4%). Of sixty-five respondents after Hurricane Maria, (47.7%) lacked access to medications at a minimum of 1 day, and over half proceeded to lack access to medication between 1 and 7 days. Difficulty in getting in touch with the pharmacy was the most commonly noted reason to lack access to medications. Vast majority (78.5%) noted medication-related issues, and following the hurricane, almost half (47.7%) reported difficulties in getting in touch with or getting to their pharmacy. Medication supply, counseling, and counseling regarding storing medications were the top pharmacist-provided services throughout the disaster (83%, 24.6%, 23%, respectively) . Patients’ impressions about the role of pharmacists during disasters included medication supply, counseling, providing their prescription medication records, and counseling on over-the-counter products and self-care during disasters (92.3%, 73.8%, 63%, 63%, respectively). Most patients noted that pharmacists provided help in solving medication-related problems (86.2%) and that pharmacists were willing to offer help and were trustworthy (97%, 95.4%, respectively).
Austin et al. (2007)	Canada	Cross-sectional	Pharmacists in a direct-patient care setting	The severe acute respiratory syndrome (SARS) outbreak and the electrical system failure “blackout”	Preparedness, Response	A total of 27 pharmacists were interviewed for this study. Five key themes emerged from this research: (1) During times of crisis, pharmacies are among the first-line health care facilities: Large increases in patients and severity and acuity levels of cases presented to pharmacies were reported by participants. (2) “A Vacuity of Leadership/Lack of Utility of Emergency Preparedness Guidelines and Policies”: During the SARS outbreak, the lack of comprehension of the disease, disorganization and poor communication from public health officials resulted in individuals searching for leadership at a local level. “Emergency preparedness training” was provided to several participants, ranging from fulfillment of reading requirements of guidelines and policies to workshops and lecture-based training. Participants also noted that attained knowledge and skills from such training appeared to be of limited applicability in assisting them in adapting to these crises. (3) Dependence on experience and professional judgment and their role: Individuals were obligated to make “microjudgments” in the environment where time is limited due to the sensitivity and the complicated professional practices in the best case scenario possible. Dispensing and practice management skills were arguably overlooked as a result of emphasizing clinical skills and problem solving in pharmacy education. Newer graduates found it more challenging to cope during disasters because of the lack of a solid basis in drug distribution systems management. (4) Significance of Documentation: Pharmacists participated in risky behavior that is ambiguous in medical and legal aspects due to the crisis. As crises continued, flaws and defective documentation systems were observed to be problematic to pharmacists over time. (5) “Teamness” During Times of Crisis: A determinant of successful coping with disasters was the degree of “teamness” that existed before the disaster ensued. The literature on team effectiveness has demonstrated the importance of teamwork, particularly in high-stress, highly ambiguous situations. Characteristics of high-performing teams include role flexibility, fluid boundaries, sense of shared purpose, and lack of rigid hierarchy. A key finding of this study suggests that a determinant of successful adaptation to both the SARS and blackout situations was the level of “teamness” that existed before the crisis erupted. Efficient teams are characterized as having role adaptability, fluid boundaries, a sense of common goals and aims, and flexible hierarchy.
Chin et al. (2004)	Canada	Review article	Pharmacy-related events and tasks	Two SARS crises that occurred in Toronto from March–June 2003	Response	In a direct-patient care setting, pharmacists performed several tasks that were categorized into five categories: 1-Drug Information: Except for ribavirin, due to the lack of research in patients with SARS, guidelines were developed for antimicrobial intravenous administration. However, guidelines for ribavirin were assumed to be the pharmacist’s responsibility concerning oral and intravenous preparation and administration, renal impairment dosage adjustment and monitoring. For interferon alfacon-1, which was an investigational drug, pharmacists assumed responsibility of developing guidelines. SARS drug kits that offered dosing information on Ribavirin and multiple other antimicrobial agents, Ribavirin guidelines in both normal and renally impaired patients, and management algorithms for SARS were created, kept updated, and stored in the emergency department. Nebulizers were limited to all hospital patients, thereby minimizing other sources of SARS spread. A chart for conversion between nebulizer dosing and metered-dose inhalers was created by drug information pharmacists. 2-Direct Patient Care: Under the stressful conditions and the meticulous infection-control precautions, pharmacists proceeded to offer direct patient care for SARS patients. Investigational tests and direct communication between health care providers and the patients were minimized. For SARS patients, pharmacotherapy end points were monitored in modified plans compared to those used with normal patients. Weighing risk versus benefits, counseling and side effects monitoring were required during the use of investigational agents. 3-Pharmacy Operations: To transfer drugs between areas and for drugs to be returned and recycled in the pharmacy department, new procedures were provided. Entering SARS-designated areas was kept to a minimum, and unit-dose cart and ward restocking were assigned to specified pharmacy technicians. Intubation kits for SARS patients were established, and in case of use, all remainders of the kit were discarded in biohazard waste. Moreover, a designated cart for cardiopulmonary arrest codes was established. After the code, all remainders of the cart were discarded in a biohazard bag and sent for decontamination. Reminders for the staff for the new procedures were on auxiliary labels. Special Access Program, Health Canada (SAP) was utilized by drug information and research pharmacists for the procurement of ribavirin and interferon alfacon-1. 4-Collaboration and Communication: A multidisciplinary approach was taken to complete urgent tasks efficiently. Pharmacists collaborated closely with key partners and stakeholders. Treatment information was provided in a SARS binder. 5-Personnel Management: Staff were educated and deployed to high-demand areas, and situations were managed innovatively. A multidisciplinary SARS tertiary acute response team that involved pharmacists was created upon the second SARS disaster.
Nazar and Nazar (2020)	United Kingdom	Cross-sectional	Pharmacists involved in the humanitarian field based in England	Humanitarian field and emergency response situations	Preparedness	Nazar and Nazar (2020) identified four descriptive themes to explore the experiences and preparedness of humanitarian pharmacists (n = 12) in response to an emergency. 1-Training and preparation Since the actuality of humanitarian crises cannot be fully predicted, no amount of training is assured to fully prepare pharmacists. Pharmacists found the most effective training for deployment preparedness to be simulation training concerning culture and existing resources and was best introduced through hospital pharmacy-based experience. All deployed participants stated that most of their learning was attained during their employment and that limited predeployment training contributed to a staggering sense of unreadiness in deployed areas. The need to have good knowledge of the culture and resources of the environment to be deployed to was expressed by most participants. 2- Required Skills Inventive and creative working, consultation skills, leadership, self-reliance and firmness in skills required to have during disasters. 3-Challenges/barriers Since humanitarian pharmacy is usually associated with medical logistical resources and support, vague roles and misunderstanding of pharmacists’ roles were reported as a result. Moreover, humanitarian organizations enlist staff through pursuing specific training and/or experience requirements, which are considered rare opportunities. 4-Profession development Pharmacists noted assertiveness in working in high-pressure environments resulting from their experiences in deployment, which also contributed to improving cultural knowledge and analytical thinking.
Ford et al. (2014)	USA	Review article	Pharmacy literature	Pharmacists’ roles in disasters	Response	The study reported a decreasing trend in weighted counts of patient management, followed by pharmaceutical supply pharmacist role reports and policy coordination categories in all journals. Weighted counts were analyzed using chi-square goodness-of-fit analysis. The results of analysis for pharmacists’ roles in response integration, pharmaceutical supplies, patient management, and policy coordination showed very significant differences between these roles (P < 0.001). Role categories were found to be unequally proportioned through sampled journals (P = 0.002). In the AJHP, pharmaceutical supply roles predominated other roles; however, they were emphasized to a lesser extent in other journals. In the JAPHA, commonly reported roles are patient management roles. Other possible pharmacists’ roles, policy coordination and response integration, were not emphasized to a great degree in sampled journals. Differences did not reach statistical significance in natural disasters-weighted counts (P = 0.358). The leading natural disaster recorded was hurricanes. In the sample articles, other natural disasters were not recorded, such as floods, earthquakes, and fires. In CBRN disasters, biological disasters were the leading role noted in the pharmacy journals, where documented CBRN disaster proportions were significantly different (P < 0.001).
Armitstead and Burton (2006)	USA	Descriptive	Licensed pharmacists	Training program for counterterrorism and disaster response	Preparedness	In the training program for Kentucky’s licensed pharmacists, (4.7%) were certified. In pre- and posttest results, a significant improvement was noted in knowledge in bioterrorism training for pharmacists trained in the period between February and August 2005. As a result of the training program, trained pharmacists in bioterrorism established a network for the state that provided name, address, and contact details of each participant to be used as first responders during bioterrorism disasters.
Awad and Cocchio (2015)	USA	Cross-sectional	Hospital pharmacy directors or representatives	Mass casualty scenarios	Preparedness	Most respondents are practicing in community-based hospitals (66%). Most institutions have not been classified as trauma centers (64.7%). Estimated numbers of beds and visits to emergency departments each year varied considerably among institutions. Among institutions, centralized pharmacies were common in (94.1%, 16/17), as was having a clinical pharmacist in the institution (76.5%, 13/17). Survey respondents (n = 18) indicated that they have institutional protocols for disaster preparedness at their facility, and (55.5%) had pharmacy department plans. Most respondents (55.5%) were doubtful about essential medication supplies in their hospitals. Of respondents, (27.7%) agreed to have hospitalized patient care plans during disasters for the pharmacy department, and (22.2%) agreed that the medication supply was adequate for both patients and employees. National or international guidelines determined the medication stock (16.6%). Eight participants reported on medication-stockpiling expense payments, (62.5%) reported that the medication stockpiling budget was considered in the pharmacy department budget. Eight participants reported on disaster drill frequencies. Disaster drills were conducted every six months in half of respondents’ facilities with annual disaster drills in (37.5%).
Watson et al. (2020)	Australia, Canada, UK, US and New Zealand	Review	Pharmacy legislation specific to disasters	Disasters	Preparedness	Disaster-specific pharmacy legislations in Australia, Canada, the UK, the US and New Zealand were reviewed. Specifically, four aspects were noted: the everyday emergency supply rule (3-day supply), emergency supply rule specific to disasters (greater than3-day supply), the vaccination rule in disasters and the mobile pharmacy rule. International legislation comparison: In (74.3%) of international pharmacy legislations, the everyday ‘3-day emergency supply’ rule was established. In only (41.9%) of cases, this rule was prolonged to account for state-declared disasters. In (15.1%) of international legislations, disaster-specific vaccination rules were implemented that declared applicability in disasters to not limit pharmacists practicing in disasters. In (23%) of international legislations, a legislation for mobile pharmacy was found. An association between everyday emergency supply legislation and a disaster-specific extension of the legislation existed (P = 0.007). Disaster-specific emergency supply legislation was found to have a relationship with disaster-specific vaccination legislation but not with mobile pharmacy legislation (Fisher’s exact test, P = 0.04, P = 0.21, respectively). Effects of disasters on pharmacy legislation: There were six models in total. The number of disasters over periods of 5 and 10 years and its association with pharmacy legislations specific to disasters were examined using a generalized estimating equation (GEE) binary logistics regression. Six models resulted. Significant associations between disaster-specific emergency supply were suggested in models 1 and 2 in both the 5- and 10-year periods. A country with a 10-year period increasing number of disasters had a 1.58-fold greater likelihood of having a disaster-specific emergency supply legislation, as suggested in model 1 (odds ratio (OR) 1.58; 95% confidence interval (CI) 1.14–2.19; P < 0.01). These odds rise to 1.78-fold more likely in a 5-year period, as suggested in model 2 (OR 1.78; 95% CI 1.58–2.01; P < 0.01). A significant association between the number of disasters in a 5-year period (2013–17) and mobile pharmacy legislation was proposed in model 6. This supports the statement of an increase in the number of disasters increasing the odds of mobile pharmacy legislation 1.05-fold (95% CI 1.01–1.09; P = 0.01).
Zheng et al. (2020)	China	Descriptive	Community pharmacies	COVID-19	Prevention, Preparedness, Response	The study gathered and summarized the experience of community pharmacies during COVID-19 pandemic. Recommendations and guidance on providing pharmaceutical care: Pharmacy management Operations were actively modified in accordance with characteristics of the COVID-19 pandemic and patients’ needs. -Securing medication supply and products for COVID-19 prevention: Securing supply was thought of as a priority during the pandemic. Community pharmacists provided appropriate pharmaceutical product stock to comply with suggestions of FIP’s “Information and interim guidelines for pharmacists and the pharmacy workforce” during COVID-19. Medication purchases and delivery services real-time information were exchanged between community pharmacies to support chronic disease patients’ medication supply. Online consulting services and drug supply information were also provided through mobile apps or online. Medication supplies for cancer patients, and patients with hepatitis and irritable bowel disease were ensured through cooperation of pharmacies with drug companies. -Securing safety and efficiency of operations: Safety and efficiency of operations secured through suitable environment control staff protection and implementing emergency plan was another approach taken to prevent COVID-19. National or local regulations were followed to clean and disinfect the environment. PPE was provided to all staff for protection. Emergency plans and protocols were established alongside new pharmacy workflows for the management of COVID-19 and potential drug shortages. -Staff training: New workflow and emergency plans guidance were provided to Chinese community pharmacies staff. Staff training that ensured adequate knowledge on COVID-19 prevention was provided. Staff were also provided with training on the diagnosis and treatment of COVID-19. Pharmaceutical care services -Guiding principles of providing pharmaceutical care: Pharmaceutical care services provided principles of having COVID-19 prevention and control and safe medication use as an ultimate goal. To accomplish such goals, patients’ visits to pharmacy or any medical institutions were reduced. Pharmacies offered pharmaceutical care services that catered to patient population characteristics of their surrounding communities. -Approaches to provide PC: In addition to regular drug dispensing and patient education, online access to pharmacies through mobile apps and home delivery was considered among the approaches to minimize unnecessary pharmacy visits. Such approaches were publicized via flyers, internet notifications and text messages or emails. The model of community pharmacy services during the COVID-19 pandemic 1. Drug dispensing, patient screening and referrals A cooperative relationship was established between surrounding community pharmacies fever clinics and designated COVID-19 medical institutions to share mutual patients’ information. Suspected patients were identified by pharmacists based upon clinical symptoms (e.g., fever, cough, fatigue) and epidemiological history (e.g., travel to Wuhan city or its surrounding areas over the last 14 days). Medication reconciliation and consultation were provided by pharmacists. Home care guidance was provided to patients on home isolation. Community pharmacists focused and provided consultation on emotional situations and self-protection for patients. Therapeutic substitution was considered in case of medication shortage. 2. Chronic disease management Chronic disease patients were actively offered guidance on management to enhance medication adherence and support self-monitoring for medications’ safety and effectiveness. Patients were also advised to minimize unnecessary hospital visits. Additionally, patients were advised to check their medications expiration dates before taking them and to avoid expired medications in case of drug shortages or to avoid visits to pharmacies. Pharmacists promoted home delivery of medication to patients during the pandemic. Common adverse effects of medications and distinguishing the severity and need for medical intervention were taught to patients, along with what side effects they should monitor during their home stay. Cancer patients, irritable bowel disease or other special chronic disease patients, or patients on chronic use of a high-risk medication were offered additional guidance on the basis of their diseases or medications and were grouped using mobile apps to provide such services online. 3. Safe use of infusions Unnecessary infusions were avoided. Infusion services’ safety operation processes listed a set of strategies. Environment cleaning and disinfection, patient screening before entering the premises, reducing patient numbers to a limit, and practicing social distancing among patients were some of the strategies implemented. Community pharmacists aided infusion services care teams in establishing safety operation processes and providing regular pharmacy services. 4. Patient education Community pharmacists provided patient education and consulting services on COVID-19 prevention, early identification, and appropriate medication use. Education covered mask selection and proper use, hand and respiratory hygiene, disinfectant selection and safe use, and self-care and protection strategies. The current lack of an effective vaccine for prevention or a treatment for COVID-19 was also clearly explained to patients. Patients were provided with basic COVID-19 knowledge, particularly regarding symptom onset, routes of transmission and instructions to avoid blind use of medications. Young patients with no comorbidities and only upper respiratory symptoms were advised to be observed and isolated at home and for symptomatic treatment be given if needed. Patients were also directed to seek medical attention and comply with the treatment plan of their physician. Patients were educated on the common cold, flu and COVID-19 and how to differentiate between them and when to seek medical attention 5. Home care Pharmacists also referred to the WHO published guidelines for home care. The home environment should be prepared, cleaned and disinfected properly to comply with WHO guidelines. Isolated patients and related family members were educated on the importance of prevention and were able to implement such skills 6. Psychological support Pharmacy staff identified patients with psychological stress due to the pandemic situation (e.g., excessive anxiety, concern, fear) or blind optimism and provided psychological or emotional support for such patients, or they were referred to a psychiatrist if needed. Patient populations were educated to understand the COVID-19 pandemic properly and to view the situation in a positive light. Regular work and exercise were also promoted to the public.
Meghana et al. (2020)	India	Cross-sectional	Pharmacy Professionals	COVID-19	Preparedness, Response	The study conducted an online survey of pharmacy professionals (PP) (n = 24) regarding COVID-19 emergency preparedness and operations management. Eighty-three percent of respondents reported having a perceived preparedness for COVID-19. Additionally, (83%) of respondents reported having an adequate supply of PPE for the protection of pharmacy staff. Of respondents, (87.5%) were knowledgeable on the selection and use of masks. Respondents (41.7%) also prepared and distributed patient communication materials. COVID-19 emergency training was given by the organization to respondents (66.7%). Of those who underwent training, (87%) stated that the training was held for 1–3 h. Pharmacy professionals emphasized social distancing and isolation as infection control strategies and noted a rise in the demand for the antimalarial drugs hydroxychloroquine and chloroquine and in the demand for azithromycin and other antivirals. However, an increase in prices was not reported. Patients were screened for fever, cough, and emotional and anxiety issues (67%, 42%, 33%, respectively) by pharmacy professionals. Pharmacy professionals noted difficulties in procuring hydroxychloroquine, chloroquine, and azithromycin (20.8%) and cooperated with other pharmacies for the procurement of medications and supplies (25%).
Bahlol and Dewey (2020)	Egypt	Cross-sectional	Community pharmacists	COVID-19	Preparedness	The study conducted a survey on community pharmacists’ preparedness in COVID-19. High awareness of hygiene practices, recent travel abroad risk, importance of coming into contact with infected cases, and COVID-19 symptoms was reported in respondents (97.6%–99.2%). Ninety-one percent of respondents knew all 10 possible symptoms COVID-19. Suspected COVID-19 cases were reported by (8.8%) of respondents, and (62.9%) of respondents who reported cases did not receive any pandemic training. Pharmacy staff adopted most of the recommended behaviors to prevent COVID-19 spread (up to 99.5%), except for minimizing nonessential staff (85.7%). Staff with chronic diseases or any other medical risk were informed to take a leave (Center = 91.5%, North = 97.2%, South = 97.8% and East = 97.3%; P = 0.004). Better availability of hand sanitizers, disinfectants, thermometers, face masks, antipyretic drugs, cold formulations, and disposable gloves was reported and compared to alcohol availability. However, free hand sanitizers and masks were less available for customer use (62.1%, 86.5%, respectively). Of pharmacies, (39.1%) had antimalarial drugs available. For symptomatic patients, separated areas for service and special waste disposal measures were less adopted by pharmacies (64%, 80.4%, respectively). Card payment machine availability among regions was significantly different (Center = 42.1%, North = 24.5%, South = 35.5% and East = 30.7%; P < 0.001). A significant difference was also noted in home delivery services among regions (Center = 67.1%, North = 41.0%, South = 44.1% and East = 48.0%; P < 0.001). Verbal customer education was noted to be high (90.4%). Pharmacy managers were more likely to communicate and educate patients verbally instead of providing written educational materials (98.3% vs. 78.1%) compared to junior and senior pharmacists (juniors 91.8% vs. 82%, seniors 90% vs. 86.8%)