As the leading cause of morbidity and mortality worldwide, medication errors are becoming a global issue (1, 2). It is defined as any error during the medication use process whether in the planning or in the execution of that plan (2). Medication error threats patients’ safety, and the risk of medication error becomes higher in chronic diseases patients due to comorbidities and polypharmacy (2, 3).

The risk of medication error can be reduced effectively through a mechanism of medication therapy management (MTM) (1, 4). Its implementation follows a model framework that comprises five key elements: medication therapy review, medication-related action plan, interventions and referrals, and documentation and follow-up (5). In 2017, Indonesia adopted the MTM program to improve the quality of chronic disease care (6). In collaboration with the Social Insurance Administration Organization (BPJS), the government has piloted the program at several community health centers (CHCs), which serve as gatekeepers for patients before referral to hospitals for further treatment (6–9). Studies have shown the positive effect of this pilot project of MTM on clinical and humanistic outcomes (6–8). These findings are consistent with those of many studies that have demonstrated the benefits of MTM on clinical, economic, and humanistic outcomes in other countries (5, 10).

The implementation of MTM requires the qualification of all health professionals, including pharmacists (1). Pharmacists’ competency, which includes knowledge, attitude, and practice (KAP), contributes to MTM success (11, 12). Therefore, the assessment of KAP regarding MTM is essential to the strategic plan for effective program implementation (10). To the best of our knowledge, studies on the KAP toward MTM and its factors in Indonesia are limited. Only one study assessed Indonesian pharmacists’ perceptions regarding intention and readiness to provide MTM services (13). The study also did not report the coverage of its respondents. This study aimed to assess the level of KAP regarding MTM among pharmacists working at CHCs and its associated factors and investigate pharmacists’ perceptions of the barriers and facilitators of MTM provision in the future. The study was a national survey designed to obtain a better overview of the issue.

This study followed the Checklist for Reporting of Survey Studies (CROSS) guideline for its reporting (14). The CROSS checklists of this study are presented in Supplementary material (Supplementary Table S1).

Understanding the level of KAP of pharmacists as key providers of MTM services is crucial to the program implementation success. This study shows that approximately 75% of pharmacists in CHCs had a high level of knowledge about MTM. Nonetheless, less than 58% of pharmacists had a positive attitude and practice toward MTM.

Regarding knowledge, most respondents understood the scope of therapies covered in MTM and could characterize all five core elements, especially regarding documentation and personal medication records. However, respondents appeared to need more understanding of the comprehensive and targeted medication therapy review, medication-related action plans, and interventions. Medication therapy review is not a new practice for pharmacists in CHCs, as stated in the Technical Guidelines for Pharmaceutical Service Standards at Community Health Center (33). Nevertheless, the term comprehensive and targeted review might not be familiar. A study in Jordan has reported that pharmacists were knowledgeable about medication therapy reviews as MTM elements, but they did not report whether pharmacists were knowledgeable about the two types of reviews involved in MTM (28).

In addition, less than 58% of the respondents showed a positive attitude toward MTM services. Respondents generally agreed on pharmacists’ role in all five core elements of the MTM. Respondents also agreed that the provision of MTM services is a unique opportunity to expand the role of pharmacists in patient care. KAP studies on MTM in other countries, such as Saudi Arabia, Malaysia, and Jordan, showed similar results (1, 18, 28). However, we were concerned about the difference between the proportion at the level of knowledge and the proportion of the attitude regarding MTM. The study respondents showed an almost balanced proportion of positive and negative attitudes. This indicates that some respondents were uncertain about MTM implementation, even though they already understood the concept (34). This is in line with the finding of the study by Ahamad and Ariffin (35) on KAP regarding sustainable consumption among students in Malaysia. In certain concepts, experience is more influential than textual knowledge toward attitude (35).

In this study, we measured practices toward MTM based on pharmacists’ daily activities that support MTM implementation. Most pharmacists reported positive practices toward MTM, including interprofessional collaboration in interventions and referrals and a specific review regarding the therapy of patients with drug-related problems. However, there was an almost equal distribution between the positive and negative practice categories. Respondents reported not being accustomed to designing and implementing strategies to address or prevent treatment-related issues, documenting services, or evaluating medication progress. It is in line with the study by Wijaya et al. (26) that found pharmacists at CHCs were lack of skill to manage patient compliance and review patients’ therapy (26).

Further information about practices could provide more insights, including pharmacists’ willingness to provide MTM services (88%), their interest in attending MTM training (92.55%), and their preference for face-to-face training sessions (58%). The rates of willingness to become a provider compared with interest in training indicated the need for educational programs to improve pharmacists’ readiness. The results were similar to those of a study of community pharmacists in Lebanon (36). In addition, the proportion of respondents who felt that they had enough time to implement MTM was higher among pharmacists working in inpatients than in outpatient settings. It may be related to the number of staff and workload at inpatient CHCs (37). Conversely, fewer pharmacists working in inpatient settings reported the availability of private counseling areas/rooms. The counseling session will be conducted in an integrated room if a private room is not available in the CHC (37).

In terms of attitudes, men tend to have a positive attitude toward MTM compared with women. There may be a burnout tendency in women due to the increased workload that they perceive when providing MTM services (38). Respondents working in inpatient settings also tend to have a more positive attitude toward MTM, which could be related to their familiarity with the services. Pharmacists in these settings routinely performed medication reviews, therapy evaluations, and ward visits (33). Similarly, experience in providing MTM services becomes a factor associated with pharmacists’ KAP. A systematic review suggests that factors increasing direct involvement in patient-oriented or MTM services can improve the understanding of MTM (10).

The study found that some provinces had significant associations, not only with high levels of knowledge but also with more negative attitudes and practices toward MTM. It might be related to the regional policies of health organizations/facilities, especially those directly related to pharmacists’ KAP, such as policy on training, the scope of responsibilities, and guidelines (39). In addition, pharmacists with ≤10 years of practice had more positive practices toward MTM. Similarly, Athiyah et al. (40) reported lower practice scores for pharmacists working for more than10 years. It might be related to the tendency to feel exhausted and burned out from prolonged work (40). Moreover, the provision of the drug of the government program was associated with MTM practice. Although not significant (p = 0.060) if considered alone in the bivariate analysis, this factor became significant (p = 0.015) when simultaneously analyzed with other variables. It might occur due to mediation (collinearity) or moderation (41).

The findings of the exploratory study gave some insights into the facilitators and barriers to MTM implementation perceived by the primary providers of MTM. Chronic disease conditions, MTM features, and current practices were facilitators of MTM. On the contrary, the lack of staff, collaboration between professions, pharmacist knowledge, patient cooperation, adequacy of facilities/drug supply/documentation systems, stakeholder support, and patient compliance could hinder MTM implementation. Generally, the health facility/organization factor became the main barrier for pharmacists. Pharmacists in the studies in other countries perceived similar barriers to MTM, including the lack of time, staffing, compensation, and training (10). Fewer identified facilitators indicated that pharmacists appeared to emphasize barriers and overlook facilitators. A study on maternal health evidence products in low-and middle-income countries suggested that discovering facilitators is more challenging, especially during the initial stages of program implementation (42).

According to the categories in the health worker factor, pharmacists were worried about unfavorable knowledge, attitudes, and skills that might impede the provision of MTM. The study in Jordan raised similar concerns about the challenges in implementing pharmacists-provided MTM, including those related to pharmacists’ skills in communicating with patients and collaborating with other health workers (28). Since medication management becomes a shared professional responsibility to ensure optimal drug safety and patient care (43), health workers should collaborate well. Studies have proposed designing a particular system and process to facilitate effective interaction and communication between pharmacists, doctors, and other health workers (43, 44). Thus, the mastery of the medical coding of diseases (International Classification of Diseases), particularly the 144 illnesses covered by BPJS, is one of the additional competencies for pharmacists in Indonesia to facilitate effective communication with doctors.

Based on the practice settings, pharmacists working in inpatient settings perceived fewer barriers related to organizational factors. It might correlate with the government regulation about additional resources to improve inpatient capabilities (37). Furthermore, fewer inpatient pharmacists perceived pharmacists’ competencies and collaboration as potential barriers. Pharmacists in inpatient settings are more likely to improve their skills and interprofessional relationship because of their daily practices (37). Based on the MTM experience, pharmacists who have provided MTM services reported more barriers regarding professional collaboration and patient factors. On the contrary, pharmacists without MTM experience perceived more obstacles related to the health facility/organization factor. This is consistent with the results of a study conducted in the United States, which compared barriers between pharmacists who would and were providing MTM services. The study found that those who would provide MTM perceived the lack of staff and access to medical information, whereas those who currently provide MTM reported compensation (45).

To the best of our knowledge, this is the first thorough evaluation of KAP toward MTM and its predictors among pharmacists in CHCs. The results of this study demonstrated the need to improve pharmacists’ KAP regarding MTM. Information about the predictors of pharmacists’ KAP suggests that interventions should increase pharmacist involvement. The fact that pharmacists preferred face-to-face workshops (59.45%) to online education (32.51%) supports this suggestion. This study also proposes that training should improve collaboration between pharmacists and other health workers and enhance pharmacist communication with patients. This study is also the first national survey involving CHC pharmacists in 28 provinces. Weighting on province variables was intended to make the study results more accurately represent the population of interest. It is an effort to minimize bias caused by non-probability sampling techniques (32).

Furthermore, we demonstrated how pharmacists think about the contribution of organizations/health facilities to the success of MTM implementation. CHC managers must provide adequate staffing or review the workload and responsibilities of pharmacists. CHC managers could set formal steps to enhance health workers’ collaboration, such as communication protocols that integrate pharmacists’ access to medical records (5). In addition, it is essential to ensure that the facilities, drug supply, and documentation systems are adequate and that standard operating procedures, regulations, and program socialization are available.

We propose practical suggestions such as a socialization and education program regarding MTM services before the nationwide implementation. A lack of understanding, for example about comprehensive and targeted review, should be addressed through an educational intervention (26). In addition, training is important to improve pharmacists’ attitude and practice towards MTM. Previous studies in the United States showed that training is effective in improving essential knowledge and attitude for pharmacists in providing patient-care services (46, 47). An intervention should also be designed to enhance pharmacists’ skill to design strategies in resolving drug-related problem, manage patients’ compliance, collaborate with other healthcare professionals, and communicate with patients. To ensure the effectiveness of the training program, this study suggest that pharmacists must be directly involved in the process.

This study has limitations. First, online survey methods are prone to self-selection bias. However, the widespread use of the internet, standardized competence of pharmacists, and participation credit from IAI could minimize the bias. Second, we could not calculate the response rate of the survey. Third, given the cross-sectional design, we could not infer a causal relationship among the factors of pharmacists’ KAP. Finally, the convenience sampling technique prevents generalizability. Nevertheless, participation from the 28 provinces and the application of weighting are considered to make the study results more representative.

Further research focusing on qualitative studies may complete our understanding regarding the KAP of MTM among pharmacists at CHCs. Probability sampling techniques and multivariable weighting (province, practice settings [inpatient and non-inpatient], and CHC accreditation) may be used to yield more representative results. Future studies may also focus on designing an educational intervention to improve pharmacists’ attitude and practice towards MTM. This study may provide valuable insight for program planners about considering health facility/organization factors in the strategy of MTM implementation.

Most respondents had high knowledge of MTM; however, only about half had positive attitudes and practices toward MTM. Gender, practice settings, province of CHCs, years of practice, and experience in MTM services were factors associated with KAP about MTM. Information about factors associated with the KAP level suggests that direct involvement is essential to improve pharmacists’ understanding and view of MTM. Respondents perceived that the chronic disease conditions in Indonesia, MTM service features, and current practices were facilitators of MTM provision. The lack of interprofessional collaboration, staff, pharmacist knowledge, patient cooperation, facilities/drug supply/documentation systems, stakeholder support, and patient compliance were the most common barriers to MTM implementation in the future. A training program is needed to improve the KAP about MTM and develop skills for collaborating with other healthcare professionals and communicating with patients. Qualitative research may further advance our understanding of KAP toward MTM among pharmacists in CHCs.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Health Research Ethics Committee of Universitas Padjadjaran. The patients/participants provided their written informed consent to participate in this study.

FR, SDA, and IMP: conceptualization, resources, and visualization. FR, SDA, WW, and IMP: methodology and writing—review and editing. FR: software, formal analysis, investigation, data curation, and writing—original draft preparation. SDA and IMP: validation. SDA, WW, and IMP: supervision. IMP: project administration and funding acquisition. All authors contributed to the article and approved the submitted version.

This work was supported by Universitas Padjadjaran, Indonesia (grant number: 2203/UN6.3.1/PT.00/2022).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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