A cross-sectional survey design was utilised to investigate community pharmacists’ current practices and knowledge regarding the management of PJDs. The study also assessed referral practices and pharmacists’ familiarity with the roles of other HCPs in PJD management.

The research was conducted among community pharmacists practising across all nine provinces in South Africa, ensuring geographic representation and aiming to reflect the diversity of community pharmacy practice nationally. Pharmacists working in other pharmacy sectors, such as hospital, wholesale or manufacturing, were excluded unless they worked as locums in community pharmacies. Although hospital pharmacists dispense medication and engage directly with patients, they were excluded because their work is confined to hospital settings, where they collaborate with healthcare teams in a controlled environment to optimise medication use, ensure safe medicine administration and provide clinical patient care; they also interact with patients who have already consulted either a medical doctor or a nurse (Amedi & Gazerani 2024; Mohiuddin 2019). Lastly, pharmacy support personnel, comprising pharmacists’ assistants (Basic and Post-Basic) and pharmacy technicians, were excluded despite their roles in interacting with patients and dispensing medication in community pharmacies (Amedi & Gazerani 2024). According to the South African Pharmacy Council (SAPC) Scope of Practice and the Pharmacy Act 53 of 1974, these cadres may dispense medicines and provide basic patient counselling only under the direct supervision of a registered pharmacist (SAPC 2024); they do not have the authorisation to perform clinical tasks or provide independent patient counselling (Amedi & Gazerani 2024). Data collection commenced on 22 August 2023 and concluded on 29 September 2024, providing participants with sufficient time to complete their responses.

The sample size was calculated based on the estimated total number of community pharmacies in South Africa, which were approximately 2500 as at November 2021, according to the SAPC’s pharmacies by sector statistics. The number of community pharmacies was used because it is a legal requirement for each pharmacy to have at least one pharmacist present (Balraj et al. 2024). The number of registered pharmacists was not used because the Bachelor of Pharmacy degree in South Africa is a generalist qualification, which allows pharmacists to move across various sectors of pharmacy. Further, the SAPC database or register might not be up-to-date with the number of pharmacists working in a particular sector at any point in time (Gray, Riddin & Jugathpal 2016). A margin of error of 2.5% and a 95% confidence level were used; a target sample size (n) = 952 community pharmacists was determined, with an expected response of 286, which is 30% of the sample size. Purposive sampling was employed.

A structured questionnaire was developed using the REDCap^® version 14.8.3 web-based system hosted at the University of the Witwatersrand to gather data via closed- and open-ended questions. Prior to completing the questionnaire, participants had to go through a study information sheet (Online Appendix 1) and provide informed consent electronically by signing the participant consent sheet (Online Appendix 2). Both documents were hosted on the secure REDCap^® online platform and made accessible electronically. The questionnaire included closed-ended questions to assess demographic details, current PJD management practices, referral behaviours and knowledge of the roles of other HCPs (Online Appendix 3). Open-ended questions were included to capture additional insights and participant recommendations.

The questionnaire was pretested through a pilot study involving seven community pharmacists to validate the questionnaire’s clarity and relevance. Feedback from the pilot informed refinements to question wording, sequencing and response options to enhance comprehensibility and contextual appropriateness. Internal consistency reliability was examined using preliminary Cronbach’s alpha values, with coefficients above 0.70 considered acceptable (Menon et al. 2021). The final instrument was therefore deemed valid and reliable for use in the main study. The responses from the pilot study were excluded from the main study.

The key variables included were:

The questionnaire was administered electronically using an online survey platform and distributed through professional associations, WhatsApp^® groups identified through professional affiliations and open groups such as those for pharmacy locums, emails to pharmacies searched online, physically visiting some of the pharmacies and social media channels.

The quantitative data were analysed using STATA^® SE 18 statistical software. Quantitative data were analysed using descriptive statistics, such as frequencies and percentages, to summarise participant characteristics and responses. The REDCap^® version 14.8.3 web-based system was used to build and manage the online survey; the data were extracted from the system in Microsoft^® Excel^® version 2411 comma-separated values format. The open-ended responses were analysed using content analysis to identify key trends and patterns, supported by the use of MAXQDA software 24.9.

Ethical approval was obtained from the University of Witwatersrand Human Research Ethics Committee (Medical) with clearance certificate number: M220344. Participants provided informed consent electronically, where they were able to review the information sheet, indicate their consent to participate, enter the date of consent and append their signature using a touchpad or mouse. Confidentiality was maintained by anonymising responses, and all data were stored securely.

In our survey, the majority of participants who completed the study were female (60.9%), which aligns with SAPC statistics indicating that as of May 2025, approximately 66.3% of registered pharmacists in South Africa were female (SAPC 2025). The racial composition of participants (54.7% black/African people and 26.5% white people, with the remainder of Indian, Asian and coloured backgrounds) reflects South Africa’s diverse population. This distribution varies from the overall SAPC register, where the majority of pharmacists are white people (40.2%), followed by black/African people (34.6%) (SAPC 2025). The underrepresentation of white pharmacists in our survey might be because of response bias; it is possible that some demographic groups were more willing or available to participate, or it could simply reflect chance. The age distribution of our respondents was skewed towards younger pharmacists, with 47.5% being 29 years or younger, and nearly 45% having less than 2 years of work experience. This likely results from our survey dissemination methods (heavy reliance on digital platforms such as email, WhatsApp and social media), which younger pharmacists may be more engaged with, as well as the possibility that early-career pharmacists were more interested in the topic or had time to respond (Bosson et al. 2023; Mohiuddin 2019).

Further analysis revealed a significant disparity in age distribution across racial groups. Among white pharmacists, 43 out of 99 (43.4%) were over the age of 50, whereas only 28 of 274 non-white pharmacists (10.2%) were above 50. A Chi-square test confirmed a strong association between race and age distribution (χ² = 49.93, p < 0.001). This skew likely reflects broader historical and systemic influences in South Africa. During the apartheid era, access to pharmacy education (and higher education in general) was disproportionately limited for non-white South Africans, resulting in an older cohort of pharmacists that is predominantly white people. Since the end of apartheid in 1994, transformation policies have expanded access to education for black, coloured and Indian individuals, leading to a newer generation of younger pharmacists from these groups entering the profession (DHET 2020; Mosiane et al. 2022).

The survey found that 84.5% of pharmacists were familiar with PJDs. Graduation timing (whether before or after 2013) and the possession of a postgraduate qualification do not appear to influence a pharmacist’s familiarity with PJDs. The distinction between pre- and post-2013 graduates was made because, in 2013, the Bachelor of Pharmacy curriculum in South Africa was formally aligned with the Higher Education Qualifications Sub-Framework (HEQSF), introducing a national shift towards outcome-based education (Mosiane et al. 2022; SAPC 2021). The observed differences in familiarity levels are likely because of random variation rather than any systematic effect of graduation timing or postgraduate education. This does not mean that postgraduate education is not beneficial. A study examining changes in pharmacists’ professional activities after completing a postgraduate qualification revealed that most participants believed their acquired skills were effectively applied in practice (Aston & Black 2009). The study further highlighted that postgraduate education improved confidence, evidence-based practice, reflective practice and critical thinking as essential and beneficial for their professional development (Aston & Black 2009). However, it has been demonstrated that the Bachelor of Pharmacy degree in South Africa equips graduates with the necessary knowledge to manage PJD, as these conditions are comprehensively covered by all the universities offering the Bachelor of Pharmacy degree (Modau, Constantinou & Orchard 2025). This is consistent with studies conducted in Canada, where pharmacists are frequently involved in screening and recommending treatments for joint conditions, including over-the-counter analgesics, and have been shown to improve patient outcomes through appropriate management and follow-up (Robinson 2019).

However, research also highlights that gaps exist in pharmacists’ knowledge, particularly regarding non-pharmacological interventions and the management of more complex cases, such as inflammatory arthritis (Cottrell et al. 2021; Robinson 2019). While pharmacists are generally familiar with first-line treatments for conditions like osteoarthritis, they may lack the specialised knowledge required for comprehensive management or for effectively referring patients to other specialists, such as physiotherapists (Cottrell et al. 2021; Robinson 2019). Furthermore, although pharmacists are capable of addressing the physical aspects of joint pain, such as recommending medications and lifestyle changes, their ability to manage these conditions holistically is often hindered by a lack of formal training and support (Cottrell et al. 2021; Robinson 2019). It is important to note that this study does not imply that pharmacists are expected to diagnose PJDs. Rather, their role lies in supporting the ongoing management of patients who have already been diagnosed and in signposting individuals with potential red flag symptoms for further medical evaluation.

The most commonly encountered PJD was gout, reported by 32.7% of the pharmacists, followed by osteoarthritis, 30.7% and rheumatoid arthritis, 30.1%. This aligns with a study conducted in the United Kingdom, which identified gout as the most common form of inflammatory arthritis, with rising prevalence rates, often managed in community pharmacies because of its recurring acute flares and chronic complications (Dickson 2022). Similarly, osteoarthritis and rheumatoid arthritis are known to be among the most prevalent PJDs globally, with osteoarthritis affecting large numbers because of ageing populations and mechanical joint stress, while rheumatoid arthritis remains common because of its autoimmune nature (Alzahrani et al. 2022; WHO 2022). Furthermore, a study conducted across nine South African universities to review the curricula on musculoskeletal conditions reported that gout, osteoarthritis and rheumatoid arthritis were comprehensively covered by all universities offering the Bachelor of Pharmacy qualification (Modau et al. 2025). The comprehensive coverage of gout, osteoarthritis and rheumatoid arthritis in pharmacy curricula equips pharmacists with a strong understanding of these conditions, making them more familiar and confident in recognising them. This familiarity likely influenced pharmacists’ responses in this study, as they are more inclined to identify and report conditions they encounter frequently in practice and feel knowledgeable about.

The study reveals that pharmacists primarily refer patients with musculoskeletal conditions, such as osteoarthritis, back pain and rheumatoid arthritis, to physiotherapists, occupational therapists and chiropractors, indicating an awareness of the need for multidisciplinary care. However, uncertainty exists regarding referrals to osteopaths, podiatrists and acupuncturists, with many pharmacists unsure of the appropriate conditions for which to refer patients to these providers. Some providers do not recognise acupuncture and alternative therapies as valid options, hindering referrals (McKay et al. 2021). Pharmacists in this study reported a strong preference for referring patients with musculoskeletal conditions to medical doctors, with 41.0% indicating they refer all such cases to them. This trend was further supported by referral frequency data, which showed that medical doctors were the most commonly referred to providers, often on a weekly or monthly basis. In contrast, referrals to physiotherapists were reported only a few times a year by many pharmacists, and referrals to other HCPs, such as occupational therapists, chiropractors, osteopaths, biokineticists, acupuncturists and podiatrists, were even less frequent or absent altogether. Furthermore, almost 40% of pharmacists reported referring fewer than 10 patients to other HCPs over 12 months. This pattern suggests an over-reliance on doctors, possibly because of limited exposure, guidance or healthcare norms.

Only a small proportion of pharmacists (2.1%) referred patients to other HCPs such as physiotherapists, biokineticists and chiropractors, highlighting a gap in interprofessional collaboration and the underutilisation of non-pharmacological expertise in managing PJDs. Timely referrals are vital when symptoms persist, worsen or require care beyond a pharmacist’s scope, helping to prevent disease progression and reduce inappropriate analgesic use (McKay et al. 2021). Other HCPs provide critical interventions, such as exercise therapy, pain management and lifestyle modification, which improve outcomes and reduce reliance on medication (McKay et al. 2021; Mujtaba & Gazerani 2024). Yet, evidence suggests that many pharmacists still overlook their role, despite growing support for multidisciplinary approaches (Mujtaba & Gazerani 2024; Thapa et al. 2021).

Pharmacists in this study primarily referred patients because of ineffective medications (36.9%) or worsening pain (13.4%), affirming their role as first-line responders in chronic pain management (Nsengimana et al. 2022; Thapa et al. 2021). Other reasons included lack of improvement, complex symptoms and concerns over medication dependency, reflecting pharmacists’ involvement in ongoing assessment and safe medication use. Notably, only 0.6% reported using formal guidelines when referring, highlighting an opportunity to promote disease management protocols and structured referral pathways (Nsengimana et al. 2022).

Two-thirds (66.7%) of pharmacists indicated their patients had consulted other HCPs for PJD management, consistent with evidence showing patients often seek care from multiple providers simultaneously (Takahashi et al. 2019; Taylor et al. 2022). However, these efforts are often uncoordinated, risking fragmented care (Takahashi et al. 2019). Encouragingly, over 80% of pharmacists expressed a desire to offer greater support, aligning with prior research that has shown knowledge gaps despite pharmacists’ willingness to manage musculoskeletal pain (Dabbous et al. 2020).

Pharmacists who wished to do more cited goals such as improving patient education, raising awareness and enhancing interprofessional collaboration. Yet, over a third (37.5%) gave no specific reason, possibly indicating uncertainty around role boundaries in musculoskeletal care. This ambivalence may stem from high workload demands or unclear expectations in expanding responsibilities (Abdul Razzak et al. 2024).

The findings reveal strong support among pharmacists for interdisciplinary care in managing PJDs. Over 90% acknowledged the importance of other HCPs in pain management, and more than 80% agreed they can positively influence disease progression, echoing evidence that multidisciplinary care can improve outcomes and slow joint degeneration. Nearly all pharmacists recognised the role of other HCPs in enhancing patient functionality, with only 0.5% in strong disagreement. These results highlight pharmacists’ awareness of the value of collaboration with other HCPs to improve quality of life for PJD patients (Mujtaba & Gazerani 2024; Thapa et al. 2021).

According to our study, 61.4% of pharmacists reported using some form of guideline when managing PJDs. However, chi-square, OR and RR analyses revealed no significant association between guideline use and familiarity with the roles of other HCPs. This may be because of the nature of the guidelines used, such as the STGs, SAMF, EMGuidance, MIMS and the WHO Analgesic Ladder, which primarily focus on pharmacological treatment without explicitly outlining interdisciplinary roles (Kredo et al. 2020).

The absence of multidisciplinary content in these resources likely limits their impact on referral behaviour. This highlights the need for structured, evidence-based referral guidelines that incorporate both pharmacological and non-pharmacological management strategies. Such tools could streamline care, support early referral, reduce healthcare costs and improve collaboration across disciplines (Cottrell et al. 2021; Dixon et al. 2023).

Additionally, keeping up with new evidence remains a challenge for practitioners, which can lead to potential gaps in optimal care delivery (Dixon et al. 2023). Tailored referral protocols could enhance consistency, clarify pharmacists’ roles in musculoskeletal care and alleviate pressure on public healthcare services through more effective community-level triage (Makhavhu, Masala-Chokwe & Ramukumba 2024). Despite these advantages, no such referral guidelines currently exist in South Africa for pharmacist-led management of PJD, and no studies have explored their specific use in this context.

The majority of pharmacists (78.2%) recommended non-selective NSAIDs as the primary over-the-counter treatment for PJDs, followed closely by colchicine (77.2%) and combinations of NSAIDs with paracetamol, opioids or muscle relaxants (58.5%). Non-steroidal anti-inflammatory drugs remain a preferred first-line option for PJDs because of their analgesic and anti-inflammatory properties (NICE 2020). Colchicine, widely used for the treatment of gout and osteoarthritis, offers an affordable and effective alternative (Li et al. 2021). Combining NSAIDs with central analgesics can enhance pain control while minimising adverse effects (Cottrell et al. 2021; Simons et al. 2022). However, concurrent use with corticosteroids is discouraged because of the heightened risk of gastrointestinal complications (Cottrell et al. 2021; Simons et al. 2022).

Over 45% of pharmacists recommended mineral and vitamin supplements, particularly those containing vitamins D and K and calcium, reflecting their emerging role in musculoskeletal health (Birlik 2023; WHO 2022). While strong evidence supports the use of vitamin D and calcium in managing bone health and osteoarthritis, the effectiveness of other supplements remains inconclusive (Aaseth et al. 2024; Lips et al. 2010). Therefore, supplementation should be patient specific and guided by current evidence in collaboration with other HCPs (Bigham 2023).

Pharmacists employed diverse counselling strategies. Dietary advice was the most common approach (23.9%), particularly for gout management, emphasising the avoidance of purine-rich and inflammatory foods in favour of whole, nutrient-rich diets (Tsigalou et al. 2020). Exercise counselling (20.4%) also featured prominently, supporting evidence of the benefits of physical activity for joint function (Alzahrani et al. 2022). Additionally, 16% of pharmacists addressed proper medication use and dependency risks, underscoring their role in preventing analgesic misuse (Mujtaba & Gazerani 2024; Thapa et al. 2021).

The study has demonstrated that pharmacists will benefit from clear referral guidelines within a structured and nationwide referral system, which will aid the evolving community care workforce and ensure that patients self-presenting at pharmacies can be formally and appropriately referred (Simons et al. 2022). The implementation of a referral pathway between other HCPs and pharmacists should be established so that medication-related issues may also be directed towards the pharmacist, reducing some of this burden for the medical doctors and reducing patients’ costs (Mujtaba & Gazerani 2024; Simons et al. 2022).

The study provides valuable insights into the role of pharmacists in managing PJDs, offering a comprehensive view of their recommendations, counselling and referral practices. By highlighting gaps in interprofessional referrals and the limited use of multidisciplinary care, the study identified critical areas for improvement while contributing to global discussions on evidence-based pharmacist-led interventions. However, the reliance on self-reported data introduces potential recall and social desirability biases, and the use of convenience sampling limits the generalisability of the findings. Additionally, the study does not assess clinical outcomes to evaluate the impact of pharmacists’ practices on patient care, and the underrepresentation of older pharmacists because of digital survey distribution may have skewed the results. Despite these limitations, the study serves as a foundation for addressing gaps in PJD management and improving pharmacist-initiated multidisciplinary care.

Future research should explore the perspectives of other HCPs to enhance interprofessional collaboration in PJD management while also investigating pharmacists’ educational needs regarding non-pharmacological and multidisciplinary approaches. Studies linking pharmacists’ interventions to patient outcomes are essential to assess their impact on disease progression and quality of life. Exploring the route followed by patients who are being treated by these HCPs will also provide valuable insights into the effectiveness of referrals. When patients with progressive joint diseases receive appropriate and timely management, clinical outcomes such as reduced pain, improved joint function, slower disease progression, enhanced mobility and better overall quality of life are more likely to be achieved. Additionally, research should address barriers to effective referrals, develop structured, locally relevant guidelines and compare South African practices with global standards to identify best practices.