Upscaling the pharmacy profession: Knowledge and willingness of the Lebanese pharmacists to practice the administration of dermal fillers

Abstract

Background

The rapid global development of the pharmacy profession has led pharmacists to enter the cosmetic industry by administering injectable dermal fillers (DFs) to those in need. However, there is no clear indication that the Lebanese pharmacists are familiar with these procedures or are willing to do so.

Objectives

We aimed to investigate the Lebanese community pharmacists' knowledge about DFs and their willingness to administer them.

Methods

A self-administered questionnaire was sent to 461 randomly selected pharmacists who agreed to participate in the study after a phone call. A scoring system for the knowledge about DFs was employed.

Results

Only 31.4 % of participants reported formal education as the source of knowledge about DFs, and 3.7 % of them reported practicing them on patients. The mean score of knowledge was 5.9 ± 2.5 (out of 14). High level of knowledge was observed in only 25 % of the participants, where females, older and experienced pharmacists, and those working in Beirut region were more significantly knowledgeable. Around 67 % of participants were willing to be trained in this field to expand their field of practice and improve their income.

Conclusions

Lebanese community pharmacists are not yet ready for this new dimension in the career. Legislative procedures, training, licensing, and developed pharmacy curriculum must precede the practice of DFs by pharmacists in Lebanon.

1. Introduction

Over the years, the landscape for pharmacy practice has been evolving, from the traditional role of drug dispensing, with limited contact with patients, to a more clinical, patient-oriented role (Abu-Farha et al., 2021, Itani et al., 2021a, Itani et al., 2021b, Mukattash et al., 2022a, Mukattash et al., 2022b). A wide latitude of attributes has already been used to describe pharmacists' duties, where the World Health Organization (WHO) has described pharmacists as caregivers, decision-makers, communicators, managers, life-long learners, teachers, leaders, and researchers (Thamby and Subramani, 2014). In many developed countries, pharmacists have also been assigned additional roles including raising public awareness on preventive measures, counseling on specific disease states, providing vaccination services, and screening for blood pressure, blood glucose and lipid panel (Alameddine et al., 2019, Ilardo and Speciale, 2020, Khojah et al., 2021). These healthcare professionals also provide medication therapy management to improve patient outcomes, either in the hospital or the community settings (Alameddine et al., 2019). Furthermore, pharmacists are expected to provide pharmaceutical services at the patient’s bedside alongside a multidisciplinary healthcare team (Chong et al., 2018). However, while pharmacists have transitioned to job descriptions that are more prominent to case-oriented services, some of them have taken a path to another dimension added to the practice of pharmacy profession (Toklu and Hussain, 2013).

The booming aesthetic industry, that worth $63.5 billion in 2021, is expected to expand at a compound annual growth rate (CAGR) of 9.6 % from 2022 to 2030, even during pandemic circumstances (Grand View Research, 2022; Cosmetic surgery National Data Bank Statistics, 2018, Ramirez et al., 2021). While government guidelines are trying to restrict the administration of these therapies to only fully experienced and trained health care professionals, there are still a large number of unqualified medical professionals practicing on the field. These practitioners are not knowledgeable on facial anatomy, therapeutic and aesthetic application of injectable dermal fillers (DFs), management of complications, possible adverse events, and other patients’ medical conditions (GOV.UK, 2022, Joint Councel for Cosmetic Practitioners, 2021). Therefore, the aesthetics industry is full of dilemmas, especially when it comes to the subject of who is the most eligible personnel to carry out aesthetic non-invasive procedures (Amy, 2019, Health Education England, 2015). Many believe that these procedures could only be performed by well-trained physicians and dentists, whereas others request other healthcare providers to be permitted to practice in this area (Amy, 2019).

To improve patient safety, and to raise the standards of the aesthetic industry profession, pharmacists can make a difference. These easily accessible and affordable healthcare providers may have an added-value factor for a closer follow-up with patients post-procedure, helping them feel much better about themselves (Palmer, 2020; Pharmacy Pharmacy Mentor, 2020, Itani et al., 2021a, Itani et al., 2021b, Mukattash et al., 2022a, Mukattash et al., 2022b). Pharmacists also possess deep clinical knowledge and skills, and are available within the community at various retail pharmacies, and across inpatient settings in hospitals (Soubra and Karout, 2021, Karout et al., 2022). This upscaling into the cosmetic industry puts them in a position where they can help relieve the strain on exhausted workplaces, especially when there is a lack of pharmacist job opportunities (Fromage, 2019).

The increasing demand for the less aggressive or invasive aesthetic procedures, particularly those with short duration and quick recovery, has created opportunities for pharmacists to practice their clinical expertise in this regard (Babar, 2021, Jankovic, 2017). For instance, in the United Kingdom, Scotland, Wales, Brazil, and Alberta province of Canada, pharmacists were granted authorization to conduct non-invasive cosmetic procedures after receiving sufficient training and certification, fulfilling the eligibility criteria (Alberta College of Pharmacy, 2020, Ferreira, 2016, Health Education England, 2015, Pacific Training Institute for facial asthetics and Therapeutics, 2021, Royal Pharmaceutical Society, 2019).

Aesthetic procedures are also expanding in Lebanon, where treatments like DFs continue as the market leader in the anti-aging industry. This country has been recognized long time ago as the Botox capital of the Middle East region (TRT World, 2021). On the other hand, the pharmacy profession in Lebanon has been facing multifaceted crises related to the regular protection of pharmacists’ rights and practicing of the profession (Alameddine et al., 2020, Alameddine et al., 2019). This small Middle Eastern country has one of the highest pharmacists to population ratios (20/10,000) in the world (Alameddine et al., 2020). However, the limited workforce planning, practice environments, regulations protecting pharmacists’ rights elicited serious concerns on the future existence of the pharmacy profession in Lebanon (Alameddine et al., 2020). Previous studies revealed that community pharmacists in Lebanon are dissatisfied with their profit margin, distribution of pharmacies, professional ethics, rules and regulation governing the profession with extreme restrictions that do limit the pharmacists' modern role, in addition to the political interventions (Alameddine et al., 2022, Alameddine et al., 2020, Alameddine et al., 2019).

However, no previous studies have investigated the pharmacists’ knowledge and willingness to work in the era of the non-invasive aesthetic industry. Studying the pharmacist’s role in this modern field is necessary to expand the pharmacy profession, distribute the workforce, and create career opportunities for current and future pharmacists. Patients are expected to be in safe hands with trained and certified pharmacists, who are more reachable and affordable, making aesthetic facial, non-invasive procedures a natural and straightforward career step to expand the pharmacy practice. As such, this study aims to assess the Lebanese community pharmacists’ degree of knowledge related to DFs and to investigate their willingness to practice them.

2. Methods and materials

2.1. Study design

A descriptive, cross-sectional study was conducted among the Lebanese community pharmacists using a random sampling approach between December 2021 and February 2022. The study targeted the licensed Lebanese pharmacists currently practicing in community pharmacies across all governorates of Lebanon (Beirut, Mount Lebanon, North, South, and Beqaa). Pharmacists working in settings other than the community pharmacies and those not currently working in Lebanon were excluded. Participants were contacted via phone by the study principal investigator to explain the study purpose, assure the anonymity of the retrieved data, and invite them to participate. A link to the self-administered questionnaire was texted to the pharmacists who were willing to participate.

2.2. Selection and recruitment of the study participants

A list of registered community pharmacists was obtained from the website of the Order of Pharmacists of Lebanon (OPL) (Order of Pharmacists of Lebanon, 2022). The list included full names of the licensed community pharmacists along with their phone numbers. The pharmacists were sorted in alphabetical order, and Microsoft Excel was utilized to randomly shuffle the names after coding them, using the RAND function, to obtain a random sample. The online Raosoft® calculator was used to determine the sample size for the current study (Raosoft Inc, 2022). It was assumed that 50 % of the Lebanese community pharmacists (out of 4,382) have adequate knowledge about DFs. The sample size was calculated at a 95 % confidence interval using an absolute precision of 5 %. Thus, the calculated sample size for the current study to achieve a representative sample was 354. The required sample size was increased by 30 % to allow for subjects lost during the study and incomplete responses. Accordingly, the estimated sample size was 460. Moreover, a random list of another 10 % (46) pharmacists was prepared to replace those who failed to join the study. A pharmacist was replaced with one from the reserve list whenever the call was not answered upon two spaced attempts or when the pharmacist refused to participate.

2.3. Questionnaire development and structure

The questionnaire was designed after a thorough literature review of relevant studies (Abu Khalid et al., 2020, Afiqah et al., 2020, Al Hamdan et al., 2013, Alturkistany et al., 2018, Chiang et al., 2017, Imam et al., 2019, Laorpipat et al., 2022, Liu et al., 2019). The questionnaire consisted of 28 close-ended questions with pre-defined answers divided into four sections and preceded by an introduction. The introduction outlined the study's nature, purpose, anonymity of personal participant information, and the estimated time for completion of the questionnaire, followed by an informed consent statement. The first section was dedicated to retrieving participants' socio-demographic data, including age, sex, highest educational level, social status, the community pharmacy geographic region, pharmacy ownership status, and years of experience. The second section assessed the participants’ level of knowledge about DFs. It included 14 multiple choice questions related to DFs such as types, indications, onset and duration of action, mode of action, contraindications, side effects, and complications. The third section identified the participants’ source of knowledge, whether they received official training, and whether they are currently practicing DFs. Finally, the fourth section was dedicated to investigate the attitudes towards DFs. This section aimed to examine participants’ willingness to receive official training to practice DFs and whether they agree on legally authorizing aesthetic qualified pharmacists to practice DF injections in Lebanon.

The questionnaire was validated for face and content by two academic researchers in the field of pharmacy surveys and three professional experts running their community pharmacies. The experts also revised the questionnaire for its comprehensiveness, relevance, and ease of completion. Certain amendments where then made in the second section (see the Supplementary Appendix).

2.4. The pilot test

A pilot test was performed on a convenience sample of 15 community pharmacists, where they were requested to fill out the self-administered questionnaire and provide their feedback on its’ structure, understandability, clarity, and length and to give their overall impression. Some questions were then modified based on their feedback. One week later, the questionnaire was retested on the same participants to ensure its reliability and reproducibility. Additional questions related to the reasons for the pharmacists’ willingness to practice DFs were added. Finally, the data obtained from the pilot test were not included in the final data analysis.

2.5. The dermal fillers’ knowledge score

A scoring system was developed to measure the participants’ knowledge about DFs. The score ranged from 0 to 14, where one mark was counted for each correct answer and zero was given to each wrong or uncertain answer. Furthermore, the participant's level of knowledge was classified into two levels based on the number of correct answers, where high-level of knowledge was associated with 8–14 correct answers and low-level of knowledge with 0–7 correct answers. Cronbach's alpha test was used to test the internal reliability of the DFs’ knowledge score, which yielded 0.72, indicating that the scale was reliable with good internal consistency.

2.6. Statistical analysis

Completed questionnaires were analyzed by the Statistical Package for the Social Sciences software version 24 (SPSS®, International Business Machines Corp., Armonk, New York, USA). Frequencies and ratios were used for categorical variables, and mean ± standard deviation (SD) for continuous variables of descriptive data. Also, the Shapiro-Wilk test was used for testing all continuous variables for normality before statistical comparisons. Kruskal-Wallis and Mann-Whitney U tests were used to test the association between the DFs' knowledge score and the pharmacists’ socio-demographic data. Pearson’s Chi-square test was used to screen for predictors of willingness to practice DFs. In addition, bivariate logistic regression, using backward stepwise analysis, was utilized to test the association between different significant independent variables and the participants’ willingness to practice DFs, and the adjusted odds ratio (AOR) was calculated. The significance level was set at P < 0.05 with a confidence interval (CI) of 95 %.

2.7. Ethical considerations

The World Medical Association Declaration of Helsinki’s guidance was followed in designing and conducting this study (World Medical Association, 2013). The study protocol was approved by the Institutional Review Board of Beirut Arab University (No. 2022-H-0082-P-R-0473). The purpose of the study was clearly stated, and the participants had the right to defer from submitting their response at any time. Participants were requested to approve an electronic informed consent, which contained a statement about the anonymity of the survey and voluntary participation. Participants’ confidentiality, anonymity, and non-traceability were strictly maintained. The database was password-protected by one of the researchers, and the details related to pharmacy or pharmacist identification were replaced by codes. Pharmacists were not contacted afterward for additional questioning.

3. Results

3.1. Participant’s socio-demographics

The study included 461 community pharmacists who completed the questionnaire. Twenty-six pharmacists were replaced by others from the reserve list because they either did not answer two calls on different days or they refused to participate. The mean age of the participants was 31 ± 10 years, and 286 (62.0 %) of them were females. Almost two-thirds of these participating community pharmacists were found to be employees working in community pharmacies (326; 70.7 %), while 29.3 % were owners of the pharmacies, and the mean of the participants’ working experience is 8.56 ± 8.38 years. Almost two-third of the participants have only a bachelor's degree in pharmacy as their highest academic degree (308; 66.8 %). The participants’ socio-demographic information is presented in Table 1.

Table 1.

Participants’ sociodemographic information (N = 461).

Information	n (%)
Sex
Male	175 (38.0)
Female	286 (62.0)
Age (mean ± SD)	31 ± 10 years (range = 22–65)
21–30 years	286 (62.0)
31–40 years	90 (19.5)
41–50 years	53 (11.5)
> 50 years	32 (6.9)
Education
Bachelor of Pharmacy	308 (66.8)
Doctor of Pharmacy	74 (16.1)
Masters	68 (14.8)
Ph.D.	11 (2.4)
Marital status
Single	286 (62.0)
Married	155 (33.6)
Divorced	17 (3.7)
Widowed	3 (0.7)
Pharmacy geographic region
Beirut	172 (37.3)
Mount Lebanon	138 (29.9)
South	73 (15.8)
North	29 (6.3)
Bekaa	48 (10.4)
Pharmacy ownership
Owner	135 (29.3)
Employee	326 (70.7)
Years of experience (mean ± SD)	8.56 ± 8.38 (range = 0.5–40 years)
< 5 years	217 (47.1)
5–9.9 years	83 (18.0)
10–14.9 years	53 (11.5)
15–20 years	54 (11.7)
> 20 years	54 (11.7)

SD, standard deviation.

3.2. Participants’ source of knowledge and current practice

Participants have reported a variety of sources of information about DFs. Sources included the traditional (television, radio, newspapers, and magazines) or social media (374; 81.1 %), academic lessons learned in the university (144; 31.2 %), and their friends and family members (132; 28.6). In addition, most of the respondents did not receive any formal training for injecting DFs (435; 94.4 %), and only 3.7 % of them reported practicing DFs injections on their clients.

3.3. Participants' level of knowledge about DFs and its association with different factors

Table 2 presents the participants’ background knowledge related to the DFs. Most of the participants knew the different types of dermal fillers such as collagen (342; 74.2 %), hyaluronic acid (342; 74.2 %), and silicone (243; 52.7 %). However, almost half of the participants (211; 45.8 %) recognized botulinum toxin as a type of DFs. Most of the participants recognized the different indications for DFs such as lip augmentation (402; 87.2 %), frown lines (343; 74.4 %), and nasolabial folds (305; 66.2 %). Nonetheless, less knowledge was reported about DFs’ therapeutic use for the treatment of scarring occurring from acne vulgaris (201; 43.6 %) and for hand rejuvenation (162; 35.1 %). Notably, more than one-third of the participants reported that the DFs’ mechanism of action involves blocking the transmission of nerve impulses to prevent muscle contractions (176; 38.2 %).

Table 2.

Participants’ knowledge about DFs (N = 461).

Item	n (%)a
Q01. Types of dermal fillers include:
Collagen*	342 (74.2)
Hyaluronic acid*	342 (74.2)
Botulinum toxin	211 (45.8)
Silicone*	243 (52.7)
Uncertain	14 (3.0)
Q02. Time for results to become visible after dermal filler injection:
Immediately after injection*	165 (35.8)
One week after injection	108 (23.4)
Two weeks after injection	52 (11.3)
One month after injection	18 (3.9)
Uncertain	118 (25.6)
Q03. How long does the effect of dermal filler persist?
Three months	29 (6.3)
Six months	86 (18.7)
One year	23 (5.0)
Depends on the type of filler used*	260 (56.4)
Uncertain	63 (13.7)
Q04. Dermal fillers consist of either biodegradable or permanent agents.
True*	250 (54.2)
False	75 (16.3)
Uncertain	136 (29.5)
Q05. Performing dermal fillers injections on pregnant females is contraindicated.
True	196 (42.5)
False*	99 (21.5)
Uncertain	166 (36)
Q06. Which of the following fillers have longer persistence of treatment?
Calcium hydroxylapatite	35 (7.6)
Collagen	75 (16.3)
Hyaluronic acid	85 (18.4)
Poly-l-lactic acid*	29 (6.3)
Uncertain	237 (51.4)
Q07. Dermal fillers can be used for the following indications:
Nasolabial folds (smile lines)*	305 (66.2)
Lip augmentation (for fuller lips)*	402 (87.2)
Hand rejuvenation (enhancement)*	162 (35.1)
Scarring occurring from acne vulgaris*	201 (43.6)
Frown lines (expression lines)*	343 (74.4)
Uncertain	41 (8.9)
Q08. Dermal fillers consisting of collagen are no longer recommended.
True*	135 (29.3)
False	96 (20.8)
Uncertain	230 (49.9)
Q09. The mode of action of dermal fillers includes:
Stimulation of the endogenous collagen synthesis and increasing dermis volume*	225 (48.8)
Blocking the transmission of nerve impulses to prevent muscle contractions	176 (38.2)
Uncertain	60 (13.0)
Q10. Dermal fillers are authorized to be injected by:
Dermatologists*	447 (97.0)
Dentists with aesthetics license*	135 (29.3)
Estheticians	57 (12.4)
Pharmacists with aesthetics license in specific countries*	164 (35.6)
Q11. The use of dermal fillers is contraindicated in:
Autoimmune diseases	53 (11.5)
Active infections at the site of injection*	223 (48.4)
Uncontrolled diabetes mellitus	14 (3.0)
Cancer	28 (6.1)
Uncertain	143 (31)
Q12. The hyaluronic acid filling can be removed and reversed after improper placement and nodule formation.
True*	201 (43.6)
False	86 (18.7)
Uncertain	174 (37.7)
Q13. Hyaluronic acid dermal filler is FDA approved.
True*	281 (61.0)
False	22 (4.8)
Uncertain	158 (34.3)
Q14. The complications of the dermal fillers include:
Drooping of eyelid	196 (42.5)
Vision loss*	74 (16.1)
Temporary paralysis of facial muscles	300 (65.1)
Fibroids*	106 (23.0)
Migraine	59 (12.8)
Vascular occlusion resulting in tissue necrosis*	190 (41.2)
Uncertain	81 (17.6)
Level of Knowledge
High level of knowledge (8–14 correct answers)	116 (25.17)
Low level of knowledge (0–7 correct answers)	345 (74.83)
Total DFs’ knowledge score (out of 14)	5.9 ± 2.52 (1–12)

^aAs multiple responses were given, numbers do not add up to 461.

^*Correct answers.

When inquired about the duration of the persistence of DFs, more than half of the participants responded that it depends on the type of filler used (260; 56.4 %). However, almost half of them were uncertain about which type of DFs persists for a longer duration (237; 51.4 %). Moreover, almost one-third of the participants were uncertain if DFs consist of either biodegradable or permanent agents (136; 29.5 %). However, 37.7 % of them were unaware that hyaluronic acid filling can be removed after improper placement and nodule formation. Remarkably, almost half of the participants have incorrectly recognized that the temporary paralysis of facial muscles (300, 65.1 %) and drooping of the eyelid (196; 42.5 %) are among the complications of DFs. Furthermore, when questioned about the practitioners authorized to inject DFs, the majority responded that they are the dermatologists (447; 97.0 %), while only 35.6 % of the participants identified that pharmacists with aesthetics license are authorized to practice DFs in specific countries.

The participants’ mean of the DFs’ knowledge score was 5.9 ± 2.5 (out of 14), ranging from 1 to 12 correct answers. Particularly, only 25.0 % of the participants had a high level of knowledge about DFs (8–14 correct answers), while the majority (75.0 %) had a low level of knowledge (0–7 correct answers).

Female pharmacists were more likely to have a higher DFs' knowledge score than males (6.03 ± 2.44 and 4.97 ± 2.41, respectively, P < 0.001). Moreover, pharmacists who were older than 40 years (6.67 ± 2.82, P = 0.04) and those having>20 years of working experience (6.68 ± 2.48, P < 0.001) had a higher DFs' knowledge score. In addition, a significant increase in the DFs’ knowledge score was noticed among pharmacy owners compared with pharmacy employees (6.01 ± 2.53 and 4.47 ± 2.44, P = 0.01, respectively), as well as among pharmacists working in Beirut region compared with those working in other Lebanese governorates (6.20 ± 2.18, P = 0.001). Table 3 summarizes the association between various factors and the DFs' knowledge score.

Table 3.

The DFs’ knowledge score and its association with different factors (N = 461).

Factors	DF’s knowledge score (out of 14) (mean ± SD)	Mann-Whitney U test	Kruskal-Wallis test	P-value
Sex		19,217		< 0.001*
Male	4.97 ± 2.41
Female	6.03 ± 2.44
Age (mean ± SD)			8.012	0.04*
21–30 years	5.41 ± 2.39
31–40 years	5.76 ± 2.54
41–50 years	6.67 ± 2.82
> 50 years	6.33 ± 2.27
Education			1.652	0.64
Bachelor of Pharmacy	5.54 ± 2.42
Doctor of Pharmacy	5.67 ± 2.63
Masters	5.97 ± 2.49
Ph.D.	5.72 ± 3.13
Marital status			2.198	0.53
Single	5.60 ± 2.38
Married	5.71 ± 2.63
Divorced	5.70 ± 2.71
Widowed	3.66 ± 2.08
Pharmacy geographic region			18.02	0.001*
Beirut	6.20 ± 2.18
Mount Lebanon	5.48 ± 2.57
South	5.72 ± 2.76
North	4.89 ± 2.42
Bekaa	4.79 ± 2.23
Pharmacy ownership		18,967		0.01*
Owner	6.01 ± 2.53
Employee	4.47 ± 2.44
Years of experience (mean ± SD)			13.93	< 0.001*
< 5 years	5.56 ± 2.39
5–9.9 years	5.21 ± 2.38
10–14.9 years	5.52 ± 2.63
15–20 years	5.57 ± 2.54
> 20 years	6.68 ± 2.48

SD, standard deviation.

^*Statistically significant (P < 0.05).

3.4. Participates’ willingness to practice DFs

Almost two-thirds of the participants were willing to seek appropriate training to practice DFs injections (308; 66.8 %). The factors that influenced the participants’ willingness to practice DFs included broadening the scope of pharmacy practice (238, 77.3 %), being able to tackle patients’ cosmetic needs (216, 70.1 %), gaining a better financial income (194, 63.0 %), and providing a unique service among other pharmacists (184, 59.7 %).

On the other hand, 33.2 % of the study respondents were not willing to seek appropriate training to practice DFs injection. The reported reasons for their unwillingness included that injecting DFs is not within the pharmacy practice scope (70, 45.8 %), pharmacists are not skilled practitioners to perform such procedures (63, 41.2 %), presence of high risk of complications and side effects (62, 40.5 %), being against artificial beauty that might affect facial expressions (57, 37.3 %), and having no interest in cosmetics (52, 34.0 %). Likewise, some participants who were unwilling to practice DFs were also concerned that practicing DFs might expose the pharmacists to liability claims resulting from medical errors (43, 28.1 %), and might negatively affect the profession's reputation (33, 21.6 %). In addition, some participants were against practicing DFs due to religious beliefs (16, 10.5 %), while few respondents perceived DFs as a culturally and socially unacceptable practice (9, 5.9 %). Finally, most of the respondents (363, 78.7 %) agreed on legally authorizing the aesthetic qualified pharmacists to practice DFs injections in Lebanon.

3.5. Predictors of pharmacists’ willingness to practice DFs injections

Binary logistic regression, using backward stepwise analysis, has identified four predictors that were significantly associated with the pharmacists’ willingness to practice DFs injections (Table 4). Accordingly, females (P = 0.03), older participants (P = 0.01), and those having longer years of experience (P = 0.003) were more likely to be willing to practice DFs injections. Moreover, a higher DF knowledge score was significantly associated with a greater willingness to practice DFs (P = 0.026).

Table 4.

Logistic regression analysis^a of significant predictors associated with pharmacists’ willingness to practice dermal fillers.

Predictors		B	SE	Wald	AOR	95 % CI	Pb
Constant		3.24	0.75	20.35	2.6		< 0.001
Age
		0.86	0.36	10.28	1.71	1.15–3.85	0.018
Sex (reference = male)
Female		0.76	0.37	3.10	2.05	1.02–4.52	0.03
Years of experience
		0.94	0.35	8.13	2.10	1.32–3.33	0.003
DFs knowledge score
		0.98	0.44	4.74	1.90	2.20–1.37	0.026

AOR, adjusted odds ratio; B, coefficient for the constant in the null model; CI, confidence interval; SE, standard error; Wald, Wald chi-square test that tests the null hypothesis that the constant equals 0.

^aBinary logistic regression analysis was conducted on significant variables using backward stepwise analysis. Hosmer and Lemeshow test: 2.66, P-value = 0.954.

^bStatistically significant (P < 0.05).

4. Discussion

Authorizing pharmacists to administer facial aesthetic injections would definitely expand pharmacy services, enable them to meet patients’ emerging needs, and generate an additional income for them. Nevertheless, a large majority of low to middle- income countries still lag behind to adopt the contemporary pharmacy profession (Babar, 2021). It is noteworthy that Health Education England (HEE) has issued guidelines and qualification requirements for practitioners offering non-surgical cosmetic procedures, and has featured the inclusion of pharmacists (Health Education England, 2015). To meet the qualification requirements, pharmacists willing to perform facial aesthetic injectables have to complete a postgraduate level qualification and undertake a formal learning program from a recognized and accredited training provider (Health Education England, 2015). In particular, the HEE recommendations are endorsed by the Royal Pharmaceutical Society (RPS) and the General Pharmaceutical Council (Andalo, 2016).

The current study has reflected a low level of awareness about DFs among Lebanese pharmacists, although most of the participants exhibited the willingness to practice them. However, 3.7 % of the participants reported practicing DFs injections on their clients. This could be interpreted by the fact that there is no legislative permission in Lebanon for this regard. Moreover, there are no accredited aesthetic medicine training courses to certify pharmacists on these minimally invasive cosmetic procedures in the country. As such, community pharmacists may have lost their interest to seek more knowledge about this issue. Moreover, almost half of the participants were confused, and could not distinguish the difference between the botulinum toxin and DFs. This could be explained by the fact that>80 % of respondents relied on ordinary social network platforms as a main source of knowledge. Our findings were in line with several studies conducted among dentists that reflected a low level of knowledge about different injectable facials aesthetics including DFs and botulinum toxin (Abu Khalid et al., 2020, Afiqah et al., 2020, Al Hamdan et al., 2013, Alturkistany et al., 2018, Imam et al., 2019, Laorpipat et al., 2022). Nonetheless, our study findings cannot be compared with these studies since dentists are authorized in many countries to inject facial aesthetics especially that several of them have dental indications such as gummy smile, masseteric hypertrophy, and bruxism (Laorpipat et al., 2022).

Interestingly, most of the participants have the exhibited willingness to receive formal training to be able to administer DFs to their clients. This high intention should be employed as an opportunity for pharmacists to claim for the attention of the Lebanese Ministry of Public Health and the Order of Pharmacists of Lebanon to allow them to practice in the aesthetic industry aiming to expanding pharmacy profession and creating job opportunities for future Lebanese pharmacists.

Several measures should be implemented prior to permitting pharmacists to perform facial injectables. First, we recommend embedding cosmetics and facial aesthetic modules in pharmacy curriculum to enable pharmacy students to in-depth understand the facial anatomy, identify relevant dermatological conditions/diseases, distinguish common health conditions that may affect the cosmetic treatment, define various types of aesthetic injectable, and recognize specific adverse effects and complications of these injectable (Health Education England, 2015). Second, a special department must be established within health authorities to control cosmetic industry standards, cosmetic education and training, and to license qualified practitioners (Health Education England, 2015). Third, accredited training courses and international board certification for pharmacists willing to practice facial aesthetics must be available. These courses should include theoretical and hands-on training courses aiming to facilitate the acquaintance of essential facial aesthetic skills (Andalo, 2016, Health Education England, 2015). Fourth, the law and standards for pharmacy practice should be updated to permit licensed and qualified pharmacists to administer facial aesthetics. Fifth, specialized continuing professional education for pharmacists must be enforced in different specialties, and an auditing system to clinically oversight the practitioners’ performance must be established. Sixth, suitable and safe environments to practice facial aesthetics on clients must be available. Finally, the administration of aesthetic procedures must be restricted to only fully qualified medical professionals, prohibiting inexperienced and unqualified clinicians from practicing facial injectable. It is worth mentioning that the current study has tackled the pharmacists’ willingness to administer DFs to their patients, without investigating the public’s readiness to receive such service from qualified pharmacists. Hence, a future study should explore the community’s trust and willingness to receive non-invasive facial aesthetics from certified pharmacists.

4.1. Study limitations

Although this study was proactive in investigating the pharmacists’ knowledge and willingness to practice DFs injections, several limitations must be pointed out. First, the web-based cross-sectional nature of this study is a potential weakness due to the possible introduction of socially desirable responses which may not reflect the pharmacists’ actual knowledge about DFs, as they might conduct a literature search before responding to questions. However, the overall DFs’ knowledge score was relatively low, reflecting a low level of knowledge among the participants. Second, we recruited a random sample of community pharmacists only, which might introduced career selection bias and might not reflect other pharmacists’ willingness to practice injecting DFs. Third, the sampling technique through conducting a phone call prior sending the self-administered questionnaire may have subjected the study to a sampling bias The contacted pharmacists who were not interested in the cosmetic industry may have refused to participate in the study, which might not reflect the actual rate of the pharmacists’ willingness to administer dermal fillers. However, only 26 pharmacists out of the total random sample (460) did not partake in the study because either they refused to participate or did not answer the calls. This implies that the nonresponse rate is minimal (5.6 %), and those pharmacists were replaced from the random reserve list. Fourth, this study was conducted in Lebanon during the COVID-19 pandemic with the concurrent occurrence of the drastic economic crisis and medication shortage that the Lebanese pharmacists were experiencing (Itani et al., 2022). Pharmacists were struggling to survive all these complex challenges and upscaling the profession was not among their priorities.

5. Conclusions

The profession of pharmacy is still constantly evolving and entering into many fields that pharmacists did not engage in before. In several countries, these highly qualified health professionals are currently envolved in the cosmetic industry, not only in the manufacturing process, but in the direct, licensed administration of injectable dermall fillers to customers. Unfortunately, Lebanese community pharmacists are still way behind this new dimension in their career based on the generally low score they achieved in this study. This might be due to the lack of legislative regulations by the health and pharmacy authorities in addition to the unavailability of special cosmetics modules in the pharmacy curriculum. These authorities should adopt clear directions to modernize the concept of practicing the profession of pharmacy in Lebanon, which will provide more opportunities for the increasing number of pharmacists.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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.

Appendix A. Supplementary data

The following are the Supplementary data to this article: