Although assessing the extent of community pharmacists’ involvement in health promotion activities in the prevention and management of NCDs is critical in tackling the increasing prevalence of NCDs and its associated burdens, comprehensive evidence is lacking in Ethiopia. Because community pharmacists have varying public health roles from their primary dispensing service to a more comprehensive involvement in healthcare issues and are recognized throughout the world [37, 38], assessing their level of involvement and barriers in health promotion activities for NCDs would be vital for taking measures. Thus, this community-based multicenter study explored the willingness, involvement, and barriers of community pharmacists in health promotion activities for the prevention and management of NCDs at CDROs in selected cities in Northwest Ethiopia. Consequently, this study showed that more than half of the community pharmacists had a high level of involvement in health promotion activities. The findings also revealed that differences in educational status and the number of clients per day were associated with the level of involvement. In this study, the lack of appropriate working areas in the CDROs, increased workload, lack of time, insufficient guidance resources and training, and low management support were the most commonly reported barriers.

In this study, more than half of the community pharmacists had a high level of involvement in health promotion for the prevention and management of NCDs. The results highlighted that a most community pharmacists were willing to provide health education and health promotion, and a majority of the participants also agreed that health promotion activities are responsibilities for the pharmacy profession. This indicates that community pharmacists are among the healthcare professionals involved in promoting public health priorities and issues. Currently, community pharmacists provide wide public health services from drug dispensing to medication therapy management, child immunization, health education, screening of diabetes, advice on health risks such as smoking cessation, weight management, blood glucose and blood pressure monitoring, osteoporosis, substance abuse, response to symptoms, and general medication and health information [21, 25, 28, 36]. Consistent with other studies [21, 26, 28, 39,40,41,42,43], in this study, community pharmacists were involved in health promotion activities for the prevention and management of NCDs. Because community pharmacists believe that NCDs are largely associated with obesity, a sedentary lifestyle, and an unhealthy diet, they agreed to give more attention to healthy lifestyle modifications, and they are also involved in lifestyle modification promotion activities such as healthy weight reductions with low-calorie non-weight-bearing diets, promotion of alcohol consumption restrictions, healthy physical activity promotions, and promotion of cigarette smoking cessation, which could decrease the potential risks of NCDs. The result highlighted the fact that most pharmacists have good involvement in NCD health promotion activities for the prevention and management of these disorders. This may implicate those pharmacists have enormously increased their awareness and attitudes about the public’s healthcare priorities and the risks of NCDs. As a result, they are willing to get involved in health promotion activities aimed at preventing and managing NCDs.

This study implies that the majority of community pharmacists were involved with various degrees of involvement, from being involved to being very involved, in most of the important health promotion activities in the prevention and management of NCDs. The reason might be that those pharmacists have been involved in patient education and counseling approaches following the new development of the country’s pharmacy education curriculum, which has undergone a paradigm shift from traditional dispensing-only practices to patient-oriented approaches. Herewith, pharmacists working in CDROs have been graduated after being prepared with various clinical cases and scenarios, along with patients’ approaches and communication skills. In this study, most of the participants also agreed that the curriculum is adequate for providing health care, and they also agreed that health promotion activities are the responsibility of pharmacists. Thereby, this study showed that most of the community pharmacists had a better level of involvement in most of the health promotion activities in the prevention and management of NCDs. Conversely, fewer pharmacists were trained regarding health promotion activities related to the prevention and management strategies of NCDs, which need to be improved to maximize the effectiveness of pharmacists in these services. Therefore, community health authorities, national NCD STEPS authorities, and other stakeholders could have been involved in taking initiatives and endorsements on training and regularly promoting the educational background of the pharmacists. Collaborations between CDROs, health authorities, and relevant educational training centers could be encouraged with the goal of involving community pharmacists in initiatives and workshops promoting health priorities such as NCDs.

In contrast to previous studies [44, 45], this study showed that pharmacists’ involvement in promoting alcohol consumption and smoking cessation was much higher. These findings may indicate that the pharmacists in this study may have observed that an increase in the sedentary lifestyles of the community became their concern and motivated them to become involved in promoting the risks of unhealthy alcohol consumption and smoking habits. Furthermore, in contrast with earlier studies [44, 46], pharmacists’ involvement was low in some health promotion activities, such as promoting the consumption of cholesterol-free and lowering diets, increasing the consumption of soluble fiber, participating in screening and measuring weight, blood pressure, and glucose levels, and monitoring patients’ treatment responses. Lower involvement levels would imply that community pharmacists were not inclusively involved in all basic points concerning the prevention and management of NCDs. This might be because of a gap in skills in some selected areas or the poor commitment of the pharmacists in these areas. But this was correlated with previous studies conducted on the counseling involvement of pharmacists in cardiovascular disorders [25] and metabolic syndrome [26].

The current study also assessed the potential predictor variables linked to the health promotion activities of community pharmacists in the prevention and management of NCDs. Consequently, the finding showed that those pharmacists graduating with a bachelor’s degree and above were more likely to have a high level of involvement in the provision of health promotion services compared with those who were druggists. An independent samples t-test revealed that pharmacists with a bachelor's degree or higher had higher mean health promotion involvement scores than pharmacists with a lower educational level. This study correlated with an earlier study regarding pharmacists’ involvement in preventing cardiovascular diseases [25]. The reason for these disparities could be that pharmacists with a higher level of education may have more up-to-date knowledge and the ability to participate in health promotion activities than pharmacists with a lower level of education. They could also easily access the updated resources and understand how they could be implemented and changed in practice, which helped them become highly involved in health promotion activities for the prevention and management of NCDS. In addition, an earlier survey of bachelor’s degree pharmacy students regarding their health promotion activities while on attachment also revealed that professional training, knowledge, and standard guidelines for the services are important [33]. But in this study, most of the pharmacists had a lower educational background. Therefore, pharmacists would be recommended to upgrade their educational backgrounds to provide better healthcare services in the area of public health priorities such as health promotion aiming to prevent and manage NCDs. Besides their academic education, they must also increase their knowledge, skills, and confidence through training in health promotion services.

Moreover, this study revealed that community pharmacists who served lower numbers of clients per day were found to be more likely to have high involvement in health promotion activities in the prevention and management of NCDs. This could be justified by the fact that those who serve more clients per working day might be busy with other duties and dispensing services. Their counseling services may also go through traditional medicine dispensing rather than adequately engaging in health promotion activities and counseling. The finding may also imply that community pharmacists would serve an optimal number of clients in their working day to provide better counseling, health promotion activities, and healthcare services to patients. Furthermore, pharmacists who worked shorter working hours (8 h/day) in CDROs were found to be less likely to participate in health promotion activities than pharmacists who worked longer working hours (> 8 h/day). This might be because pharmacists working shorter hours may not have better access to clients, and they may use their longer working hours for other duties that are not related to healthcare activities. This finding may indicate those pharmacists could be attached to the optimal number of clients for sufficient hours per working day to increase their healthcare activities in public health priorities like NCDs, which require pharmacists’ involvement.

Although most of the participants had high levels of health promotion involvement in most important health services for the prevention and management of NCDs, many barriers were reported. Community pharmacists reported different types of barriers to being involved in health promotion activities, which need to be addressed to optimize the effectiveness of pharmacists in health promotion activities for the prevention and management of NCDs. Consistent with previous studies [19, 21, 25, 29, 44, 47], the lack of an appropriate working area in the CDROs, increased workload/lack of time, insufficient guidance resources and training, and low management support were the most commonly reported barriers. Additionally, a lack of coordination with other healthcare providers is also an important reported barrier that limits the active involvement of pharmacists in public healthcare priorities like promoting NCDs [19]. Moreover, a study conducted on pharmacy students who were in community pharmacy practice revealed that clients’ lack of time and interest, the absence of a guideline for health promotion services, a lack of training and/or knowledge, and a lack of confidence by pharmacists were the main barriers perceived to hinder the provision of health promotion services. These findings indicate that the barriers are common and similar across different study settings. The findings also suggest that these barriers are multifactorial and related to pharmacy professionals’ knowledge, attitudes, and skills; the structural systems of healthcare; and the clients themselves. Most of the reported barriers are also preventable and modifiable. Therefore, a system could be designed to minimize the effects of barriers and boost the effectiveness of pharmacists in health promotion services. In addition to formal education they received, pharmacists must improve their knowledge, skills, and confidence through formal and informal life-long training in health promotion services. It can reduce the barriers related to pharmacists’ knowledge and skills, and the educational gaps. In particular, the provision of health promotion services for NCDs is crucial because their burden has been increasing in low- and middle-income countries, including Ethiopia. As a result, minimizing the effect of barriers to health promotion practices is among a multifactorial intervention that could be important to tackle the significant burdens associated with NCDs.

Generally, this study has highlighted the levels and extent of involvement and barriers of community pharmacists in health promotion activities for the prevention and management of NCDs. These roles range from promoting lifestyle modification by maintaining a healthy weight with low-calorie diets, promoting physical activities, alcohol consumption restrictions, salt restrictions, and cigarette smoking cessation, to screening and monitoring of weight, blood pressure, glucose levels, and treatment responses, and promoting medication adherence. Therefore, this study may indicate that the rapid rise in the prevalence and burden of NCDs in developing countries like Ethiopia is an urgent call for multisectoral and multidirectional prompt prevention to minimize associated burdens. In fact, promoting healthy behavior among the public is a key population strategy for reducing the burden of NCDs, and this may also be the driving point for community pharmacists to deliver NCD prevention and management.

The current study has some limitations. Initially, the findings from this study may not be generalized to all community pharmacists in the country, particularly in rural settings. Data collection may be influenced by participants' honesty and faith in the outcome, resulting in an overestimation or underestimation of current practices and community pharmacists' involvement in NCD health promotion activities. Therefore, the findings of this study should be interpreted with caution. Despite this limitation, this study assessed the extent and level of involvement of community pharmacists in health promotion services in the prevention and management of NCDs at CDROs in selected cities of Northwest Ethiopia, where there is a need for evidence in the area. We hope this study may add a body of knowledge to the existing literature gap in the area, and we believe it will inform policymakers to integrate CDROs with health promotion practices and nationwide efforts to tackle the increasing prevalence of NCDs and their associated burdens in the country. Finally, we recommend that future research investigate the attitudes and beliefs of pharmacists regarding their involvement in the provision of health promotion for noncommunicable diseases in the study settings, which according to existing research, has proven to be very significant.