Knowledge, attitude and practices of community pharmacists regarding COVID-19: A paper-based survey in Vietnam.

OBJECTIVE: To survey the knowledge, attitude, and practices of Vietnamese pharmacists regarding the COVID-19 pandemic.
METHOD: This cross-sectional, paper-based study was conducted from June to August 2020. A validated questionnaire (Cronbach's alpha = 0.84) was used to interview 1,023 pharmacists in nine provinces of Vietnam. Analysis of covariance was employed to identify factors associated with the knowledge of pharmacists. The best model was chosen by using the Bayesian Model Averaging method in R software version 4.0.4.
RESULTS: The mean knowledge score was 12.02 ± 1.64 (range: 6-15), which indicated that 93.4% of pharmacists had good knowledge of COVID-19. There was no difference in the average score between males and females (p > 0.05). The multivariate linear regression model revealed that the knowledge was significantly associated with pharmacists' age, education level, and residence (p < 0.001). About attitude and practices, pharmacists daily sought and updated information on the COVID-19 pandemic through mass media and the internet (social network and online newspapers). Nearly 48% of them conceded that they communicated with customers when at least one person did not wear a face mask at the time of the COVID-19 outbreak. At medicine outlets, many measures were applied to protect pharmacists and customers, such as equipping pharmacists with face masks and hand sanitizers (95.0%), using glass shields (83.0%), and maintaining at least one-meter distance between two people (85.2%).
CONCLUSION: The pharmacists' knowledge of COVID-19 transmission, symptoms, and prevention was good. Many useful measures against the spread of this perilous virus were applied in medicine outlets. However, pharmacists should restrict forgetting to wear face masks in communication with medicine purchasers. The government and health agencies should have practical remedies to reduce the significant differences in the COVID-19 knowledge of pharmacists among provinces and education-level groups.

Introduction

COVID-19 is an infectious disease caused by a newly discovered coronavirus. In Wuhan City in China, the first cases of COVID-19 contamination were detected in December 2019 [1]. After that, this perilous virus was quickly spread globally and gave rise to an outbreak of an international pandemic. Up to 2021 Jul 02, globally, there were approximately 180.49 million COVID-19 confirmed cases and 3,916,771 deaths. In the previous week, there were approximately 2.60 million new cases, and 57,603 deaths reported [2]. In Vietnam, up to 2021 Jul 02, there were 17,902 COVID-19 confirmed cases, 84 deaths, and 7,247 recoveries [3]. This pandemic begot many negative influences on local and global economies. Recently, many stringent measures have been implemented in countries, such as social distancing, complete lockdowns with the aim of curbing the COVID-19 spread [4, 5]. At this time, at least 13 kinds of vaccines have been administered all over the world. In addition, 105 vaccines are in clinical development and 184 vaccine candidates are in pre-clinical development [6].

Medicine outlets are commonly the reliable and first place for citizens to take advice about health issues. Along with doctors and nurses, community pharmacists can play an important role in putting a curb on the spread of the COVID-19 pandemic [7, 8]. They can bear responsibilities for being the rapid point of care tests for COVID-19, taking notes about suspected cases, ensuring the medicine quality, mitigating drug shortages, supplying reliable information on COVID-19 to the community, ensuring education and home care for citizens, suspected patients, and family members while in self-isolation [9]. In China, when the outbreak had just commenced, pharmacists quickly compiled documents to introduce detailed information on therapeutic drugs for COVID-19. Hence, doctors could master the characteristics and instructions of these medications [10]. In the United States, the active engagement of pharmacists in COVID-19 testing can assist in addressing many gaps in testing availability and demonstrating the value that pharmacists can provide in addressing unmet health needs [11]. In Vietnam, roughly 82.000 community pharmacists are working in 61.000 medicine outlets. There are three main groups of Vietnamese pharmacists licensed to sell medicines: the Uni group (pharmacists who graduated universities of pharmacy with five years of training), the Col group (assistant pharmacists who graduated colleges of pharmacy with three years of training), and the Mid group (middle pharmacists who finished two-year-training courses). Normally, Vietnamese pharmacists with higher levels of education (such as Master, Ph.D.) do not directly sell medicines in medicine outlets.

The KAP is a representative survey conducted on a particular population to identify the knowledge (K), attitudes (A), and practices (P) of that population on a specific topic [12]. This standardized method has been used for conducting abundant studies all over the world. Regarding COVID-19, globally, many studies on the KAP of pharmacists and pharmacy students were carried out [13-30]. Up to 2021 Jul 02, there are only two published articles assessing COVID-19 related KAP of healthcare workers in Vietnam [13, 14]. There is no previous report of a nationwide study assessing the KAP of pharmacists about COVID-19. This study was conducted to survey the KAP of 1,023 Vietnamese community pharmacists regarding COVID-19 in the year 2020.

Materials and methods

Study design

This cross-sectional, paper-based survey was conducted in Vietnam during the COVID-19 outbreak (from June 01 to August 31, 2020). This study was approved by the ethical committee of Hanoi University of Pharmacy, Hanoi, Vietnam (reference number 3-20/PCT-HĐĐĐ).

The questionnaire

After reviewing numerous articles in PubMed and the websites of the World Health Organization (WHO) [31-34], the research team developed the first draft of the questionnaire. To guarantee the clarity and plainness of questions, three senior lecturers of Hanoi University of Pharmacy assisted the research team in reviewing the questionnaire. Furthermore, to ensure logic, suitability, and validity, this questionnaire was employed to conduct a pilot study with 40 pharmacists working in 20 medicine outlets in Hanoi in April 2020 before interviewing pharmacists all over Vietnam. The Cronbach’s alpha was 0.84. The final questionnaire started with a short introduction, including the objectives, the procedures, the declaration of confidentiality and anonymity, and the volunteer nature of the participants. It was designed in Vietnamese and included the following main parts: pharmacists’ profile (5 questions), knowledge (15 questions), and attitude/practices (33 questions) (S1 Questionnaire).

Data collection

The Raosoft sample size calculator was used for computing this study’s sample size. To achieve a margin of error of 5%, the confidence level of 99%, the response distribution of 50%, and the population size of 82,000 pharmacists, the sample size was 659. With the aim of increasing the generalizability and validity of this research, we strived to approach as many pharmacists as possible to collect data. A total of 1,200 pharmacists were approached. The response rate was 85.25%. 1,023 pharmacists voluntarily answered the questionnaire and verbal informed consent was obtained from all of them. The study sample can be representative of Vietnamese pharmacists. The general characteristics of the participants are shown in Table 1. Pharmacists were mainly women (78.2%). Most of them were aged from 20 to 39 years old (75.8%). Their time of working in medicine outlets was mostly less than 15 years. Nearly 66% of pharmacists were from the northern part of Vietnam.

Table 1

The general characteristics of the study sample (n = 1,023 pharmacists).

No.	Characteristics			Number	(%)
A1	Gender	Male		223	21.8
		Female		800	78.2
A2	Age	20–29		320	31.3
		30–39		455	44.5
		40–49		156	15.2
		≥ 50		92	9.0
A3	Education level	University and higher (Uni)		364	35.6
		College (Col)		394	38.5
		Middle (Mid)		265	25.9
A4	Working time in medicine outlets (years)	< 5		367	35.9
		5–9		309	30.2
		10–14		182	17.8
		15–19		68	6.6
		≥ 20		97	9.5
A5	Region (province)	Northern	Caobang	33	3.2
			Hanam	95	9.3
			Hanoi	124	12.1
			Namdinh	52	5.1
			Tuyenquang	193	18.9
			Vinhphuc	177	17.3
		Central	Thanhhoa	173	16.9
			Nghean	26	2.5
		Southern	Hochiminh	150	14.7

By virtue of the complexity of the COVID-19 plague, a non-probability convenience sampling technique was used for recruiting participants. Participants’ inclusion criteria were licensed pharmacists working in medicine outlets opened on the days of data collection, able to read and understand Vietnamese, and at least 18 years old. In each province, data collection forms were distributed to pharmacists with the aid of medical personnel of the Department of Health (data collectors). At medicine outlets, each pharmacist was given one data collection form. After the forms were filled in, data collectors would check them to guarantee that all questions were answered adequately and legibly. Then, all data collection forms were sent to the research team by post.

Data analysis

The data were entered and analyzed using Microsoft Excel 2020 and R software version 4.0.4. The descriptive analysis was undertaken using mean and percentage. Data normality was checked using histogram, Q-Q plot, boxplot, and Shapiro-Wilk test (p-value > 0.05 indicating a normally distributed continuous variable). Differences among groups were analyzed using the Wilcoxon rank-sum test, the Kruskal-Wallis rank-sum test, and the Dunn test for multiple comparisons.

Analysis of covariance (ANCOVA), a general multivariate linear model, was employed to identify factors associated with pharmacists’ knowledge scores. The model was chosen by using the Bayesian Model Averaging method. The score for each pharmacist was computed based on three main topics: the ways of viral transmission (three questions), related symptoms (eight questions), and COVID-19 prevention (four questions). The right and wrong answer for each question was assigned 1 point and 0 point, respectively. The total knowledge score of one pharmacist varied from 0 to 15. The score ≥ 10 and < 10 indicated good knowledge and poor knowledge, respectively. Correct answers were mainly compared to information from the WHO [31-34].

Results

The knowledge

Almost all pharmacists (> 93%) knew that the COVID-19 virus could be directly transmitted by close contact with infected people via secretions of the mouth and nose, and direct contact with blood is not one way of viral transmission. About 13.4% of pharmacists did not know the indirect COVID-19 transmission (touching a contaminated surface and then touching eyes and nose). Some COVID-19 symptoms which numerous pharmacists (> 84%) knew were fever, dry cough, tiredness, and difficult respiration. The percentages of pharmacists who knew less common symptoms of COVID-19 (nausea, vomiting, bellyache, and diarrhea) were low (< 50%). In addition, most pharmacists (> 93%) comprehended the main ways of COVID-19 prevention (Table 2).

Table 2

The knowledge of Vietnamese pharmacists about COVID-19.

No.	COVID-19 knowledge	Right answers (%)
	K1. Ways of COVID-19 transmission (B1-B3):
B1	The virus that causes COVID-19 spreads primarily through droplets generated when an infected person coughs, sneezes, or speaks.	1,003 (98.0)
B2	People can become infected by touching a contaminated surface and then touching their eyes, nose, or mouth before washing their hands.	886 (86.6)
B3	Direct contact with blood is not one way of COVID-19 transmission.	957 (93.5)
	K2. COVID-19 symptoms include (B4-B11):
B4	Fever (common symptom)	1,016 (99.3)
B5	Dry cough (common symptom)	1,009 (98.6)
B6	Tiredness (common symptom)	867 (84.8)
B7	Difficulty breathing and shortness of breath	975 (95.3)
B8	Sore throat	461 (45.1)
B9	Nausea and vomiting	315 (30.8%)
B10	Headache	764 (74.7%)
B11	Bellyache and diarrhea	113 (11.0%)
	K3. How to prevent COVID-19 (B12-B15):
B12	Maintain at least one-meter distance with people coughing/sneezing	993 (97.1)
B13	Use a mask, cover your mouth and nose when coughing/sneezing	1,005 (98.2)
B14	Wash hands regularly with soap or alcohol-based hand rub, and not touch the face	976 (95.4)
B15	Supplement nutrition and regularly do exercise	955 (93.4)

The mean knowledge score of 1,023 pharmacists was 12.02 ± 1.64, which indicated that 93.4% of pharmacists had good knowledge about COVID-19. There was no difference in the average scores between males and females (p > 0.05, Wilcoxon rank-sum test). The average knowledge score of Col pharmacists was significantly higher than that of Uni and Mid pharmacists (p < 0.05, Dunn test). The average score of pharmacists in the central part of Vietnam was significantly higher than that in other parts (p < 0.001, Dunn test) (Table 3).

Table 3

The average score involving COVID-19 knowledge of pharmacists.

No.	Characteristics		Number	Average score (SD)	p-value
1	Gender	Male	223	12.03 (1.39)	0.660
		Female	800	12.02 (1.70)
2	Age	20–29	320	12.02 (1.63)	0.159
		30–39	455	11.93 (1.67)
		40–49	156	12.29 (1.53)
		≥ 50	92	11.97 (1.65)
3	Education level	University and higher (Uni)	364	12.23 (1.33)	< 0.001
		College (Col)	394	12.45 (1.60)
		Middle (Mid)	265	11.09 (1.72)
4	Working experience in medicine outlets (years)	< 5	367	11.92 (1.53)	< 0.001
		5–9	309	12.06 (1.73)
		10–14	182	12.36 (1.64)
		15–19	68	11.87 (1.65)
		≥ 20	97	11.76 (1.64)
5	Region	Northern (Caobang, Hanam, Hanoi, Namdinh, Vinhphuc, Tuyenquang)	674	11.60 (1.65)	< 0.001
		Central (Thanhhoa, Nghean)	199	13.20 (1.29)
		Southern (Hochiminh)	150	12.34 (1.06)

Among provinces, the average knowledge scores of pharmacists were seemingly equal, except for Thanhhoa and Tuyenquang province. The average score of pharmacists in Hanam, Hanoi capital, Hochiminh city, Thanhhoa, Tuyenquang, Vinhphuc, and other provinces was 11.60, 12.13, 12.34, 13.38, 11.02, 11.97, and 11.51, respectively. The knowledge score of pharmacists in Tuyenquang province was significantly lower than that in Hanam, Hanoi, Hochiminh, Thanhhoa, and Vinhphuc (p < 0.001, Dunn test). The knowledge score of pharmacists in Thanhhoa province was significantly higher than that in other provinces (p < 0.001, Dunn test) (Fig 1).

Fig 1

The COVID-19 knowledge scores of Vietnamese pharmacists in provinces.

In the multivariate linear regression analysis, after controlling for other variables, age, education, and residence (provinces) were three factors associated with the knowledge scores of Vietnamese pharmacists (p < 0.001). Gender was not associated with the knowledge scores of pharmacists. There is a strong relationship between the age and the working experience of pharmacists in medicine outlets (p < 0.001, Spearman’s rank correlation) (Table 4).

Table 4

Analysis of factors associated with the knowledge scores of Vietnamese pharmacists.

No.	Variables	Univariate linear regression			Multivariate linear regression
		Coef.	t-value	p-value	Coef.	Adjusted coef.	t-value	p-value
1	Age (continuous variable)	0.002	0.512	0.608	0.018	0.104	3.506	< 0.001
2	Gender (ref.: Female)
	Male	0.011	0.086	0.932
3	Working experience (continuous variable)	-0.005	-0.63	0.529
4	Education level (ref.: College)
	Middle	-1.356	-11.078	< 0.001	-0.941	-0.252	-7.839	< 0.001
	University and higher	-0.216	-1.928	0.054	0.020	0.006	0.172	0.863
5	Residence (provinces) (Ref: Caobang)
	Hanam	0.206	0.700	0.484	0.429	0.076	1.509	0.132
	Hanoi	0.735	2.575	0.010	0.866	0.172	3.141	0.002
	Hochiminh	0.946	3.375	< 0.001	1.052	0.228	3.840	< 0.001
	Namdinh	-0.048	-0.147	0.883	0.514	0.069	1.620	0.106
	Nghean	0.606	1.586	0.113	1.008	0.096	2.721	0.007
	Thanhhoa	1.987	7.178	< 0.001	2.035	0.466	7.583	< 0.001
	Tuyenquang	-0.373	-1.359	0.174	-0.090	-0.022	-0.339	0.734
	Vinhphuc	0.572	2.070	0.039	0.526	0.122	1.976	0.048

Adjusted R-squared (for the multivariate linear regression): 0.2685.

PostProbs (Bayesian Model Averaging): 0.267.

coef.: coefficient, ref.: reference.

The attitude and practices

In general, almost all pharmacists (99.5%) quotidianly sought and updated COVID-19 information. Common sources of information included mass media (television, radio) and the internet (social networks and online newspapers). Approximately 89.4% of pharmacists were questioned by customers about COVID-19. Popular questions included the ways of COVID-19 transmission, related symptoms, and prevention. If customers had symptoms of viral contamination, 91.0% of pharmacists would ask them about some information (such as symptoms, travel history) to take notes and then report the information to health agencies when necessary. Nearly half of pharmacists communicated with customers when at least one person did not wear a face mask. The most popular reason was that pharmacists forgot to wear face masks (79.2%). Recently, several kinds of pharmaceutical products were usually purchased by customers, including vitamins, dietary supplements, antiseptics, and hand sanitizers. Moreover, in medicine outlets, there were many measures applied to curb viral transmission, such as equipping pharmacists with face masks and hand sanitizers (95.0%), maintaining the minimum distance between pharmacists and customers (85.2%), and using glass shields (83.0%) (Table 5).

Table 5

The attitude and practices of pharmacists about COVID-19.

No.	Questions	“Yes” answers (%)
C1	Do you seek and update information on COVID-19 every day?	1,018 (99.5)
	Your sources of COVID-19 information (C2-C4):
C2	Shares from other colleagues/pharmacists	533 (52.1)
C3	The internet: social network (Facebook, Messenger, Zalo apps), and online newspapers (websites of the government and the health agencies)	882 (86.2)
C4	Mass media (national news, radio, television)	987 (96.5)
C5	In the last three months, whether or not customers have asked you questions involving COVID-19	915 (89.4)
	Common questions of customers (C6-C9):
C6	The ways of viral transmission	788 (77.0)
C7	Related symptoms	830 (81.1)
C8	COVID-19 prevention	857 (83.8)
C9	What they should do if suspecting of being infected with the COVID-19 virus	579 (56.6)
	In the last three months, pharmaceutical products usually purchased in your medicine outlet include (C10-C13):
C10	Vitamins and dietary supplements*	978 (95.6)
C11	Medicines for treating influenza and headache	420 (41.1)
C12	Painkillers and antipyretics	364 (35.6)
C13	Antiseptics and hand sanitizers	842 (82.3)
C14	Do you think taking notes about the information of people who purchase medicines treating cough, fever, and flu is necessary?	946 (92.5)
C15	Will you ask customers some questions if they have symptoms the same as COVID-19 viral contamination?	931 (91.0)
	You will ask them about (C16-C19):
C16	Their symptoms	889 (86.9)
C17	Travel history	738 (72.1)
C18	People who they had close contact with	731 (71.5)
C19	Whether or not they update information on COVID-19 regularly	752 (73.5)
C20	Have you ever communicated with customers when at least one person did not wear face masks in the last three months?	490 (47.9)
	If you already did it, list your reason(s) (C21-C23):
C21	Because of lacking face masks in my medicine outlet	148 (14.5)
C22	I forgot to wear face masks	388 (37.9)
C23	Customers did not wear face masks	19 (1.9)
C24	Is there any measure to limit viral contamination and protect pharmacists and customers in your outlet?	996 (97.4)
	Measures for COVID-19 prevention in your outlet include (C25-C33):
C25	Install glass shields (barriers or partitions)	849 (83.0)
C26	Put hand sanitizers at the doors of the outlet and require customers to use them before entering the outlet	969 (94.7)
C27	Maintain at least one-meter distance between pharmacists and customers	872 (85.2)
C28	Maintain at least one-meter distance between two pharmacists	722 (70.6)
C29	Equip pharmacists face masks and hand sanitizers	972 (95.0)
C30	Reduce the number of pharmacists in the outlet	664 (64.9)
C31	Organize courses of training and sharing information on COVID-19 among pharmacists	550 (53.8)
C32	Indirectly give customers advice on medicines (through phones, messenger, social media)	464 (45.4)
C33	Deliver medicines to customers’ doors	430 (42.0)

* dietary supplements: products made in the form of capsules, pellets, tablets, glues, granules, powder, liquid, and other processed forms containing one or a combination of the following substances: Vitamins, minerals, amino acids, fatty acids, enzymes, probiotics, and other biologically active substances; active ingredients naturally derived from animals, minerals, and plants through extraction, isolation, concentration, and metabolism processes.

Discussion

Results from previous studies show that pharmacists were and are making vital contributions to impeding the expansion of COVID-19 pandemics [35-38]. As a result, enhancing knowledge of COVID-19 for pharmacists is of paramount importance. The average knowledge score of Vietnamese pharmacists was 12.02 (out of 15). Our results demonstrated that a majority of Vietnamese pharmacists have good knowledge about COVID-19 (93.4%), which was consistent with the findings of studies conducted in Lebanon (> 90%) [15], India (85.3%) [16], Pakistan (84%) [17], Cairo (83%) [18] but far higher than the results of Addis Ababa (53.2%) [19] and Gondar, Ethiopia (63%) [20].

In Vietnam, the fact that the number of females is far higher than that of males is one typical characteristic of the pharmaceutical industry. The proportion of female pharmacists in our study was high (78.2%), in line with results from the studies of Jordan (78%) [21], Goa (79.5%) [22], Cairo (70%) [18], and Lebanon (85.2%) [15]. Although the number of females was far higher than that of males, there was no difference in the COVID-19 knowledge score between these two groups in Vietnam. This finding was similar to results from the United Arab Emirates [23], Saudi Arabia [24], Nepal [25], and Jordan [26]. In Saudi Arabia, Pakistan, Nepal, and the United Arab Emirates, age was not the factor associated with the knowledge score of pharmacists [23–25, 27]. In Vietnam, it seems that better knowledge scores were associated with higher age of participants (β = 0.104, p < 0.001), compatible with the findings in Jordan [28]. In the light of the strong correlation between age and working experience, the latter was excluded from the multivariate linear regression model. This factor was still significantly associated with Vietnamese pharmacists’ knowledge. In Gondar, Ethiopia, pharmacists with more than six years of experience had better knowledge about COVID-19 in comparison with their counterparts with less than six years of experience [20]. In the United Arab Emirates, the knowledge score of pharmacists with more than five years of experience was significantly higher than that of pharmacists with less than two years of experience [23].

Education level was not a factor significantly associated with the knowledge score of pharmacists in several countries like the United Arab Emirates [23], Punjab and Khyber Pakhtunkhwa of Pakistan [27], and Saudi Arabia [24]. However, in Vietnam, there were significant differences in the mean knowledge scores among three education-level groups. A special point is that the average score of graduates from pharmacy colleges (Col pharmacists) was significantly higher than that of graduates from pharmacy universities (Uni pharmacists). Their time of studying and training was three and five years, respectively. The important rationale behind this result is that in Vietnam, the curriculum of pharmacy colleges usually focuses on practical subjects involving opening medicine outlets, selling medications, addressing health issues in the community. The curriculum of pharmacy universities commonly focuses on theoretical and academic subjects, such as drug manufacturing, pharmacological, and clinical pharmacy.

In Vietnam, the knowledge regarding COVID-19 of pharmacists was significantly different by region and province (residence). The average score of pharmacists in Thanhhoa province is the highest (13.38) while that in Tuyenquang province is the lowest (11.02). Thanhhoa is a border province located in the central part of Vietnam, having a flourishing economy and healthcare system. This province is located on the main road connecting the north and the south of Vietnam. The government and health authorities attached special importance to setting up activities involving COVID-19 prevention and pandemic control in border provinces. Besides, the Thanhhoa Department of Health usually organizes training courses for pharmacists to broaden their knowledge. For Tuyenquang, this is a highland province with a low population density. The economy, healthcare, and traffic systems in many villages of this province are still undeveloped. In addition, at the time of data collection, there were COVID-19 confirmed cases in Thanhhoa while there were no cases found in Tuyenquang. The lack of hands-on experience on COVID-19 prevention may be a reason for the low knowledge scores of pharmacists in Tuyenquang.

In Ethiopia, 71.1% of community pharmacists checked new updates on COVID-19 more than once per day [20]. In Lebanon, many pharmacists spent about one to two hours per day getting information about this pandemic [15]. In Vietnam, COVID-19 drew pharmacists’ special attention when 98.8% of pharmacists said that they sought and updated information on COVID-19 on a daily basis. They used the internet (online apps and newspapers) and mass media as the main sources to seek COVID-19 information. In Jordan, the sources of information for pharmacists mostly came from general media, WHO reports, published research papers, and social networks [28, 29]. Mass media (television, radio), the internet, and social media (Facebook, WhatsApp) were also the main sources of information of pharmacists in India [16], Turkey [30], Ethiopia [19, 20], and Cairo [18]. In Vietnam, due to the incompetence in reading and understanding documents written in English (language barriers), most pharmacists accessed sources of COVID-19 information spoken or written in Vietnamese. In many provinces, pharmacists were required to participate in groups on apps, such as Zalo or Messenger. These online groups are the sites where pharmacists can share their news and experience, and health agencies can directly and quickly send accurate information on COVID-19 to all pharmacists. In addition, to disseminate correct information about COVID-19, many text messages were sent to all citizens by the government and the Ministry of Health. Information on COVID-19 from the WHO was also translated and propagandized through national news on television. Recently, customers have usually purchased vitamins, dietary supplements, antiseptics, and hand sanitizers. This result showed that the knowledge involving COVID-19 prevention of the public was fairly good and activities involving propagandizing COVID-19 prevention of the government may be effective.

Community pharmacists can take an important part in disseminating COVID-19 knowledge to the public. Roughly 89% of Vietnamese pharmacists told that customers asked them about topics involving COVID-19 (such as the ways of viral transmission, symptoms, and preventative measures). In addition, 92.5% of pharmacists thought that it is necessary to collect the information of customers purchasing medicines treating cough, fever, and flu. This activity can help health agencies to contact people with suspected COVID-19. At present, the Hanoi Department of Health required all pharmacists to collect information about customers purchasing the aforementioned medicines to trace and contact them if necessary. These beneficial activities played a considerable part in bringing about impressive achievements in the battle against the COVID-19 pandemic in Vietnam.

During the period of the COVID-19 outbreak, pharmacists were equipped with face masks and hand sanitizers. At many medicine outlets, glass shields were installed to restrict the spread of droplets from saliva/nose when pharmacists directly communicated with customers. Hand sanitizers were also put at the doors of medicine outlets, and purchasers were encouraged to use them before entering the outlets. These useful activities contributed to protecting both pharmacists and customers. However, 47.9% of pharmacists conceded that they communicated with customers when at least one person was not wearing face masks in the last three months. The main reason is that pharmacists forgot to use face masks. In Turkey, 72.6% of pharmacists said that they did not wear any kind of mask [30]. In Lebanon, 30% of pharmacists rarely worn masks [15]. There is no denying that continually wearing face masks for many hours can render anyone uncomfortable. When medicine outlets were devoid of customers, pharmacists usually took off their face masks. In case of not wearing face masks, Vietnamese pharmacists could be still protected since 86.3% of medicine outlets had fixed glass shields which can assist in reducing the capacity of viral contamination.

To prevent the transmission of the COVID-19 virus, Vietnam had many useful and practical remedies, such as isolating infected individuals, tracing and quarantining their contacts. From April to June 2020, schools were closed and activities for large crowds (such as festivals, conferences) were canceled. Citizens were encouraged to stay at home to minimize exposure and viral transmission. More importantly, face masks and hand sanitizers have been highly encouraged to be used. To hinder the capacity of COVID-19 spread from other countries, several rigorous measures were imposed, including a temporary suspension of entry of all foreigners who have come from or transited through COVID-19 affected areas, and a new mandatory regulation that all incoming travelers to Vietnam have to be quarantined at centralized facilities for 14 days [39, 40]. With good knowledge about COVID-19, Vietnamese pharmacists could bear numerous responsibilities and make a considerable contribution in the battle against the COVID-19 pandemic.

Limitations

This national survey is the first paper-based study conducted to investigate the KAP of pharmacists about COVID-19 in Vietnam with a large sample size. Many effective measures against the spread of this perilous virus mentioned in this article can be applied in other countries. Most of the recent KAP studies involving COVID-19 were online surveys. A paper-based study has several following strengths: generate higher response rates than an online survey, easily and suitably approach various kinds of respondents who are not technology savvy. However, this research has some limitations. Besides the lack of human resources, there were difficulties in data collection. Social distancing was employed two times in Vietnam in April and July of 2020 due to the discovery of many COVID-19 patients in metropolises. Hence, the time for data collection was quite long and the number of surveyed pharmacists in some provinces was low. Furthermore, questions about COVID-19 knowledge only focused on three topics: ways of COVID-19 transmission, symptoms, and prevention. The results may not reflect the comprehensive knowledge of pharmacists about this pandemic.

Conclusions

The knowledge, attitude, and practices of Vietnamese pharmacists about COVID-19 were good. There are many practical measures to curb viral contamination at medicine outlets and protect both pharmacists and medicine purchasers. However, pharmacists should restrict forgetting to wear face masks in communication with medicine purchasers. Besides, health agencies should have solutions to enhance knowledge for pharmacists, thereby guaranteeing that among provinces and education-level groups, there is no significant difference in the COVID-19 knowledge of pharmacists.

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13 Apr 2021

PONE-D-21-08000

Knowledge, attitude and practices of community pharmacists regarding COVID-19: a paper-based survey in Vietnam

PLOS ONE

Dear Dr. Dinh,

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

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We look forward to receiving your revised manuscript.

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Bing Xue, Ph.D.

Academic Editor

PLOS ONE

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For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

4. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants.

Please ensure you have provided sufficient details to replicate the analyses such as:

a) the recruitment date range (month and year),

b) a description of any inclusion/exclusion criteria that were applied to participant recruitment,

c) a table of relevant demographic details,

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e) a description of how participants were recruited, and

f) descriptions of where participants were recruited and where the research took place.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: No

**********

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

Reviewer #1: No

Reviewer #2: I Don't Know

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

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

Reviewer #1: The manuscript is an excellent topic within this time we are living in. It discusses the KAP of COVID-19 in Vietnamese pharmacist. The sample size is quite big although the different backgrounds of provinces can be a source of misrepresentation of the sample.

I have added my notes to the attached PDF file, but I would like to highlight two points of mine:

1) would the authors consider performing a regression analysis of independent variables to check which of these factors is affecting the pharmacists' knowledge the most?

2) would the authors clarify the difference between different provinces and different health professions a bit further.

please check the attachment

Reviewer #2: This paper discusses Vietnamese pharmacists’ knowledge, attitude and practices regarding the COVID-19 pandemic through administering a national paper-based survey. There were 1,023 responses that were analyzed to look at the demographics, knowledge, attitudes, and practices with patients through the studies time frame (June to August 2020). The authors analyzed the responses based on descriptive statistics to gather the results. There were several typos and grammatical issues, the sentences’ structure was confusing at times making it hard to keep a logical flow of thought. There were major issues with the manuscript, for example:

1. There is no report on the response rate from all pharmacists who were given the survey

2. There was a majority of female respondents and no analysis was done to show if this was a confounder.

3. Authors attributed Vietnam’s unique low number of COVID cases/deaths to two reasons “copious doctors and nurses have strongly fighted the uphill battle in the frontline. In addition, drugstores are commonly a reliable and first place for citizens to take advice about ailments”. The reviewer is not sure how Vietnamese doctors and pharmacists are achieving significantly better outcomes than their global counterparts who can claim are doing the exact same measures.

4. What does the P values listed in Table 3 signify?

5. In looking into attitudes and practices of pharmacists, the survey included mainly non-reliable sources like other colleagues, internet and media, it didn’t include any scientific primary or secondary literature sources, WHO reports, even governmental health agencies. The authors called it “good knowledge” in line 181.

6. The authors did not elaborate in the results or discussion why there was a question in the survey about the pharmaceutical products usually purchased in drugstores.

7. Table 4, C14: the reviewer is not sure of the meaning (or legality) when the authors mention asking patients about “medical declaration” when they purchase cold and flu medicine.

8. Line 150, 151 mentions statistics about Iran with two different percentages.

9. Line 155: What do authors mean by “possessing many nimble and proficient authorities”?

10. Line 170-171: The authors did not offer adequate explanation for their results on why assistant pharmacists with 3 years of training scored higher in COVID-19 knowledge than “Uni” with 5 years training, mentioning that “it seems that they (Unis) don’t care much about issues in the community in comparison with Col pharmacists”!

11. The reviewer thinks the statement in line 220 on how paper surveys “approach various kinds of respondents who are not technology savvy (like old people)” is considered ageism and should be modified or removed.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-21-08000_reviewer_RA.pdf

Click here for additional data file.

27 May 2021

Journal Requirements

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

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

We endeavored to revise mistakes in our manuscript.

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Upon resubmission, please provide the following:

• The name of the colleague or the details of the professional service that edited your manuscript

• A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

• A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

We strived to correct typos and grammar.

In addition, Ms. Chi Nguyen Phuong, a Research Ph.D. Student from the University of Groningen, Netherlands, assisted us in language editing.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

The original questionnaire written in Vietnamese was added in the Supporting Information (S1 Questionnaire).

The pre-test and validation of our questionnaire were added on page 5 (lines 93 - 98).

4. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants.

Please ensure you have provided sufficient details to replicate the analyses such as:

a) the recruitment date range (month and year),

b) a description of any inclusion/exclusion criteria that were applied to participant recruitment,

c) a table of relevant demographic details,

d) a statement as to whether your sample can be considered representative of a larger population,

e) a description of how participants were recruited, and

f) descriptions of where participants were recruited and where the research took place.

Information on the aforementioned requirements can be found on pages 5 - 7 (lines 92 - 124).

Review Comments to the Author

Reviewer #1

The manuscript is an excellent topic within this time we are living in. It discusses the KAP of COVID-19 in Vietnamese pharmacist. I have added my notes to the attached PDF file, but I would like to highlight two points of mine:

1. Would the authors consider performing a regression analysis of independent variables to check which of these factors is affecting the pharmacists' knowledge the most?

We used the analysis of covariance (ANCOVA), a general multivariate model to identify factors associated with pharmacists’ knowledge scores.

The model reported in Table 4 was the best model chosen by using the Bayesian Model Averaging method (packages BMA and BAS in R software version 4.0.4).

2. Would the authors clarify the difference between different provinces and different health professions a bit further.

We added some information and explanations for these results in the Discussion section (lines 222 - 253).

3. Could the difference in scores be due to years of experience? Regression analysis of different independent variables affecting knowledge score would be a good tool to find out.

When working experience, a continuous variable, is divided into five subgroups, there are differences in knowledge scores among subgroups: less than 5 years, 5-to-9, 10-to-14, 15-to-19, and ≥ 20 years (p < 0.001) (Table 3). However, in the multivariate linear model (Table 4), this factor was excluded because there is a strong relationship between the age and the working experience of pharmacists in medicine outlets (p < 0.001, Spearman’s rank correlation). We used the Bayesian Model Average method for selecting the best model (income variables include age, gender, education level, working experience, and residence). The results from this model show that the knowledge score was significantly associated with pharmacists’ age, education level, and residence (p < 0.001).

4. Line 124: Sometimes there are confusions about what is meant with "functional foods" and some might use the term "nutraceuticals”. Can the authors give a clear definition of what is meant with "functional foods" or to give examples in order to clarify.

We used “Dietary Supplements” to supersede “Functional foods”. The definition of dietary supplements was added at the end of Table 5.

In 2014, the Vietnam Ministry of Health published a Circular regulating the management of functional foods. The definition of the dietary supplement was taken from this Circular. https://vanbanphapluat.co/circular-no-43-2014-tt-byt-regulating-the-management-of-functional-foods

5. This study included dentists. I believe that there are Jordanian studies about pharmacists. The other referenced studies within this paragraph includes nurses and healthcare workers and not pharmacists. The comparison would be better represented if done among studies including pharmacists.

References involving healthcare workers not pharmacists were removed.

In addition, many previous studies on pharmacists were added [reference 15 - 30].

6. Results (line 99 - 104): Sentences can be clarified. Add numerical percentage for clarity.

Line 158 – 159, 179 - 184: Paraphrase the sentence to clarify.

Line 186 – 187, 211 – 212: Could "not inconsiderable" be stated as considerable. The double negatives are confusing.

We revised these mistakes.

Reviewer #2:

This paper discusses Vietnamese pharmacists’ knowledge, attitude and practices regarding the COVID-19 pandemic through administering a national paper-based survey. There were 1,023 responses that were analyzed to look at the demographics, knowledge, attitudes, and practices with patients through the studies time frame (June to August 2020). The authors analyzed the responses based on descriptive statistics to gather the results. There were major issues with the manuscript, for example:

1. There is no report on the response rate from all pharmacists who were given the survey.

This information can be found in lines 108 - 110.

2. There was a majority of female respondents and no analysis was done to show if this was a confounder.

What does the P values listed in Table 3 signify?

We used the analysis of covariance (ANCOVA), a general multivariate linear model, to identify factors associated with the knowledge scores of pharmacists. The model was chosen by using the Bayesian Model Averaging method. The old Table 3 was removed. New results can be seen in Table 3 and Table 4.

3. Authors attributed Vietnam’s unique low number of COVID cases/deaths to two reasons “copious doctors and nurses have strongly fighted the uphill battle in the frontline. In addition, drugstores are commonly a reliable and first place for citizens to take advice about ailments”. The reviewer is not sure how Vietnamese doctors and pharmacists are achieving significantly better outcomes than their global counterparts who can claim are doing the exact same measures.

We revised this mistake. We listed some possible reasons explaining why the COVID-19 confirmed cases and deaths in Vietnam were low. We did not mean to compare the roles and achievements among health workers or countries. We are truly sorry for this misunderstanding.

4. In looking into attitudes and practices of pharmacists, the survey included mainly non-reliable sources like other colleagues, internet and media, it didn’t include any scientific primary or secondary literature sources, WHO reports, even governmental health agencies. The authors called it “good knowledge” in line 181.

We added some information on pages 14, 19, and 20.

In the data collection form, for questions that we think that pharmacists can have other answers to (such as the question about sources of COVID-19 information), there are some blank rows in which pharmacists can write their additional answers.

In districts/provinces, community pharmacists are required to participate in online groups (on apps, such as Messenger and Zalo). These online groups are sites where pharmacists can share their news and experience, and health agencies can directly and quickly send accurate information on COVID-19 to all pharmacists. In addition, monthly, health agencies commonly organize meetings/courses to enhance the knowledge and practices of pharmacists.

In Vietnam, in fact, due to the language barriers, a majority of pharmacists only access sources of COVID-19 information spoken or written in Vietnamese. WHO reports and scientific literature sources spoken or written in English will be translated and propagandized through national news on television (by the government and health agencies). In addition, Facebook is extremely popular in Vietnam. The government and health agencies have some official pages on Facebook (for example https://www.facebook.com/tintucvtv24/), and accurate and reliable information can be disseminated to not only pharmacists but also the public. For online newspapers, the government has the website “vnexpress.net”. Everyone can find news and related information on COVID-19 from these sources. Last but not least, information on COVID-19 was strictly controlled by the government. For example, if a person posts inaccurate or controversial information on Facebook, he/she will be quickly fined.

Each person has their favorite sources to seek information they need. We think that people aged 18 and older (especially pharmacists) have to know how to distinguish between inaccurate and reliable information. Whether the sources were reliable or not, our results showed that 93.4% of interviewed pharmacists had good knowledge about COVID-19.

5. The authors did not elaborate in the results or discussion why there was a question in the survey about the pharmaceutical products usually purchased in drugstores.

We added some information in lines 189 - 191, 269 - 274. Vitamins and dietary supplements can be used for boosting the immune system. Antiseptics and hand sanitizers can be used for COVID-19 prevention as per the recommendations of the Vietnamese Ministry of Health.

In the period of time of COVID-19 outbreak, the fact that these products were usually purchased showed that the COVID-19 prevention knowledge of the public was fairly good and activities involving propagandizing COVID-19 prevention of the government may be effective.

6. Table 4, C14: the reviewer is not sure of the meaning (or legality) when the authors mention asking patients about “medical declaration” when they purchase cold and flu medicine.

We revised this mistake. This is a translation mistake when we wrote the first draft. The phrase “medical declaration” was superseded by “taking notes”. For this question, we only wanted to ask about the attitude of pharmacists (not the practices). Several symptoms the same as COVID-19 contamination (such as cough and sore throat) can be omitted by patients if these symptoms are mild. Taking notes about the information (address, phone number) of customers purchasing medicines treating cold and flu can assist health agencies to trace and contact people with suspected COVID-19. In fact, at present, in Hanoi, the Department of Health required all pharmacists to collect information on these customers to contact them if necessary. In addition, everyone can access and easily do their medical declarations on the website of the government when necessary (only about 3 minutes). Citizens are recommended to do their medical declarations if suspecting of being infected with the COVID-19 virus.

7. Line 150, 151 mentions statistics about Iran with two different percentages.

Line 155: What do authors mean by “possessing many nimble and proficient authorities”?

We revised this mistake.

8. Line 170-171: The authors did not offer adequate explanation for their results on why assistant pharmacists with 3 years of training scored higher in COVID-19 knowledge than “Uni” with 5 years training, mentioning that “it seems that they (Unis) don’t care much about issues in the community in comparison with Col pharmacists”!

The explanation for our results on education level can be seen in lines 222 - 239.

9. The reviewer thinks the statement in line 220 on how paper surveys “approach various kinds of respondents who are not technology savvy (like old people)” is considered ageism and should be modified or removed.

We revised this mistake and removed the example “old people”.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Jun 2021

PONE-D-21-08000R1

Knowledge, attitude and practices of community pharmacists regarding COVID-19: a paper-based survey in Vietnam

PLOS ONE

Dear Dr. Dinh,

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

Please submit your revised manuscript by Aug 13 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Bing Xue, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

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

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: (No Response)

Reviewer #2: Thank you for addressing most of the previous comments. I have two more comments due to the changes in the manuscript:

1. The statement "In addition, a majority of Uni pharmacists who directly sell medicines in medicine outlets are graduates from private universities of pharmacy" is not supported by any reference. This information is also not captured in the survey and cannot be verified. Accordingly the explanation in lines 232-237 should be removed.

2. Table 3 in the changes tracked version contain the name of the provinces which matches the data analysis. This got dropped in the cleaned up version of the paper! Please make sure the final version has the breakdown of the region by the provinces.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

2 Jul 2021

Journal Requirements

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

The first reference (from WHO) was removed and another article with similar information was cited.

Regarding the second, the third, and the 6th references, some new information involving COVID-19 confirmed cases, deaths (in Vietnam and global), and COVID-19 vaccines was updated in the revised manuscript.

We checked twice whether or not articles were retracted (in Pubmed and Google Scholar). If any reference should be removed, please let us know.

Review Comments to the Author

Reviewer #2:

1. The statement "In addition, a majority of Uni pharmacists who directly sell medicines in medicine outlets are graduates from private universities of pharmacy" is not supported by any reference. This information is also not captured in the survey and cannot be verified. Accordingly the explanation in lines 232-237 should be removed.

Although that is the reality in our country, we do not have any references to cite. Some information in lines 232-237 is quite sensitive. Therefore, we removed these lines. Thank reviewer #2 for this practical advice.

2. Table 3 in the changes tracked version contain the name of the provinces which matches the data analysis. This got dropped in the cleaned up version of the paper! Please make sure the final version has the breakdown of the region by the provinces.

We added the names of provinces for each region in Table 3. In Table 3, we did not analyze the COVID-19 knowledge scores of pharmacists in each province because they were presented in Figure 1 with box plots and lines 213-220.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

16 Jul 2021

Knowledge, attitude and practices of community pharmacists regarding COVID-19: a paper-based survey in Vietnam

PONE-D-21-08000R2

Dear Dr. Dinh,

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

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

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Bing Xue, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #2: All comments have been addressed

**********

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

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

Reviewer #2: I Don't Know

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: No

21 Jul 2021

PONE-D-21-08000R2

Knowledge, attitude and practices of community pharmacists regarding COVID-19: a paper-based survey in Vietnam

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