Hypertension is a major global health concern and one of the leading modifiable risk factors for cardiovascular diseases (CVDs), including heart attacks and strokes, and is also a primary cause of premature death worldwide. ^{1, 2} As of 2023, approximately 1.28 billion adults aged 30-79 are affected by hypertension. ² Despite the availability of effective treatment options, blood pressure control remains suboptimal, particularly in low- and middle-income countries. ¹ Only about 54% of individuals with hypertension are globally diagnosed, 42% receive treatment, and just 21% achieve adequate blood pressure control. ³ In the United Arab Emirates (UAE), the burden of hypertension is similarly significant. ⁴ A systematic review and meta-analysis of 15 cross-sectional studies involving 139,907 adults reported a pooled prevalence of 31%, with only 38% of affected individuals achieving blood pressure control. ⁵ These figures underscore the urgent need for effective prevention, management, and patient education strategies, both globally and within the UAE.

Effective management of hypertension is critical for slowing disease progression and improving public health outcomes. A key component of this management involves enhancing patients’ awareness and understanding of their condition, which has been shown to improve treatment adherence and support better blood pressure control. ¹ Given their accessibility, extended hours, and frequent interactions with the public, community pharmacists are ideally positioned to provide this support through patient counseling, medication review, and lifestyle advice. The transition from product-centered to patient-centered care has further expanded the role of community pharmacists in hypertension management. ^{1, 6} In the UAE, community pharmacists interact directly with nearly 90% of the population each year, including individuals at high risk for CVDs. With over 2,500 licensed pharmacies operating an average of 13 hours daily, pharmacists are among the most accessible healthcare providers, positioning them as ideal partners in public health initiatives aimed at preventing and managing CVDs. ⁷ By helping patients understand their medical conditions, community pharmacists can promote healthier behaviors, improve clinical outcomes, and enhance medication adherence. ¹ Evidence from various countries supports the effectiveness of pharmacist-led interventions, particularly those involving patient education and counseling, in enhancing hypertension control. ^{8– 12}

Understanding the knowledge, attitude, and practice (KAP) of community pharmacists is essential for identifying gaps in education and training, optimizing their role in hypertension management, and improving the quality of pharmaceutical services in community settings. ⁴ While few international studies have examined the KAP of community pharmacists in relation to hypertension counseling, ^{1, 13} to date, there are no published studies from the UAE addressing this subject. ^{4, 17} This study aimed to assess the KAP of community pharmacists across the UAE with regard to counseling hypertensive patients, and to explore the factors influencing these domains.

Although the survey link was accessed by 200 community pharmacists across all dissemination channels, only 120 participants completed the questionnaire and provided electronic consent, yielding a response rate of 60.0%. Among those who declined participation or did not complete the survey, lack of time was commonly mentioned in informal communications. Among the 120 respondents, six were excluded due to ineligibility or incomplete survey responses. Therefore, a total of 114 participants were included in the final data analysis. The recruitment and response flow are summarized in Figure 1.

This study provides important insights into the KAP of community pharmacists in the UAE regarding hypertension counseling. Pharmacists demonstrated a good level of knowledge, moderate attitudes, and moderate engagement in counseling practices. In contrast, Chen et al. reported strong attitudes but inadequate knowledge and practice among Chinese pharmacists. ¹ Similarly, the study by Wijaya et al. revealed that while Indonesian pharmacists demonstrated moderate knowledge, they exhibited good attitudes and satisfactory practices in hypertension management. ¹³ These comparisons suggest that although UAE pharmacists may be better informed, their motivation or confidence to actively engage in counseling may still be suboptimal. This highlights the need for interventions that address not only knowledge gaps but also attitudinal and behavioral barriers. Similar KAP discrepancies have been observed in other therapeutic areas. Studies from India, ¹⁴ Indonesia, ¹⁵ and Malaysia ¹⁶ reported that despite favorable attitudes and a strong sense of professional responsibility, pharmacists’ knowledge and practice levels remained inadequate. These findings underscore a broader trend in pharmacy practice, underscoring the persistent gap between professional intent and actual implementation. Bridging this gap may require structured continuing education, clearly defined roles, and systems-level support to ensure consistent, high-quality patient counseling.

The findings from this study show that 70% of community pharmacists demonstrated good knowledge of hypertension and its management. The highest rates of correct responses were observed in identifying modifiable risk factors (96%) and complications of uncontrolled hypertension (94%). These results indicate that pharmacists are well-versed in the foundational epidemiology and pathophysiology of hypertension. Similar findings were reported in a study from Nigeria, where pharmacists displayed strong knowledge of hypertension-related complications. ¹⁷ Another study from Indonesia demonstrated high levels of understanding regarding the definition, etiology, and clinical consequences of hypertension. ¹⁸ Additionally, pharmacists in our study showed good awareness of diagnostic thresholds (85%) and the importance of blood pressure monitoring (89%), underscoring their familiarity with screening and monitoring aspects of care. This may be attributed to the growing emphasis on non-communicable disease (NCD) screening programs in community pharmacy practice across the UAE. ^{19, 20} Exposure to such content during undergraduate education ^{21, 22} and continuing professional development activities ²³ may also play a role. However, knowledge in pharmacologic management among the participants was comparatively weaker. Only 70% correctly identified the criteria for initiating antihypertensive therapy, and just 54% recognized thiazide diuretics as a first-line option according to JNC 8 guidelines. This points to a concerning knowledge gap in evidence-based pharmacotherapy. A similar pattern was noted in Indonesia, where pharmacists performed well in lifestyle counseling but showed limited understanding of treatment guidelines and drug selection. ¹⁸ This suggests that while pharmacists are generally competent in disease recognition, there may be insufficient emphasis on the evolving aspects of hypertension pharmacotherapy in practice. Supporting this, Soubra et al. found that although community pharmacists were competent in recognizing hypertension as a chronic disease and providing basic educational support, their engagement in dynamic pharmacotherapeutic roles remained insufficient. The study revealed that pharmacists frequently performed roles related to disease education and basic management, such as measuring blood pressure and advising on lifestyle changes, but there were notable deficiencies in medication management and care plan monitoring. ²⁴ These gaps may be due to infrequent clinical knowledge updates post-graduation, limited access to guidelines in community settings, or lack of exposure to interprofessional case discussions. In many community pharmacies, dispensing duties dominate pharmacists’ roles, leaving little room for in-depth therapeutic review or guideline-based interventions. The study by Downes et al. further emphasizes this gap. Despite referencing the ACC/AHA 2017 guidelines, many pharmacists struggled to apply blood pressure targets accurately in case-based scenarios. ²⁵ This suggests that while pharmacists may be aware of the guidelines, they often misinterpret or inconsistently apply them, possibly due to outdated habits, personal judgment, or reliance on former recommendations. Similar patterns have been reported in the context of cholesterol guidelines. Studies by Bucheit et al. ²⁶ and Lowenstern et al. ²⁷ showed high awareness but poor translation into practice. These findings highlight the issue of clinical inertia and call for more effective educational interventions. Passive dissemination of guidelines may be inadequate; instead, interactive learning and performance-based feedback could improve adherence and real-world application.

In the attitude domain, although individual item responses reflected strong professional values and positive beliefs toward counseling, only 46% of respondents achieved an overall “positive attitude” score. Notably, 95% of pharmacists agreed that counseling is a core professional responsibility, and 98% acknowledged its benefits in enhancing patient understanding and adherence. This apparent discrepancy suggests that while pharmacists endorse the importance of counseling in principle, attitudinal or contextual barriers may hinder their willingness or ability to consistently fulfill this role. Supporting this, a recent study conducted in the UAE evaluated community pharmacists’ attitudes and willingness to provide extended pharmacy services, including patient counseling. It found that over half of the participants reported below-median scores in both attitude (58.7%) and willingness (59.4%) to deliver these services. ²⁸ Furthermore, 71% of our participants stated that counseling is not easily integrated into daily practice, indicating perceived or actual challenges within the pharmacy environment. Similar observations were made in a study from Kenya, which revealed a marked gap between pharmacists’ self-reported counseling practices and their actual behavior. While 66.7% of pharmacists claimed to provide detailed medication counseling, only 26.7% of simulated patients received adequate guidance. Additionally, 75% of pharmacists provided minimal verbal counseling beyond stating the drug name and dosage. These findings reinforce the notion that, despite widespread recognition of its importance, counseling is not consistently embedded in daily pharmacy practice. ²⁹ The literature consistently cites high patient volumes, insufficient staffing, and lack of privacy as primary barriers to delivering comprehensive counseling. ^{30– 32} These environmental and structural limitations may contribute to the disconnect between pharmacists’ professional intent and what they are realistically able to implement in practice. Another important consideration is perceived competence. Although 89% of respondents reported having the skills to counsel patients, and 86% expressed confidence in counseling hypertensive patients, the mean scores suggest that actual confidence levels may be lower than self-reported perceptions. This aligns with a study by Summers et al., which found that many pharmacists had never received formal instruction in communication methods, contributing to a lack of confidence in patient interactions despite recognizing their importance. ³³ Notably, 90% of our respondents believed that counseling requires more advanced skills than basic pharmacy experience, indicating an appreciation of the complexity involved in effective patient communication. This acknowledgment reflects growing self-awareness among pharmacists about their training needs and highlights opportunities for developing tailored skill-building programs. Similarly, in the study by Jin et al., pharmacy students demonstrated strong self-awareness regarding their limitations in communication and expressed a clear desire for further skill development. ³⁴ Additionally, the fact that 98% of our respondents reported a willingness to seek information when uncertain demonstrates a positive learning orientation and adaptability, qualities that can be leveraged to support long-term improvements in counseling attitudes, skills, and professional growth.

In the domain of practice, just over half of the pharmacists (51%) demonstrated good counseling practices, indicating moderate engagement with hypertension-related patient education. While the mean scores across individual items were generally favorable, the overall distribution suggests inconsistencies in how frequently and comprehensively these practices are applied in daily community pharmacy settings. Encouragingly, 63% of our community pharmacists reported that they always or often counsel patients when dispensing antihypertensive prescriptions, and 81% consistently provided guidance on the proper use of each medication. However, more in-depth counseling practices, such as discussing side effects (60%) and drug interactions (69%), were reported less consistently, suggesting potential barriers such as limited time, lack of privacy, or insufficient confidence in managing complex therapeutic discussions. This aligns with findings from a study in Ethiopia, where most pharmacists engaged in basic counseling on route of administration and dosage, while only a small fraction consistently addressed the purpose of medications, major drug-drug interactions, side effects, and the importance of compliance. ³⁵ The average time spent on counseling was another key metric. Although 61% of respondents reported sessions lasting more than five minutes, this still indicates that nearly 40% of pharmacists may be delivering brief or superficial counseling encounters. This finding mirrors results from studies conducted in South Korea ³⁶ and the United States, ³⁷ where time constraints were cited as a major factor limiting counseling duration, despite pharmacists’ willingness to engage with patients. Since longer interactions are often needed for effective chronic disease education, this reflects the tension between operational demands and clinical responsibilities in retail pharmacy environments. Additionally, 75% of our pharmacists reported regularly updating their knowledge of hypertension management. This proactive learning behavior is encouraging and reflects a commitment to continuous professional development. However, translating knowledge into consistent practice remains a challenge, as highlighted by the gap between knowledge scores (70% with good knowledge) and practice performance (only 51% with good practice). This disconnect suggests that knowledge alone may be insufficient to drive behavioral change without institutional support and structured protocols. The American Society of Health-System Pharmacists (ASHP) emphasizes that effective patient education and counseling require more than just pharmacist knowledge. Their guidelines advocate for structured institutional support, including the development of counseling protocols and integration into healthcare teams, to ensure that pharmacists can fulfill their educational responsibilities effectively. ³⁸ Another notable finding from our study is that 74% of pharmacists inquired about blood pressure readings and advised patients on when to seek medical attention. This proactive engagement aligns with the evolving public health role of community pharmacists and reinforces their potential to support hypertension monitoring and referral. Furthermore, 79% of the respondents acknowledged that patients’ personality and behavior influenced their counseling approach. This was corroborated by the systematic review by Qudah et al., which found that pharmacists’ participative behavior was positively associated with patients’ engagement and perceived patient cues during conversations. These findings suggest that pharmacists adjust their counseling strategies based on patients’ communication behaviors and characteristics. ³⁹ This degree of patient-centeredness reflects a strong inclination toward individualized care, an essential factor in promoting adherence and patient satisfaction.

Both bivariate and multivariable analyses were conducted, revealing that several demographic and professional factors were significantly associated with KAP domains. These associations offer valuable insights into the personal and professional characteristics that may influence pharmacists’ engagement in patient-centered care. In the bivariate analysis, multiple variables were significantly associated with mean KAP scores. Notably, full-time pharmacists demonstrated significantly higher mean knowledge scores compared to part-time pharmacists, a finding that remained consistent in the multiple regression model. This may be attributed to increased patient exposure, more consistent clinical interactions, and greater opportunities to apply and reinforce knowledge in daily practice. Full-time pharmacists may also benefit from greater access to continuing professional development or in-service training opportunities offered by employers. However, despite the plausibility of these explanations, we were unable to identify existing research that specifically compares knowledge scores between full-time and part-time pharmacists. In the attitude domain, male pharmacists had significantly higher mean scores than their female counterparts in the bivariate analysis, and gender remained an independent predictor in the regression model. This gender difference may reflect variations in confidence levels or communication styles, although evidence on gender and counseling attitude remains mixed and context-dependent. For example, a study conducted in Jordan found that male pharmacists exhibited significantly more positive attitudes toward providing extended community pharmacy services compared to females. The authors suggest that this disparity may be influenced by greater domestic caregiving responsibilities among female pharmacists, which could limit their availability or willingness to engage in additional services. ²⁸ Conversely, other research on pharmacists’ attitudes toward expanding prescribing roles found that female pharmacists had higher mean attitude scores than males. ⁴⁰ Additionally, some evidence from Middle Eastern settings suggests that male pharmacists may be more likely to hold senior or independent roles in community pharmacies, which could contribute to greater autonomy and more positive perceptions of the counseling role. ⁴¹ Education level also showed a strong and consistent association with attitude. Pharmacists holding a Master’s degree scored the highest, followed by PharmD holders, and then Bachelor’s degree graduates. This supports the notion that advanced academic training enhances not only knowledge but also professional disposition and readiness for patient engagement. These findings align with those of Chan et al., who reported that healthcare professionals trained in advance care planning exhibited significantly higher levels of perceived clinical relevance, willingness, and confidence compared to those without such training. ⁴² Similarly, a study examining pharmacists’ attitudes toward expanding their prescribing roles found that those holding a PharmD degree had higher mean attitude scores compared to those with postgraduate or BPharm degrees. ⁴⁰ This suggests that advanced clinical training, such as that provided in PharmD programs, may enhance confidence and willingness to engage in expanded patient care roles, including proactive counseling. Further supporting this, a study investigating the effects of postgraduate training in depression care found that pharmacists who received specialized training engaged in longer consultations and provided more comprehensive counseling, including discussions on lifestyle and psychosocial factors. ⁴³ In the practice domain, both years of experience and counseling volume were significantly associated with practice scores in the bivariate analysis. However, only counseling volume emerged as an independent predictor in the multiple regression model. The significance of counseling frequency highlights the importance of practice-based learning and routine involvement in patient care. These findings are consistent with previous literature indicating that the time spent on counseling is a significant predictor of counseling practice quality. ⁴⁴

The correlation analysis revealed a statistically significant positive relationship between pharmacists’ attitude and practice scores (r = 0.2431, p = 0.0091), indicating that those with more positive attitudes toward hypertension counseling were more likely to engage in consistent and effective counseling practices. This finding is important because it reinforces the notion that fostering favorable attitudes among pharmacists may directly contribute to improved patient care behaviors. ^{45– 48} It also supports the theory proposed in the KAP model, where attitude serves as a motivational bridge between knowledge and actual practice. ⁴⁹ Interestingly, no significant correlations were observed between knowledge and either attitude (r = -0.0621, p = 0.5113) or practice (r = -0.0338, p = 0.7210), suggesting that knowledge alone may not predict how pharmacists feel about or implement hypertension counseling in practice. It highlights the reality that knowledge, while essential, is not always sufficient to drive behavioral change without concurrent improvements in attitude and system-level enablers.

This study highlights that while a majority of community pharmacists in the UAE possess good knowledge regarding hypertension counseling, gaps remain in attitudes and practice, with less than half demonstrating a positive attitude and just over half reporting good counseling practices. Significant associations between KAP domains and demographic factors such as employment type, education, experience, and patient load suggest areas for targeted intervention. Enhancing training opportunities, reinforcing guideline-based practice, and integrating structured counseling frameworks in community pharmacy settings may help strengthen the pharmacists’ role in hypertension management and improve patient care outcomes.

This study received ethical approval from the Institutional Ethics Committee of Gulf Medical University (Ref. no. IRB/COP/STD/29/Nov-2021). All procedures were conducted in accordance with established ethical standards and relevant regulatory guidelines. Data collection was anonymous, with no personally identifiable information obtained. Informed consent was obtained electronically through an online process. Before beginning the survey, participants reviewed a consent page outlining the study’s purpose, its relevance to pharmacy practice, and its potential value to healthcare outcomes. Consent was confirmed by selecting an “I agree” option, which was required to access the questionnaire. Participation was entirely voluntary, and all necessary measures were taken to ensure confidentiality and protect participant privacy.