Communi y pha macis s’ eadiness o suppo
quali y ca e in ch onic obs uc i e pulmona y
disease managemen
Je on Mucaj1, Be i Dju djic1, Zo ica Naumo ska1, K is ina Mladeno ska1,
Maja Simonoska C ca e ska1
1 Facul y o Pha macy, Ss Cy il and Me hodius Uni e si y in Skopje, 1000 Skopje, Republic o No h Macedonia
Co esponding au ho :
Maja Simonoska C ca e ska (m[email p o ec ed].mk)
Recei ed
11 Augus 2025♦
Accep ed
5 No embe 2025♦
Published
24 No embe 2025
Ci a ion:
Mucaj J, Dju djic B, Naumo ska Z, Mladeno ska K, Simonoska C ca e ska M (2025) Communi y pha macis s’ eadiness
o suppo quali y ca e in ch onic obs uc i e pulmona y disease managemen . Pha macia 72: 1–9. h ps://doi.o g/10.3897/pha ma-
cia.72.e168446
Abs ac
Ch onic obs uc i e pulmona y disease (COPD) equi es ongoing ca e, and communi y pha macis s (CPs) play a key ole in
i s managemen . This s udy assessed CPs’ knowledge, con idence, and p ac ices ela ed o COPD in Koso o. A c oss-sec ional
su ey o egis e ed CPs e alua ed hei knowledge and p ac ices conce ning COPD, co e ing gene al, pha macological, and
non-pha macological aspec s. Da a analysis in ol ed c oss- abula ions and chi-squa e es s (p < 0.05). The sample ep esen ed 9.5%
o Koso o’s CPs (mean age = 39.1 yea s; 63.2% emale). Mos pa icipan s (88.8%) lacked o mal COPD aining. While 84% dispensed
COPD medica ions, only 57.6% el con iden managing he condi ion. Knowledge sco es e ealed gaps: gene al knowledge (mean
= 3.3/8), pha macological (1.42/5), and non-pha macological (2.59/5). Pha macological knowledge was weakes , wi h 60% sco ing
low. Educa ion le el co ela ed wi h gene al knowledge (p = 0.011), and con idence was linked o knowledge (p = 0.0004) and dis-
pensing (p = 0.0003). Subs an ial COPD knowledge gaps among CPs in Koso o unde sco e he need o a ge ed educa ion and
sys em-le el suppo o op imize pa ien ca e.
Keywo ds
Ch onic obs uc i e pulmona y disease, communi y pha macy se ices, educa ion, heal h knowledge and p ac ice, quali y o
heal h ca e
In oduc ion
Ch onic obs uc i e pulmona y disease (COPD) is he
hi d leading cause o dea h wo ldwide, a ec ing nea -
ly 300 million people, wi h p e alence inc easing sig-
ni ican ly a e age 40 (Olo egui-Rod iguez e al. 2022;
GOLD 2023; WHO 2023). I includes ch onic b onchi is,
emphysema, and obs uc i e as hma, ma ked by ai low
limi a ion, in lamma ion, excess mucus, and educed
lung elas ici y (ALA 2023). Common symp oms—dys-
pnea, ch onic cough, spu um p oduc ion, and a igue—
p og essi ely impai pa ien s’ unc ional capaci y and
quali y o li e. Majo isk ac o s include smoking, occu-
pa ional exposu es, and indoo ai pollu ion, especially in
low- and middle-income coun ies (WHO 2023).
Wi hou adequa e managemen , COPD can cause se-
ious complica ions, including in ec ions, ca dio ascula
and me abolic condi ions, psychia ic diso de s, and
Copy igh Mucaj J e al. This is an open access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License
(CC-BY 4.0), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal au ho and sou ce
a e c edi ed.
Pha macia 72: 1–9
DOI 10.3897/pha macia.72.e168446
Resea ch A icle
Mucaj J e al.: Pha macis s’ eadiness o deli e quali y COPD ca e2
malignancies. In e na ional guidelines ecommend com-
bining pha macological ea men s (e.g., b onchodila o s,
co icos e oids, and PDE4 inhibi o s) wi h non-pha -
macological in e en ions such as smoking cessa ion,
accina ion, and pulmona y ehabili a ion.
High-quali y COPD ca e equi es a mul idisciplina y
app oach. Communi y pha macis s (CPs), due o hei ac-
cessibili y, a e inc easingly ecognized as aluable con ib-
u o s o p e en ion, ea ly de ec ion, pa ien educa ion, and
long- e m managemen . S udies show ha pha macis -led
in e en ions can imp o e medica ion adhe ence, inhal-
e echnique, smoking cessa ion, and accina ion up ake
(Van De Molen e al. 2017; Ka le e al. 2020; Condinho
e al. 2021). Howe e , poo adhe ence and inco ec in-
hale use emain common, wi h up o 60% o pa ien s
no ollowing ea men ecommenda ions (K igsman
e al. 2007; Sanduzzi e al. 2014; WHO 2015; Newman
2017; Świą oniowska e al. 2020; Homę owska e al. 2022).
These gaps highligh he impo ance o CPs’ engagemen
in pa ien -cen e ed ca e.
Pha macis -led p og ams ha e posi i ely impac ed
ea men quali y and ou comes (FIP 2019). Pha macis s
also help manage polypha macy, p omo e guideline-based
he apies, and suppo smoking cessa ion and in luenza
accina ion (Klassing e al. 2018; Hudd 2020).
Despi e g owing e idence, CPs’ eadiness o p o ide
COPD ca e emains unde explo ed, especially in e-
sou ce-limi ed egions. Unde s anding hei knowledge,
p ac ices, and ba ie s is essen ial o imp o ing ca e
deli e y and ou comes.
This s udy aims o e alua e he knowledge, expe ienc-
es, and p ac ices o CPs in Koso o ega ding COPD man-
agemen . I explo es he ex en o hei clinical p epa ed-
ness, he a ailabili y o COPD- ela ed se ices, and hei
willingness o engage in pha maceu ical ca e. The s udy
seeks o answe : How well a e pha macis s equipped o
suppo high-quali y COPD ca e, and wha ac o s limi
hei in ol emen in e ec i e managemen s a egies?
Me hods
Resea ch design
A olun a y c oss-sec ional su ey, using a s uc u ed
ques ionnai e, was conduc ed o assess communi y pha -
macis s’ knowledge o COPD managemen and ela ed
p o essional p ac ices in Koso o. The ques ionnai e, o ig-
inally de eloped by Hu e al. (2020), was ansla ed in o
he local language and adap ed by adding con ex -speci ic
ques ions o sui he s udy se ing. I con ained 34 i ems,
including eigh demog aphic ques ions and 26 assessing
knowledge and willingness o p o ide quali y pha maceu-
ical ca e in COPD managemen .
A ocus g oup e ined he ques ionnai e o cla i y and
ele ance (expe e iew by a panel o pha macy p o es-
sionals). In July 2024, a pilo s udy wi h 10 CPs e alua -
ed comp ehension, accep abili y, and comple ion ime.
Pa icipan s p o ided eedback ha helped imp o e he
inal anonymous ques ionnai e. This s epwise de elop-
men ensu ed ha he ques ionnai e app op ia ely cap-
u ed he in ended knowledge domains and was sui able
and eliable o use in he a ge popula ion. The inalized
su ey was dis ibu ed wi h suppo om he Chambe o
Pha macis s o Koso o ia email and closed social media
g oups, eaching CPs ac oss he coun y.
E hics app o al
E hical app o al o he s udy was ob ained om he
E hics Commi ee o he Facul y o Pha macy, Ss. Cy il
and Me hodius Uni e si y in Skopje, No h Macedonia
(No. 02-284/3, da ed 29 Ap il 2024), whe e he idea o
he s udy o igina ed. Subsequen app o al was g an ed by
he E hics Commi ee o he Chambe o Pha macis s o
Koso o (No. 142, da ed 1 July 2024).
Da a collec ion and analysis
Da a we e collec ed ia Google Fo ms (3 Sep embe o
30 No embe 2024). Pa icipan s could op ionally sub-
mi email add esses o ollow-up, wi h ini ial esponses
emaining anonymous. The su ey spanned all egions
o Koso o o cap u e di e se socioeconomic con ex s.
Da a we e expo ed o Excel o cleaning and hen an-
alyzed desc ip i ely using S a g aphics Cen u ion XIX
( ial e sion).
Knowledge assessmen co e ed COPD gene al knowl-
edge ( isk ac o s, symp oms, diagnosis, ea men guide-
lines) (ques ions 15–19; maximum sco e: 8), pha maco-
logical ea men (ques ions 20–24; maximum sco e: 5),
and non-pha macological ea men (ques ions 25–27;
maximum sco e: 5). Sco es we e calcula ed by assigning
+1 o co ec answe s and −1 o inco ec ones, excep
o ques ion 27, whe e esponses we e sco ed as “Yes”
(+1), “No” (−1), and “Some imes” (0). The sco ing sys em
was applied o mi iga e po en ial in la ion o knowledge
sco es due o andom guessing, wi h nega i e poin s o
inco ec answe s ensu ing a mo e accu a e ep esen a-
ion o esponden s’ ue knowledge by balancing co ec
and inco ec esponses and dis inguishing in o med
unde s anding om chance-based selec ions. To explo e
ac o s in luencing sco es, c oss- abula ion analysis was
conduc ed, and s a is ical signi icance was assessed using
he chi-squa e es , wi h p < 0.05 conside ed signi ican .
Resul s
O e iew o socio-demog aphic da a o
he pa icipan s
Unde s anding he socio-demog aphic p o ile o CPs in
Koso o is essen ial o in e p e ing su ey indings on
COPD ca e managemen , as a iables such as age, expe i-
ence, and p o essional se ing p o ide i al con ex .
Pha macia 72: 1–9 3
The EU a e age o communi y pha macies (CPha m) is
app oxima ely 32 pe 100,000 people (GP 2024). As o Jan-
ua y 2022, Koso o had 832 licensed CPha ms, o 52.44 pe
100,000 popula ion, indica ing highe - han-a e age accessi-
bili y. Rega ding CPs, mos EU coun ies epo be ween 58
and 123 pe 100,000 people (Eu os a 2024). By Sep embe
2024, Koso o had 1,478 egis e ed pha macis s, including
1,321 in CPha m, co esponding o 83.26 pe 100,000—plac-
ing Koso o wi hin he EU mid- ange. The inal s udy sample
included 125 CPs (9.5% o he a ge popula ion). The mean
pa icipan age was 39.09 yea s (SD = 10.22), wi h an a e -
age o 13.8 yea s (SD = 9.09) o p o essional expe ience and
11.61 yea s (SD = 7.91) in CPha m p ac ice. Full socio-de-
mog aphic cha ac e is ics a e shown in Table 1.
Table 1. Socio-demog aphic cha ac e is ics o CPs pa icipa ing in he COPD su ey (n = 125).
Cha ac e is ic Ca ego y Pe cen age (%) om su eyed
popula ion 95% con idence in e al (CI%)
Gende Male 36.8 28.3–45.3
Female 63.2 54.7–71.7
Age 20–30 yea s 20 13.0–27.0
31–40 yea s 37.6 29.1–46.1
41–50 yea s 29.6 21.6–37.6
51–60 yea s 7.2 2.7–11.7
61+ yea s 4 0.6–7.4
Geog aphical dis ibu ion P ish ina 48.8 40.0–57.6
P iz en 20.0 13.0–27.0
Fe izaj 11.2 5.7–16.7
Peja 5.6 1.6–9.6
Mi o ica 4.0 0.6–7.4
Gjako a 7.2 2.7–11.7
Gjilan
O he s
1.6
1.6
0–3.8
0–3.8
Educa ion le el Mas e o pha macy 84.8 78.5–91.1
Mas e o science in pha macy 8.0 3.2–12.8
PhD 5.6 1.6–9.6
Specialis deg ee 1.6 0–3.8
Wo k expe ience 1–10 yea s 39.2 30.6–47.8
11–20 yea s 40.8 32.2–49.4
21–30 yea s 9.6 4.4–14.8
31–40 yea s 5.6 1.6–9.6
41–50 yea s 1.6 0–3.8
Communi y pha macy expe ience 1–10 yea s 49.6 40.8–58.4
11–20 yea s 37.6 29.1–46.1
21–30 yea s 8.0 3.2–12.8
31–40 yea s 3.2 0.1–6.3
Weekly wo king hou s 1–16 hou s 3.2 0.1–6.3
17–32 hou s 4.8 1.1–8.5
33–40 hou s 38.4 29.9–46.9
41–48 hou s 33.6 25.3–41.9
49+ hou s 19.2 12.3–26.1
Type o pha macy Independen pha macy 75.2 67.6–82.8
Small chain pha macy 13.6 7.6–19.6
La ge chain pha macy 9.6 4.4–14.8
Females comp ised 63.2%, highligh ing hei expand-
ing ole in CPha m ca e. Mos we e aged 31–40 (37.6%) o
41–50 (29.6%), e lec ing mid-ca ee p o essionals. Young-
e pha macis s (20–30, 20%) con ibu ed esh knowledge,
while hose 51+ (11.2%) o e ed expe ise. Expe ience was
balanced: 40.8% had 11–20 yea s o p o essional expe i-
ence, and 49.6% had 1–10 yea s in CPha m, sugges ing a
dynamic ea ly-ca ee coho d i ing change. Educa ion le -
els we e high: 84.8% held a Mas e o Pha macy deg ee, and
15.2% had pos g adua e deg ees, ein o cing s ong quali i-
ca ions and commi men o COPD ca e de elopmen .
P o essional expe ience ose s eadily wi h age— om
3.32 yea s (SD = 3.59) among hose aged 21–30 o 30.25
yea s (SD = 3.47) among hose aged 61+, unde sco ing
accumula ed expe ise. Geog aphically, nea ly hal o
esponden s we e om he capi al, wi h smalle sha es
om o he majo ci ies, while one egion showed low pa -
icipa ion, indica ing egional dispa i ies.
Mucaj J e al.: Pha macis s’ eadiness o deli e quali y COPD ca e4
Mos esponden s (75.2%) wo ked in indepen-
den pha macies. Common wo k hou s we e 33–40
(34.04%) and 41–48 (34.04%), wi h 25.5% wo k-
ing o e 49 hou s. Only 9.6% wo ked in la ge chains
(mos ly 33–40 hou s); none wo ked unde 16 o o e
48. Small chains accoun ed o 13.6%, mainly wo king
33–40 hou s (47.06%). O e all, 33–40 hou s we e mos
common (38.4%), while longe hou s (41–48, 33.6%; ≥
49, 19.2%) we e ypical in independen s, likely due o
pa ien o business demands.
Communi y pha macis s` in ol emen
in COPD ca e
A majo i y o esponden s (57.6%) epo ed being amilia
wi h COPD, wi h 11.2% e y amilia , 20% somewha amil-
ia , and 8.8% un amilia . Mos communi y pha macies (84%)
p o ided COPD medica ions, while 11.2% did no , and 4%
we e unsu e whe he hese medica ions we e s ocked.
Compa a i e da a show ha he a ailabili y o COPD
medica ions in Koso o (84%) is highe han in China
(66.7%) (Hu e al. 2020) bu lowe han in No h Macedo-
nia (96.62%) (Bozhino ska e al. 2022). The p opo ion o
pha macis s no dispensing o unsu e abou COPD medi-
ca ions in Koso o (15.2%) is lowe han in China (33.3%)
(Hu e al. 2020) bu highe han in No h Macedonia
(3.38%) (Bozhino ska e al. 2022).
Rega ding se ices, 47% epo ed o e ing o exp ess-
ing in e es in expanding COPD se ices, including inhal-
e echnique ins uc ion, medica ion counseling, smoking
cessa ion, in ec ion p e en ion, he apy moni o ing, and
pulmonologis e e als. Some CPs sugges ed ad anced
se ices such as elepha macy, g oup educa ion, and peak
low me e use.
Educa ion- ela ed indings e ealed ha 88.8% o e-
sponden s did no ecei e COPD- ela ed aining du ing
o mal educa ion, while only 11.2% had. Simila ly, 78.4%
had no COPD- ela ed aining du ing p o essional p ac-
ice, while 20.8% had.
Willingness o engage in COPD pha maceu ical ca e
was high: 49.6% we e willing i aining was p o ided,
32.8% exp essed willingness wi hou aining, 14.4%
we e unsu e, and 2.4% we e unwilling. These indings a e
compa able o Bozhino ska e al. (2022), whe e 57.43%
we e willing a e aining, 34.46% wi hou aining, and
1.35% we e unwilling. In Hu e al. (2020), 91% suppo -
ed pha macis in ol emen ega dless o aining, while
2.3% we e unwilling.
Gene al knowledge abou COPD
Fig. 1 shows CPs’ knowledge o COPD isk ac o s,
symp oms, and ai low limi a ion e e sibili y. Mos
esponden s co ec ly iden i ied smoking, lung in ec-
ions, ai pollu ion, and dus as key isk ac o s, bu
nea ly hal w ongly included alle gic eac ions. Only
11.2% ecognized pa asympa he ic hype ac i i y as a
isk ac o , hough his g oup also mis akenly includ-
ed alle gic eac ions. Abou 22.8% co ec ly iden i ied
h ee o ou isk ac o s wi hou e o s, while 1.42%
iden i ied only one. No esponden iden i ied all isk
ac o s co ec ly. Fo compa ison, Bozhino ska e al.
(2022) epo ed 24.32% ecogni ion o pa asympa-
he ic hype ac i i y, wi h 80% also inco ec on al-
le gic eac ions; Hu e al. (2020) epo ed 4% co ec
iden i ica ion o all isk ac o s.
Rega ding symp oms, 96% iden i ied ch onic cough,
spu um, dyspnea, and ches igh ness co ec ly, consis en
wi h Hu e al. (2020) and Bozhino ska e al. (2022). How-
e e , nea ly hal inco ec ly belie ed ai low limi a ion is
e e sible, simila o Bozhino ska e al. (2022) and highe
han Hu e al. (2020) (33.3%), while only ~20% acknowl-
edged i s i e e sibili y.
On diagnos ics, 67.28% inco ec ly hough an FEV/
FVC a io below 90% diagnoses COPD; only 32.74% co -
ec ly ejec ed his, knowing he cu o is < 70% (GOLD
2023). Bozhino ska e al. (2022) and Hu e al. (2020) e-
po ed lowe co ec answe s (18.24% and 13%, espec-
i ely). Meanwhile, 91.45% ecognized GOLD guidelines
o COPD ea men , simila o Bozhino ska e al. (2022)
(96%) bu much highe han Hu e al. (2020) (27.1%).
G aphical ep esen a ion o he esponses o isk ac-
o s, symp oms (ch onic cough, spu um p oduc ion, dys-
pnea, and ches igh ness), and e e sibili y o ai low lim-
i a ion in COPD, *co ec answe s; **w ong answe .
Pha macological ea men o COPD
Fig. 2 shows CPs’ knowledge o COPD pha macological
ea men . A la ge majo i y (80.67%) mis akenly iden i-
ied SABAs as i s -line ea men , wi h only 19.33% co -
ec ly ecognizing ha SABAs a e no ecommended o
ch onic use. This aligns wi h p e ious s udies epo ing
9.6% (Hu e al. 2020) and 17.57% (Bozhino ska e al.
2022) co ec esponses. Howe e , 88.3% co ec ly iden-
i ied SABAs’ ole in acu e exace ba ions, simila o Hu e
al. (2020) (74.6%) and Bozhino ska e al. (2022) (95.95%).
Rega ding inhaled co icos e oids (ICS), 47.11% ec-
ognized hei ole in COPD managemen , compa able o
Bozhino ska e al. (2022) (54%), while 52.9% inco ec ly
belie ed ICS a e a oided due o se e e side e ec s. This is
be e han Hu e al. (2020) bu indica es misunde s anding.
Mos pha macis s (88.89%) co ec ly acknowledged
he use o sho -ac ing o al glucoco icoids in managing
exace ba ions, consis en wi h Hu e al. (2020) (79.7%)
and Bozhino ska e al. (2022) (93.24%), while 11.11% e-
sponded inco ec ly.
Rega ding side e ec s o heophylline and ela ed d ugs,
74.17% co ec ly iden i ied common ad e se e ec s such as
nausea, omi ing, dia hea, egu gi a ion, and headaches,
wi h 25.83% inco ec . These esul s a e simila o Hu e al.
(2020) (79.7%) and Bozhino ska e al. (2022) (76.35%).
Pha macia 72: 1–9 5
Figu e 1. G aphical ep esen a ion o he esponses o isk ac o s, symp oms (ch onic cough, spu um p oduc ion, dyspnea, and
ches igh ness), and e e sibili y o ai low limi a ion in COPD, *co ec answe s; **w ong answe .
Figu e 2. CPs’ knowledge abou pha macological ea men o COPD.
Mucaj J e al.: Pha macis s’ eadiness o deli e quali y COPD ca e6
Non-pha macological ea men and
nico ine eplacemen he apy
CPs ecognized smoking cessa ion as c ucial in COPD
managemen , wi h 93.6% acknowledging i s ole in
slowing disease p og ession. Despi e his, only 28.1%
egula ly ecommend nico ine eplacemen he apy
(NRT), 39.67% ecommend i occasionally, and 32.23%
do no ecommend i a all.
Rega ding o he non-pha macological in e en-
ions, 72.0% ecommend seasonal lu accina ion, 62.4%
encou age inc eased physical ac i i y, and 33.6% sugges
educing sal in ake. Pulmona y ehabili a ion cen e s
we e acknowledged by 87.07% o pha macis s.
In compa ison, 20.5% o pha macis s selec ed all
h ee key non-pha macological in e en ions (smoking
cessa ion, lu accina ion, physical ac i i y), compa ed o
6.8% in Hu e al. (2020). Sal in ake educ ion was no ed
by 44.6% in Bozhino ska e al. (2022). Pulmona y ehabil-
i a ion awa eness was simila o Hu e al. (2020) (87.6%)
and Bozhino ska e al. (2022) (96.62%).
E alua ion o gene al knowledge, pha -
macological, and non-pha macological
ea men o COPD
Rega ding he pa icipan s’ gene al knowledge, he a e -
age sco e was 3.3 (SD = 1.87), wi h a ange om -1 o 7
(maximum possible sco e 8). The a e age sco e o pha -
macological ea men was 1.42 (SD = 1.89; ange -2 o
4) and 2.59 (SD = 1.37; ange -1 o 5) o non-pha maco-
logical ea men (max sco e: 5 o bo h). Fo he gene al
knowledge domain, sco es ≤ 2 we e anked as low, sco es
be ween 3 and 5 as mode a e, and sco es ≥ 6 as high. In
addi ion, o pha macological and non-pha macological
ea men knowledge domains, he anking was sco es ≤ 1
as low, sco es be ween 2 and 3 as mode a e, and sco es ≥ 4
as high. CPs’ knowledge a ied ac oss h ee domains: gen-
e al, pha macological, and non-pha macological ea -
men (Fig. 3). Mode a e gene al knowledge was ound in
49.6% o CPs, while 37.6% had low and 12.8% high gene -
al knowledge. Pha macological ea men knowledge was
he weakes , wi h 60% showing low, 32% mode a e, and
only 8% high p o iciency. Con e sely, non-pha macolog-
ical ea men knowledge was s onge : 28% had high,
51.2% mode a e, and 20.8% low knowledge.
Educa ion le el was signi ican ly associa ed wi h gen-
e al knowledge (χ² = 16.566, p = 0.011), wi h MSc holde s
mo e likely o ha e high gene al knowledge, while C am-
e ’s V = 0.2574 indica ed mode a e associa ion. No signi -
ican associa ion was ound be ween educa ion and pha -
macological o non-pha macological knowledge.
Pha maceu ical ca e p ac ices o
COPD: pa ien moni o ing, counseling,
and adhe ence
A la ge majo i y (87.71%) o esponden s epo ed lacking
ools o me hods o con inuously moni o COPD pa ien s.
The a e age com o sco e o counseling COPD pa ien s
was 2.98 (SD = 2.05) (scale 1 o 6), wi h 55.5% epo -
ing low com o , 14.4% mode a e, and 30.4% high com-
o (ca ego ized as low (≤2), mode a e (3–4), and high
(≥5)). CPs’ com o wi h counseling a ied by medica ion
ype: 47.15% el com o able wi h sho -ac ing b oncho-
dila o s, 37.6% wi h long-ac ing, 24.8% wi h bo h, 38.2%
wi h combina ion inhale s, 29.3% wi h inhaled co icos e-
oids, and only 5.7% wi h phosphodies e ase-4 inhibi o s.
Abou 25.2% el com o able wi h all COPD medica ions.
C oss- abula ion e ealed a signi ican associa ion be-
ween com o and gene al COPD knowledge (χ² = 20.674,
p = 0.0004). C ame ’s V (0.2876) indica ed a mode a e as-
socia ion. Simila ly, com o le el co ela ed wi h pha -
macological knowledge (χ² = 14.407, p = 0.0061). C ame ’s
V (0.2401) sugges ed a mode a e associa ion. In summa y,
while bo h gene al and pha macological knowledge we e
s a is ically ela ed o com o , he p edic i e powe was
weak, wi h o he ac o s likely in luencing com o le els
in counseling COPD pa ien s.
Con idence in eaching inhala ion echnique was “ e y
con iden ” in 43.09%, “con iden ” in 44.72%, “somewha
con iden ” in 8.94%, and “no e y con iden ” in 3.25%.
Con idence did no signi ican ly co ela e wi h knowledge
domains bu was mode a ely associa ed wi h dispensing
COPD medica ions (χ² = 36.128, p = 0.0003). C ame ’s V
(0.3104) and he con ingency coe icien (0.4735) indi-
ca ed a mode a e associa ion be ween he wo a iables.
Howe e , Lambda (0.0571) sugges ed weak p edic i e
powe , indica ing ha o he ac o s may also in luence he
ela ionship be ween medica ion dispensing and inhala-
ion echnique con idence.
Adhe ence awa eness was posi i e: 43.8% a ed pa-
ien s as e y coope a i e, 44.63% as mode a ely, 6.61% as
poo ly, and 4.96% did no counsel on adhe ence.
Phone con ac equency wi h pa ien s was occasional
(64.46%), o en (10.74%), always (1.65%), and no con ac
a 23.14%. Abou 46% esponded o challenges in COPD
ca e, ci ing pa ien educa ion/compliance, pa ien beha -
io , us /communica ion gaps, and sys emic ba ie s such
as medica ion sho ages and limi ed s a ing.
Figu e 3. Dis ibu ion o CPs’ knowledge le els ac oss
gene al, pha macological, and non-pha macological ea men
domains o COPD.
Pha macia 72: 1–9 7
Nea ly hal (48.8%) exp essed willingness o con in-
ue in u u e p ojec phases, showing s ong in e es and
po en ial o deepe in ol emen wi h u he suppo o
quali y COPD ca e.
S eng hs and limi a ions
This s udy is among he i s o assess COPD- ela ed com-
pe encies o CPs in Koso o, a egion wi h limi ed pub-
lished da a on he quali y o p ima y ca e in espi a o y
diseases. I p o ides insigh in o eal-wo ld p ac ice and
e eals gaps ha hinde op imal ca e.
The sample, while ep esen ing 9.5% o he CP popula-
ion, was d awn h ough olun a y pa icipa ion and may
be subjec o selec ion and esponse bias. Rec ui men ia
he Chambe o Pha macis s and social media could limi
gene alizabili y. Despi e his, he indings o e impo an
insigh in o sys emic ba ie s a ec ing he quali y o ca e
in COPD managemen .
Discussion
CPs in Koso o demons a ed a ounda ional unde -
s anding o COPD, including symp om ecogni ion and
awa eness o ea men guidelines. Howe e , signi ican
knowledge gaps pe sis , pa icula ly in pha maco he -
apy, diagnos ic c i e ia, and spi ome y in e p e a ion.
While mos CPs exp essed mo i a ion o engage in ca e,
ew had ecei ed o mal o s uc u ed aining. A ail-
abili y o COPD medica ions was inconsis en , wi h
15.2% ei he no s ocking hem o unawa e o hei
a ailabili y, po en ially hinde ing access and con inui y
o ca e. Limi ed con idence in managing complex he -
apies and low access o moni o ing ools e lec b oad-
e sys em cons ain s. Al hough CPs gene ally suppo
non-pha macological measu es such as smoking cessa-
ion and accina ion, misconcep ions abou isk ac o s
and ea men s a egies emain. Lack o o mal ain-
ing and moni o ing ools limi s hei abili y o p o ide
consis en , high-quali y ca e. None heless, o e 80% ex-
p essed willingness o engage in COPD ca e, e ealing
un apped po en ial wi hin he p o ession.
Compa ed o simila s udies, CPs in Koso o demon-
s a ed knowledge and engagemen le els be ween
hose epo ed in China (Hu e al. 2020) and No h
Macedonia (Bozhino ska e al. 2022). The a ailabili-
y o COPD medica ions is highe han in China bu
lowe han in No h Macedonia, e lec ing egional dis-
pa i ies in pha maceu ical in as uc u e and heal h-
ca e o ganiza ion. The lack o o mal aining among
mos CPs mi o s indings om o he low- and mid-
dle-income coun ies, whe e con inuing p o ession-
al de elopmen emains agmen ed (Hu e al. 2020,
Bozhino ska e al. 2022).
Al hough willingness o engage was highes in China
(Hu e al. 2020), simila ly s ong esponses in Koso o
and No h Macedonia (Bozhino ska e al. 2022) sugges a
b oadly a o able a i ude, implying ha sys emic and ed-
uca ional ba ie s may be mo e limi ing han mo i a ion.
Recogni ion o non-pha macological measu es such
as smoking cessa ion, accina ion, and pulmona y eha-
bili a ion aligns wi h in e na ional p io i ies (Au e al.
2009; Tønnesen 2013; Elle beck e al. 2018; Kopsa is e
al. 2018; A nold e al. 2020; Doo e al. 2023). Howe e ,
ecu ing misconcep ions such as inco ec iden i ica-
ion o i s -line he apies, misunde s anding o ICS, and
misin e p e a ion o diagnos ic c i e ia highligh gaps
in clinical knowledge (Hu e al. 2020; Bozhino ska e al.
2022; GOLD 2023).
These indings unde sco e he need o s uc u ed,
guideline-based educa ion aligned wi h GOLD ecom-
menda ions (GOLD 2023). S eng hening CPs’ compe en-
cies could imp o e ca e consis ency and quali y, educe
dispa i ies, and lead o be e ou comes o pa ien s wi h
ch onic espi a o y diseases.
Building on his, aligning p o essional de elopmen
and p ac ice s anda ds wi h he WHO (FIP/WHO 2011)
and FIP Communi y Pha macy Sec ion (CPS) (FIP 2020)
amewo ks would u he s eng hen pha macis s’ oles
in COPD ca e. These amewo ks highligh pha ma-
cis s’ key oles in op imizing medicine use, ad ancing
pa ien -cen e ed ca e, and con ibu ing o public heal h,
aligning wi h he CPS Mission and Vision 2020 call o
s eng hen pha macis s’ compe encies and in eg a e com-
muni y pha macy in o p ima y heal hca e sys ems. The
iden i ied knowledge gaps and limi ed access o diagnos ic
ools in Koso o highligh a eas whe e hese global objec-
i es a e no ye ully achie ed. Howe e , he s ong will-
ingness o CPs o engage in COPD ca e aligns wi h FIP’s
s a egic aims o ad ance communi y pha macy p ac ice
h ough p o essional de elopmen , imp o ed communi-
ca ion, and collabo a ion wi hin heal hca e eams. Align-
ing na ional policies and educa ional ini ia i es wi h hese
WHO/FIP amewo ks could he e o e enhance he qual-
i y, consis ency, and sus ainabili y o COPD- ela ed pha -
maceu ical ca e, enabling pha macis s in Koso o o ul ill
hei ull public heal h and clinical oles as en isioned by
he in e na ional pha macy communi y.
Based on he indings, imp o ing COPD ca e quali y
in Koso o equi es a coo dina ed, mul i-le el app oach.
Na ional policies should o mally in eg a e CPs in o
ch onic ca e pa hways, suppo ed by s anda dized ain-
ing ocused on spi ome y, pha maco he apy, and pa ien
counseling. In as uc u e upg ades such as access o
moni o ing ools, in en o y sys ems, and eleheal h a e
also essen ial o consis en , high-quali y se ice deli e y.
Va ia ion in COPD se ices ac oss CPha m highligh s
he need o na ional p o ocols o educe ca e dispa i-
ies. Gi en CPs’ s ong willingness o engage, in es ing in
s uc u ed aining and suppo p og ams could quick-
ly expand hei ole in espi a o y ca e. Fu u e esea ch
should ocus on pilo ing scalable educa ional and p ac-
ice models o enhance clinical compe ence and imp o e
pa ien ou comes. Insigh s om hese pilo p ojec s can
guide he design o con inuous educa ion p og ams wi h
Mucaj J e al.: Pha macis s’ eadiness o deli e quali y COPD ca e8
e idence-based con en ha add esses iden i ied gaps and
empowe s CPs o o e come speci ic p ac ical challenges
h ough he p oac i e in eg a ion o knowledge and
skills in o hei daily p ac ice. These e o s a e essen ial
o con incing policymake s, se ice paye s, and o he
s akeholde s o in eg a e hese se ices in o he na ional
heal hca e sys em, suppo wo k o ce planning, and de-
elop policies and guidelines aimed a minimizing medi-
ca ion e o s and imp o ing pa ien ou comes. They will
assis p o essional bodies in ad oca ing o his expand-
ed scope o p ac ice and ensu e ha policies a e ailo ed
o he esou ces and needs o he coun y’s popula ion
wi h COPD and i s heal hca e sys em. To ensu e hese
ini ia i es ansla e in o consis en , high-quali y p ac ice,
subsequen guideline de elopmen should ollow a s uc-
u ed, e idence-based p ocess ha ac i ely in ol es pha -
macis s, clinicians, and policymake s as key s akeholde s.
Clea ly de ining objec i es, a ge popula ions, and ou -
comes—suppo ed by sys ema ic e idence app aisal and
anspa en g ading o ecommenda ions—would help
ensu e igo and c edibili y (Dixon e al. 2023). Including
di e se p o essional and pa ien pe spec i es, along wi h
mechanisms o egula e iew and imely upda es, would
u he enhance ele ance, adap abili y, and sus ainabili y
wi hin Koso o’s heal hca e con ex .
Conclusion
CPs in he coun y ha e he mo i a ion and basic knowl-
edge o ake a g ea e ole in COPD ca e bu a e limi ed
by gaps in aining and esou ces. Ta ge ed educa ional
in e en ions, sys em in eg a ion, and policy suppo a e
c i ical o empowe ing pha macis s as ac i e con ibu o s
o ch onic disease managemen . S eng hening hei ole
is essen ial o imp o ing he quali y and equi y o COPD
ca e in Koso o and ac oss simila heal h sys ems.
Implica ions
Imp o ing COPD ca e equi es a coo dina ed na ional
app oach ha o mally in eg a es CPs in o ch onic ca e
h ough s anda dized aining in key a eas. In as uc-
u e upg ades, such as moni o ing ools and eleheal h,
a e essen ial. Va ia ions in se ices highligh he need o
na ional p o ocols o educe dispa i ies. Wi h CPs willing
o engage, in es ing in aining can expand hei ole. Fu-
u e esea ch should pilo scalable educa ion and p ac ice
models o enhance compe ence and ou comes. Building
on hese e o s, he indings can guide he de elopmen
o local pha macy p ac ice guidelines aligned wi h GOLD
and WHO/FIP amewo ks. Implemen ing such guide-
lines would help s anda dize COPD ca e ac oss com-
muni y pha macies and s eng hen pha macis s’ oles in
ch onic disease managemen .
Addi ional in o ma ion
Con lic o in e es
The au ho s ha e decla ed ha no compe ing in e es s exis .
E hical s a emen s
The au ho s decla ed ha no clinical ials we e used in he p es-
en s udy.
The au ho s decla ed ha no expe imen s on humans o hu-
man issues we e pe o med o he p esen s udy.
The au ho s decla ed ha no in o med consen was ob ained
om he humans, dono s o dono s’ ep esen a i es pa icipa -
ing in he s udy.
The au ho s decla ed ha no expe imen s on animals we e
pe o med o he p esen s udy.
The au ho s decla ed ha no comme cially a ailable immo -
alised human and animal cell lines we e used in he p esen s udy.
Use o AI
No use o AI was epo ed.
Funding
This esea ch did no ecei e any speci ic g an om unding
agencies in he public, comme cial, o no - o -p o i sec o s.
Au ho con ibu ions
Je on Mucaj: W i ing – o iginal d a , In es iga ion, Fo mal
analysis, Da a cu a ion; Be i Dju djic: W i ing – o iginal d a ,
W i ing – e iew and edi ing, Fo mal analysis; Zo ica Naumo s-
ka: W i ing – o iginal d a , W i ing – e iew and edi ing, Me h-
odology, Fo mal analysis, Concep ualiza ion; K is ina Mlade-
no ska: W i ing – o iginal d a , W i ing – e iew and edi ing,
Fo mal analysis; Maja Simonoska C ca e ska: W i ing – o iginal
d a , W i ing – e iew and edi ing, Me hodology, In es iga ion,
Da a cu a ion, Fo mal analysis, Concep ualiza ion, Supe ision.
Au ho ORCIDs
Je on Mucaj h ps://o cid.o g/0009-0006-7326-7058
Be i Dju djic h ps://o cid.o g/0000-0003-0122-0411
Zo ica Naumo ska h ps://o cid.o g/0000-0003-3491-0304
K is ina Mladeno ska h ps://o cid.o g/0000-0003-2503-4699
Maja Simonoska C ca e ska h ps://o cid.o g/0000-0002-
1927-7101
Da a a ailabili y
Da a a e a ailable upon eques .
Re e ences
ALA (2023) Ame ican Lung Associa ion. h ps://lung.o g [Accessed
Feb ua y 26, 2025]
A nold MT, Dolezal BA, Coope CB (2020) Pulmona y Rehabili a ion
o Ch onic Obs uc i e Pulmona y Disease: Highly E ec i e bu
Pha macia 72: 1–9 9
O en O e looked. Tube culosis and Respi a o y Diseases 83: 257–
267. h ps://doi.o g/10.4046/ d.2020.0064
Au DH, B yson CL, Chien JW, Sun H, Ud is EM, E ans LE, B adley KA
(2009) The E ec s o Smoking Cessa ion on he Risk o Ch onic Ob-
s uc i e Pulmona y Disease Exace ba ions. Jou nal o Gene al In e -
nal Medicine 24: 457–463. h ps://doi.o g/10.1007/s11606-009-0907-y
Bozhino ska B, Kapedano ska Nes o o ska A, Naumo ska Z, Pa che a J,
Simonoska C ca e ska M (2022) E alua ion o communi y pha ma-
cis knowledge owa ds ch onic obs uc i e pulmona y disease man-
agemen . Macedonian Pha maceu ical Bulle in 68: 433–434. h ps://
doi.o g/10.33320/maced.pha m.bull.2022.68.03.208
Condinho M, Ramalhinho I, Sinogas C (2021) Smoking Cessa ion a he
Communi y Pha macy: De e minan s o Success om a Real-Li e
P ac ice. Pha macy 9: 143. h ps://doi.o g/10.3390/pha macy9030143
Dixon DL, Ha is IM, Aljadeed R, Ande son KC, Aycock A, Bea e s C,
Beckman EJ, Isaacs D, McCoy E, Sandle A, Saseen JJ, Singh S, Wag-
ne J (2023) O e iew o clinical p ac ice guideline de elopmen ,
applica ion o pha macy p ac ice, and oles o pha macis s. JACCP:
Jou nal o he Ame ican College o Clinical Pha macy 6: 73–84.
h ps://doi.o g/10.1002/jac5.1743
Doo JH, Kim SM, Pa k YJ, Kim KH, Oh YH, Kim JS, Pa k SM (2023)
Smoking cessa ion a e diagnosis o COPD is associa ed wi h
lowe all-cause and cause-speci ic mo ali y: a na ionwide popu-
la ion-based coho s udy o Sou h Ko ean men. BMC Pulmona y
Medicine 23: 237. h ps://doi.o g/10.1186/s12890-023-02533-1
Elle beck EF, Nollen N, Hu cheson TD, Phadnis M, Fi zge ald SA, Vacek
J, Sha pe MR, Salzman GA, Rich e KP (2018) E ec o Long- e m
Nico ine Replacemen The apy s S anda d Smoking Cessa ion o
Smoke s Wi h Ch onic Lung Disease: A Randomized Clinical T ial.
JAMA Ne wo k Open 1: e181843. h ps://doi.o g/10.1001/jamane -
wo kopen.2018.1843
Eu os a (2024) Heal h pe sonnel. h ps://doi.o g/10.2908/HLTH_RS_
PRS2 [Accessed Ma ch 1, 2025]
FIP/WHO (2011) Join FIP/WHO guidelines on good pha macy p ac-
ice: S anda ds o quali y o pha macy se ices (WHO Technical Re-
po Se ies 961, Annex 8). h ps://www.who.in /docs/de aul -sou ce/
medicines/no ms-and-s anda ds/guidelines/dis ibu ion/ s961-an-
nex8- ipwhoguidelinesgoodpha macyp ac ice.pd [Accessed Oc o-
be 29, 2025]
FIP (2019) In e na ional Pha maceu ical Fede a ion. Bea ing non-com-
municable diseases in he communi y: The con ibu ion o pha -
macis s. h ps://www. ip.o g/ iles/con en /publica ions/2019/bea -
ing-ncds-in- he-communi y- he-con ibu ion-o -pha macis s.pd
[Accessed Ma ch 2, 2025]
FIP (2020) In e na ional Pha maceu ical Fede a ion. The FIP Commu-
ni y Pha macy Sec ion Vision 2020. h ps://www. ip.o g/ iles/con-
en /pha macy-p ac ice/communi y-pha macy/CPS_Vision_2020.
pd [Accessed Oc obe 29, 2025]
GOLD (2023) Global Ini ia i e o Ch onic Obs uc i e Lung Disease.
Global S a egy o he Diagnosis, Managemen , and P e en ion
o Ch onic Obs uc i e Pulmona y Disease: 2023 Repo . h ps://
goldcopd.o g/wp-con en /uploads/2023/03/GOLD-2023- e -1.3-
17Feb2023_WMV.pd [Accessed Ma ch 2, 2025]
GP (2024) Ge man Pha macies: Figu es Da a Fac s. h ps://www.abda.
de/ ileadmin/use _upload/asse s/ZDF/ [Accessed Ma ch 2, 2025]
Homę owska H, Świą oniowska-Lonc N, Klekowski J, Chabowski M,
Jankowska-Polańska B (2022) T ea men Adhe ence in Pa ien s
wi h Obs uc i e Pulmona y Diseases. In e na ional Jou nal o
En i onmen al Resea ch and Public Heal h 19: 11573. h ps://doi.
o g/10.3390/ije ph191811573
Hu Y, Yao D, Hu H, Ung COL (2020) Fac o s A ec ing Communi y
Pha macis ’s Knowledge Abou Ch onic Obs uc i e Pulmona y
Disease (COPD) Managemen in China: A C oss-Sec ional Su ey
S udy. In e na ional Jou nal o Ch onic Obs uc i e Pulmona y Dis-
ease 15: 3171–3181. h ps://doi.o g/10.2147/COPD.S280333
Hudd TR (2020) Eme ging ole o pha macis s in managing pa ien s wi h
ch onic obs uc i e pulmona y disease. Ame ican Jou nal o Heal h-Sys-
em Pha macy 77: 1625–1630. h ps://doi.o g/10.1093/ajhp/zxaa216
Ka le E, Pa el TP, Zweig J, K a ac A (2020) Unde s anding he knowl-
edge gap and assessing com o le el among heal hca e p o essionals
who p o ide inhale educa ion. COPD: Jou nal o Ch onic Obs uc-
i e Pulmona y Disease 17: 197–204. h ps://doi.o g/10.1080/15412
555.2020.1746251
Klassing HM, Ruisinge JF, P ohaska ES, Mel on BL (2018) E alua ion
o pha macis -ini ia ed in e en ions on accina ion a es in pa ien s
wi h as hma o COPD. Jou nal o Communi y Heal h 43: 297–303.
h ps://doi.o g/10.1007/s10900-017-0421-9
Kopsa is Z, Wood-Bake R, Poole P (2018) In luenza accine o ch on-
ic obs uc i e pulmona y disease (COPD). Coch ane Ai ways G oup
(Ed.). Coch ane Da abase o Sys ema ic Re iews 2018. h ps://doi.
o g/10.1002/14651858.CD002733.pub3
K igsman K, Nilsson JLG, Ring L (2007) Re ill adhe ence o pa ien s
wi h as hma and COPD: compa ison o a pha macy eco d da abase
wi h manually collec ed epea p esc ip ions. Pha macoepidemiolo-
gy and D ug 16: 441–448. h ps://doi.o g/10.1002/pds.1321
Newman SP (2017) D ug deli e y o he lungs: Challenges and oppo -
uni ies. The apeu ic Deli e y 8: 647–661. h ps://doi.o g/10.4155/
de-2017-0037
Olo egui-Rod iguez JJ, So iano-Mo eno DR, Beni es-Bullón A,
Pelayo-Luis PP, Hua inga-Ma celo J (2022) P e alence and incidence
o ch onic obs uc i e pulmona y disease in La in Ame ica and he
Ca ibbean: a sys ema ic e iew and me a-analysis. BMC Pulmona y
Medicine 22: 273. h ps://doi.o g/10.1186/s12890-022-02067-y
Sanduzzi A, Balbo P, Candoli P, Ca apano GA, Con ini P, Ma ei A,
Puglisi G, San oiemma L, S anziola AA (2014) COPD: adhe ence o
he apy. Mul idisciplina y Respi a o y Medicine 9: 60. h ps://doi.
o g/10.1186/2049-6958-9-60
Świą oniowska N, Chabowski M, Polański J, Mazu G, Jankowska-
Polańska B (2020) Adhe ence o The apy in Ch onic Obs uc i e
Pulmona y Disease: A Sys ema ic Re iew. In: Poko ski M (Ed.)
Medical Resea ch and De elopmen . Sp inge In e na ional
Publishing, Cham, 37–47. h ps://doi.o g/10.1007/5584_2019_477
Tønnesen P (2013) Smoking cessa ion and COPD. Eu opean Respi a o y
Re iew 22: 37–43. h ps://doi.o g/10.1183/09059180.00007212
Van De Molen T, Van Bo en JFM, Magui e T, Goyal P, Al man P (2017)
Op imizing iden i ica ion and managemen o COPD pa ien s – e-
iewing he ole o he communi y pha macis . B i ish Jou nal o Clin-
ical Pha macology 83: 192–201. h ps://doi.o g/10.1111/bcp.13087
WHO (2015) Wo ld Heal h O ganiza ion. WHO global epo on ends
in p e alence o obacco smoking. h ps://apps.who.in /i is/bi s e
am/10665/156262/1/9789241564922_eng.pd [Accessed Ma ch 10,
2025]
WHO (2023) Wo ld Heal h O ganiza ion. Ch onic obs uc i e pulmo-
na y disease (COPD). h ps://www.who.in /news- oom/ ac -shee s/
de ail/ch onic-obs uc i e-pulmona y-disease-(copd) [Accessed
Ma ch 10, 2025]
