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COVID-19 Pandemic and Mental Health of the General Population in Saudi Arabia: The Acceptance of Community Pharmacists Role in Providing Mental Health Support

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04 June 2024

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05 June 2024

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Abstract
Objective Objective of the study was to evaluate the public perception and acceptance of community pharmacists in providing mental health support in Saudi Arabia during COVID-19. Methods An online questionnaire-based cross-sectional study was carried out among the general public (aged 15 years or above) of Saudi Arabia during March-April 2020 using QuestionPro platform. The validated questionnaire was bilingual (English and Arabic), simple, detailed, and relevant to obtain focused responses from participants. Importantly, an item related to an agreement on a statement “Pharmacist can counsel people on psychological issues” was included on a five-point Likert scale. The survey link was shared across multiple social media platforms. Results A total of 773 participants completed the survey. The majority were female (65.2%) and youngsters (48.1%). Nearly half of the participants disagreed, while 19% agreed that pharmacists could provide support on psychological issues. Factors such as age, employment status, and the management of the psychological issues during the pandemic were significantly associated with the acceptance of community pharmacists’ role in providing mental health services (p
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Subject: Public Health and Healthcare  -   Public Health and Health Services

Introduction

The 2019 Global Burden of Diseases (GBD) study estimates that 1 out of 8 individuals suffers from a mental disorder, which includes anxiety disorders (ADs), depressive disorders (major depressive disorder [MDD] and dysthymia), bipolar disorder, schizophrenia, eating disorders (anorexia nervosa and bulimia nervosa), autism spectrum disorders, attention-deficit/hyperactivity disorder, conduct disorder, idiopathic developmental intellectual disability, and others. [1], [2] Since 1990, there has been a significant global rise in the number (80.8 to 125.3 million) and proportion (3.1% to 4.9%) of disability-adjusted life-years attributable to mental disorders, as evident from the 2019 GBD results. [2] In Saudi Arabia, mental health is emerging as a severe health burden. The 2011-2016 Saudi National Mental Health Survey (SNMHS; n=4,004), published in 2019, has indicated a 34% prevalence of mental disorders among the Saudi population, with the highest rates in Eastern Region (41%), followed by Riyadh (40%).[3,4] The population-attributable risk was an alarming 32.9%. [5] The most disturbing truth about mental disorders is that not all patients seek medical advice. The SNMHS, which used the Saudi version of the Composite International Diagnostic Interview tool (version 3.0), showed that 80% of those with severe mental illness fall in this category. [3] Results of an online survey published in 2021 reported several factors that prevent the Saudi population (n=1632) from mental health help-seeking behavior, which include stigma (76.3%), culture (61.5%), and negative perceptions (56.2%). [6]
The global impact of COVID-19 on mental health is enormous. Movement restrictions, social disconnect, and isolation mandates due to COVID-19 have significantly worsened people’s mental health worldwide. COVID-19 Mental Disorders Collaborators report that the pandemic has caused a global rise in MD and ADs by over 27% and 25%, respectively. [7] In a study that used the Patient Health Questionnaire-9 Scale for Depression Metrics, the prevalence of depression was 26% among adult population (n=942) in the Jazan Region. [8] Among other health priorities concerning COVID-19, tackling mental disorders has become crucial. In September 2021, the World Health Organization (WHO) updated the Comprehensive Mental Health Action Plan 2013-2030, which set priorities for member states to promote mental well-being, prevent disorders among at-risk population, and advocate for universal coverage. [9] In March 2022 Scientific Brief, the WHO indicated that the pandemic-attributable severe disruptions to mental health services reduced the patients’ access to treatment and resulted in disruption of essential services for mental, neurological, substance use, and other conditions, including for suicide prevention. [10]
The pandemic has put enormous pressure on the health system and infrastructure globally, leading to potential burnout and a shortage of workforce.[11,12] Community pharmacists are essential healthcare providers; they are part of the frontline public health warriors and serve as direct access points for patients. [13] Pharmacists can play a vital role in mental health settings. They can recognize mental illness symptoms, ensure the quality of medicines use and adherence, serve as an educational resource for the community, detect barriers, and facilitate mental health pharmacy services. [14] As a consequence of restrictions in non-emergency clinical services, there is an increased need to have easily accessible resources like community pharmacies to deal with these issues, where pharmacists are in a prime position to interact with and assist in caring for those with mental health issues. [15]
Pharmacists’ role in providing mental health support during COVID-19 is crucial, and its significance is highly valued and widely stressed by leading professional societies and prominent researchers. [16,17,18,19] However, the scholarly literature on accepting pharmacists as key mental health service providers is scarce. Especially, there is no or limited evidence available in Saudi Arabia. Thus, the present study aimed to evaluate the public perception and acceptance of community pharmacists in providing mental health support in Saudi Arabia during COVID-19.

Methods

Study Design

An online questionnaire-based cross-sectional study was carried out among the general public of Saudi Arabia during March-April 2020 using the QuestionPro platform.

Instrument Development, Validation, and Translation

We developed a simple, detailed, and relevant questionnaire in English using scholarly sources. Discrepancies were resolved after discussion between authors. We performed validation using a reliability pre-test in 20 participants and obtained a Cronbach’s alpha coefficient of 0.803, which is within the acceptance limit of >0.7. We then translated the questionnaire into Arabic by a native Arabic-speaking author. Backward translation was independently performed by another native Arabic-speaking author.

Questionnaire

The questionnaire has two sections. The first part consists of items related to socio-demographic and clinical characteristics of participants including gender, age, educational level, employment status, and the presence of chronic conditions. The second part consists of a section related to participant-adopted strategies to overcome psychological issues during COVID-19. If a participant sought medical consultation on psychological issues, details on type of consultation were collected. Finally, an item related to an agreement on a statement “Pharmacist can counsel people on psychological issues” was included on a five-point Likert scale. The bilingual survey link was shared across multiple social media platforms.

Sample Size

A previous study on mental health issues during the COVID-19 pandemic reported that one in five of general population had exhibited anxiety or depression. [20] Based on this information, the study required 246 participants to detect the prevalence with a 95% confidence level and 5% margin of error.

Participants

Residents of Saudi Arabia who aged 15 years or above were eligible for participation if they can fill the online questionnaire in English or Arabic.

Statistical Analysis

Descriptive data were presented as frequency and percentage. Chi-square test was used to assess the statistical association between socio-demographic and clinical characteristics and the acceptance of pharmacists among the public. P-value less than 0.05 was considered as statistically significant. All analyses were carried out using SPSS Statistics (version 24).

Ethical Considerations

The study protocol and questionnaire (containing informed consent) were approved by the Institutional Review Board of Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia (Approval number: IRB-2020-05-173). Participants were requested to provide consent online before commencing the questionnaire.

Results

Participants’ Characteristics

Among 1077 people who viewed the online survey link, 956 were screened for eligibility and 773 (80.1%) completed the survey. The socio-demographic characteristics of the 773 participants were summarized in Table 1. The majority were female (65.2%), whereas only one third were male (34.8%). Regarding age of the participant maximum were from youngsters (48.1% with the age range of 15-24 years) group, the proportion 13.6%, 11.5%, 13.6% and 13.2% was for the age group 25-34, 35-44, 45-54 and more than 55, respectively. Most (76.8%) had an undergraduate education, 17.7% had secondary or lower education and only 5.4 hold master or higher education. In terms of employment most of them were students (41.5%), without having job (24.6%) holds second largest proportion, while 13.1% were from private job holder, 11.8% having government job and only 9.1% were healthcare professionals. Only 12.9% of participants had reported to have a chronic illness.

Acceptance of Pharmacists

While nearly half of the participants (49%, n=379) disagreed, whereas only 19% (n=142) agreed and rest of the 32% respondent were unsured that pharmacists could provide support on psychological issues (Figure 1). Among those of 8% (n=61) who sought medical consultation for on psychological issues during COVID-19, a small number of them (15%, n=9) consulted a pharmacist; while highest 51% (n=31) consulted physician, second most 41% (n=25) consultation service received from online mental health service, whereasone fourth (25%) of them received medication and only 16% taken sleeping pills to get relief (Figure 2).
Around one fifth (21%) of the participants solved their depression issues by self-management, only 12% discussed with peer, while around two third (59%) had no issues or required to take any efforts during pandemic due to overcome phycological issues. (Figure 2).

Association between Acceptance and Sociodemographic Characteristics

Table 2 presents the distribution of the acceptance of pharmacist to deal with psychological issues. It was found that age, employment status and the management of the psychological issues during the pandemic (p<0.001) were significantly associated with the acceptance of community pharmacists’ role in providing mental health services. Descriptive statistics reviled that the highest (24.3%) agreement observed from youngest (15-24y) age group in terms of acceptance of pharmacist due to phycological issues, while lowest (9.1%) were from oldest age group. Surprisingly, health care professional reported highest (27.1%) agreement than other professionals like: students 24.1%; privet job 15.8%, government job 11.5% and no job 10.6% (Table 2).

Discussion

This is a first-of-its-kind study in Saudi Arabia assessed the acceptance of pharmacists among the public in providing mental health support. We attempted to provide a clear picture about the role of community pharmacist as health care provider during COVID 19 and whether the people seek the help of community pharmacist to overcome the mental issues that they might had during the pandemic. It’s well known that the role of community pharmacist in Saudi Arabia can is to help patients and the public, assessing their conditions and making decisions about which OTC medications they should take. In addition, as per the ASHP, pharmacists are essential in upholding and advancing public health including providing mental consultation for those who need them.
The results of this study showed that nearly half of the participants (49%, n=379) believed that pharmacist cannot provide the mental support needed and only 19% (n=142) agreed that pharmacists could provide consultation regarding mental health. This finding suggests that respondents expectations of community pharmacists are low and do not match the services that pharmacists can provide. In contrary to our findings, one study found that 90% of the respondents had recognized the services of community pharmacist in mental health and 82% of respondents agreed that pharmacist can understand the needs of community when it comes to helping people with mental illness [30]. A recent study from Saudi Arabia, revealed 53% of general public were satisfied and 17.8% were very satisfied with the community pharmacy services. [31] which indicates people with mental illness may have positive attitude towards the community pharmacy services in future provided awareness campaigns. Several other studies documented the positive impact of the pharmacist on psychiatric patient outcomes. [32] Another study revealed study pharmacists were perceived as valuable sources of unbiased and evidence-based drug information for both mental health team staff and their clients and caregivers. [33] Another study indicated that the perception of community pharmacists (n=96) on mental health support was assessed using a 40-item survey. While 84% recognized their prominent role in mental health care, 60% were cognizant of their responsibility to provide pharmaceutical care to the patients with mental illness. [25] It is imperative to understand the reason for lack of acceptance among general public and even younger generation and formulate policies and implement action plans to create awareness on the role of pharmacists in this crucial healthcare domain. The FIP has identified several key structural and systems-level barriers to pharmacists’ engagement in mental health support. These include lack of time, reimbursements, access to health data/medical records, knowledge, training, and privacy. Most importantly, the existing models of care in various countries prevent pharmacists’ full-fledged involvement in mental health services. At the patient-level, stigma and negative attitudes remain the most challenging barriers [22]. In a recent Australian-based focus group study, lack of recognition and integration of community pharmacy within primary healthcare were reported as the key barriers. Besides, patients’ stigma and unawareness of service offering were also hindered pharmacists’ role in mental health services [27].
The findings of this study highlighted the strategies used by the participants to overcome psychological issues during COVID-19 where the majority of participants, 51% consulted physicians and 41% utilized online mental health services. This might be a result of the fact that Ministry of Health (MOH) has introduced several key initiatives/programs on mental-wellbeing through the National Center for Mental Health Promotion, including Psychological Consultation Center, Comprehensive Health Counseling Initiative (Primary Mental Care Program), Ajwad Rehabilitation Services for patients with psychiatric illness, Qareboon App, and tele-consulting services [3,21]. In consistent with these findings one study had revealed psychiatrists were ranked highest, as the most commonly used and best resource for information about psychotropic medications however, pharmacist were ranked highly and best source of information about medications but, only next to the psychiatrists. [30] In the Eastern Regional city of Dhahran, pharmacist-led telehealth psychiatric services were successfully implemented in Johns Hopkins Aramco Healthcare, during the pandemic. Pharmacists assessed appropriate medication use, resolved medication-related problems, reviewed medications for polypharmacy, counseled patients, observed treatment adherence, discussed tolerance issues, examined mental status, observed for any unusual patient characteristics, and organized special clinics for those using lithium and clozapine. [26] It is expected that these impressions would change by increasing the awareness among the Saudi Arabia community regarding the different services that a community pharmacist can provide consultation in mental health settings.
The study findings showed that young age, employment status and the management of the psychological issues during the pandemic (p<0.001) were significantly associated with the acceptance of community pharmacists’ role in providing mental health services. No similar studies were found to correlate these finding in mental health settings however, the finding of one recent study from Saudi Arabia which assessed the attitude of general public towards community pharmacy had shown, older people were found less willing than their younger counterparts to approach a community pharmacist. [31]
At the time when the global burden of mental disorders has seen an exponential rise during COVID-19, there is an excessive shortage and burnout of the health workforce. [11,12] It is high time to recognize the potential of pharmacists in promoting mental health and providing improved care services. [22] During this unprecedented time, they can expand beyond their regular services and help perform opportunistic risk screening of mental disorders. [23,24] The International Pharmaceutical Federation (FIP), in its 2022 Mental Health Care Handbook for Pharmacists, details the potential role of pharmacists at various mental health settings and transitions of care, including preliminary screening and diagnosis, psychological counseling, signposting to mental health facilities, and care at discharge and follow-up. [22]
Lack of knowledge and training on mental health among pharmacists is a recognized problem globally. In the study by Wong et al., not a single community pharmacist (out of 96) believed that they had sufficient knowledge on the mental health disorders. Majority of the participants (93%) hinted lack of training was the reason for inadequate knowledge. Interestingly, over half of them stated poor curriculum at the undergraduate level or that they perceived mental health as a comparatively difficult health field. [25] It is crucial to develop and strengthen Psychiatric or Mental Health Pharmacy specialization even in resource-poor settings. [16] Besides, it is also important to encourage pharmacists to train on Mental Health First Aid training, which is a proven resource for improving mental health literacy. [28]
Moreover, in Saudi Arabia, it is essential to develop public awareness campaigns on pharmacists’ role in mental health. These campaigns should have a wide public representation from the community, since psychological distress was significantly higher among younger age groups and unmarried individuals in Saudi Arabia during the pandemic. [29] We suggest community pharmacists should be included as a member of mental health care team in primary health care centers in the Kingdom. Unfortunately, our present research did not assess the barriers that prevent participants from seeking pharmacist support in mental health issues, which is the key limitation. However, we conducted the study amid the pandemic and used a highly reliable questionnaire.

Conclusions

Although community pharmacists were easily accessible during the pandemic in Saudi Arabia, participants mostly choose physicians to discuss mental health issues. There is a lack of acceptance of community pharmacists’ role in providing mental health support. Public awareness of the role of community pharmacists in mental well-being needs to be improved, which will help reduce health workforce shortage and burnout.

Source of Funding

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

Ethical Approval

The study protocol and questionnaire (including the consent form) were reviewed and approved by the Institutional Review Board of Imam Abdulrahman Bin University, Dammam, Saudi Arabia (Approval number: IRB-2020-05-173).

Authors Contributions

All authors equally contributed and finally approved the manuscript.

Conflicts of Interest

The authors have no conflict of interest to declare.

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Figure 1. Acceptance of Community Pharmacists in Providing Mental Health Support During COVID-19.
Figure 1. Acceptance of Community Pharmacists in Providing Mental Health Support During COVID-19.
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Figure 2. Strategies to Overcome Psychological Issues During COVID-19.
Figure 2. Strategies to Overcome Psychological Issues During COVID-19.
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Table 1. Sociodemographic Characteristics of Survey Participants.
Table 1. Sociodemographic Characteristics of Survey Participants.
Characteristics n %
Gender
Male 269 34.8
Female 504 65.2
Age (years)
15-24 372 48.1
25-34 105 13.6
35-44 89 11.5
45-54 105 13.6
55 or older 102 13.2
Education
Secondary school or lower 137 17.7
Bachelor degree 594 76.8
Masters or higher 42 5.4
Employment Status
Student 321 41.5
Healthcare professionals 70 9.1
Other government sector 91 11.8
Other private sector 101 13.1
Not working 190 24.6
Existing chronic condition
Yes 100 12.9
No 673 87.1
Table 2. Association Between Acceptance and Sociodemographic Characteristics of Participants.
Table 2. Association Between Acceptance and Sociodemographic Characteristics of Participants.
Acceptance of Pharmacist [n(%)] P-Value
Disagree Maybe Agree
Gender
Male 133 (50.6) 83 (31.6) 47 (17.9) 0.898
Female 246 (48.9) 162 (32.2) 95 (18.9)
Age (years)
15-24 144 (38.8%) 137 (36.9%) 90 (24.3) <0.001
25-34 54 (51.4) 37 (35.2) 14 (13.3)
35-44 47 (54) 32 (36.8) 8 (9.2)
45-54 67 (64.4) 16 (15.4) 21 (20.2)
55 or older 67 (67.7) 23 (23.2) 9 (9.1)
Education
secondary school or lower 68 (50) 42 (30.9) 26 (19.1) 0.336
Bachelor degree 284 (48.3) 192 (32.7) 112 (19)
Masters or higher 27 (64.3) 11 (26.2) 4 (9.5)
Employment Status
Student 122 (38.1) 121 (37.8%) 77 (24.1) <0.001
Health Professionals 35 (50) 16 (22.9%) 19 (27.1)
Other government sector 48 (55.2) 29 (33.3%) 10 (11.5)
Other private sector 61 (60.4) 24 (23.8) 16 (15.8)
Not working 113 (60.1) 55 (29.3) 20 (10.6)
Existing chronic condition
Yes 49 (49) 30 (30) 21 (21) 0.77
No 330 (49.5) 215 (32.3) 121 (18.2)
Mental illness management
No issues 257 (57.1) 119 (26.4) 74 (16.4) <0.001
Self-management 69 (41.8) 66 (40) 30 (18.2)
Discussed with peers 33 (36.3) 38 (41.8) 20 (22.0)
Obtained consultation 20 (33.3) 22 (36.7) 18 (30.0)
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