**4. Discussion**

The extreme psychological pressure felt by health care providers in the last year could affect not only patients, but also entire public healthcare systems [11,12]. However, pharmacists were required during this challenging pandemic to enlarge their traditional pharmaceutical activities and to ensure a primary point of care and triage for many patients [31–33].

A strong statistical correlation was found between discomfort and specific symptoms and mental functions among the pharmacists who participated in our study. Our study did not underline the higher vulnerability to psychological impact during the COVID-19 pandemic among female pharmacists, as other studies [34]. Batra et al. reported higher levels of depression, distress and behavioral dysfunctionalities among female health workers who have prolonged contact with patients [5]. The mental health impact of COVID-19 pandemic has been noticed in more than 50% of pharmacists, and some studies even highlighted higher rates of burnout among pharmacists in comparison with nurses and physicians [35]. Another study, conducted by Lange et al. [36], showed that approximately 35% of community pharmacists reported mental health disturbances (anxiety, stress, insomnia, sense of losing control, fear, hopelessness [37]), with females being more affected [36]. These results, coming from the very first studies analyzing the psychological impact of COVID-19 pandemic among community pharmacists, in the French region of Normandy [37], are not consistent with our results because of the different period of the studies. The same results about the level of quality of life of Romanian young physicians during COVID-19 pandemic were obtained, with no association between gender and distress [38].

Furthermore, our study included more specialists and older pharmacists from Romania, which could be characterized by better ability to assist, emergency preparedness and probable stress coping mechanisms due to longer experience [35]. Thereby, we noticed that Romanian pharmacists reported a better quality of life, whereas Bulgarian pharmacists reported more sleeping disturbances, distress and depression. Our statistical correlations proved that Bulgarian pharmacists had more difficulties in coping with usual activities, also underlining the mental pandemic burden.

Dror et al. [39] mentioned that first-line medical staff have less hesitancy towards vaccination against COVID-19 and its efficacy, while medical workers who have less or no contact with infected patients are more skeptical [39]. Vaccine acceptance could be increased not only by recommendations and proper information transmitted to patients by community pharmacists, who play an essential educational role, but also by pharmacists considering themselves eligible for vaccine acquiescence [39,40]. Although conditional marketing authorization for COVID-19 preventive vaccines is used in case of benefits outweighing risks for patients [14], clarifications regarding importance of vaccination are still needed among general population. Pharmacists are important pawns in the immunization campaign in both European countries included in our study, relieving the COVID-19 burden [9,41,42]. Most individuals are still skeptical and have misconceptions about receiving vaccines, even though more than 2.5 million deaths are prevented annually worldwide through vaccination programs [42]. Community pharmacists are not only able to increase vaccination rates through direct recommendations, but also by receiving approval to administer vaccines to patients [42]. One of the most important predictive factors for vaccine acceptance is the self-perception of a high risk for COVID-19, which could be achieved through medical education [39,41]. On the other hand, females are less likely to accept vaccination [39], a result consistent with our statistic, due to the higher prevalence of female pharmacists from both countries in our study.

This study offers an important insight into the quality of life of community pharmacists during COVID-19 pandemic and their perception towards vaccination. A limitation could be the lower age category for the community pharmacists who answered to this survey, which could be due to the dissemination channels we used. More professional experience accumulated over the years could have influenced the pharmacists' answers to this survey. Additionally, the timeline for the survey dissemination may have influenced the pharmacists' opinion about COVID-19 impact and, therefore, their responses may differ over time.

Another limitation of the study could be the comparison between the pharmacists' income in the two countries, since the World Bank Country classification by income sets Bulgaria and Romania in different groups (Bulgaria is upper middle income and Romania is high income) [42]. Moreover, even if the World Bank Country sets Romania in the high-income group, the actual income for community pharmacists is still very low.

Our study represents one of the first published studies that, to our knowledge, analyzes COVID-19's impact on quality of life among pharmacists in Romania and Bulgaria. We found only one study that underlined the pressure that community pharmacists are subjected to during lockdown [36]. Our work also stands as a comparison between two neighboring countries regarding psychological disturbance in community pharmacists, as front-line health-care workers. Moreover, our study is a first attempt to evaluate the consumption and recommendation of vitamin C and D among pharmacists during the pandemic.

For the European countries, an inverse correlation was described between national estimates of vitamin D levels and COVID-19 incidence [43,44] and mortality [43–45]. There is evidence that vitamin D is correlated with diminished risk and severity of COVID-19 infection through different mechanisms (decreasing the production of inflammatory cytokine, decreasing the survival and replication of viruses, preserving endothelial integrity, and augmenting angiotensin-converting enzyme 2 concentrations) [46]. The prophylactic vitamin D administration in the COVID-19 management was underscored [47]. Various studies were revised and the recommended daily dose by consensus during the COVID-19 pandemic, 2000 IU for teenagers and adults, is 20 times lower than the amount which must be taken for many months to cause toxicity [48].

Vitamin C and D supplements are easily available on the pharmaceutical market in each country, have a low risk of adverse effects, and are inexpensive. Both vitamins are recommended with precise doses for prophylaxis and treatment as part of the COVID-19 management protocol [49]. However, the results of ongoing clinical trials are expected to elucidate various aspects of the vitamin C/vitamin D relationship with COVID-19 (52 [50] and 71 [51], respectively of clinical trials registered at present on ClinicalTrials.gov). The outcomes of these clinical trials could also contribute to future training programs for community pharmacists in order to recommend vitamin C and D supplementation during the pandemic to better manage the COVID-19 burden.

Both Bulgaria and Romania are countries where a large-scale peak in COVID-19 infection would lead to overcrowded health facilities and a shortage of medical specialists. Reliability of information and control of fear and disinformation are important issues during the spread of the disease. Community pharmacies are one of the few places that are kept open for public service even during strict safety measures. They have a unique, credible role with ease of accessibility [2].

In Romania, reducing the program or patients' access to it, the installation of protective panels or air purifiers, and disinfection of surfaces and personal objects at regular intervals (less than one hour), were measures adopted in order to ease the pandemic burden for both pharmacists and patients [52]. A survey conducted by Padureanu et al. between April and May 2020, in Romania, underlined that 52% of pharmacists were satisfied with the provided

protection measures [53]. However, the same survey mentioned that 57% of pharmacists were afraid of COVID-19 exposure and infection, consistent with our results. Community pharmacists from Romania were allowed to release over-the-counter antibiotics for a correct and complete treatment of dental abscess during lockdown or whenever dental health services were blocked [52]. Elbeddini et al. showed that the increased distress was also caused by verbal abuse and harassment from patients demanding COVID-19 protocol drugs even if they did not have a prescription or were not diagnosed [9].

During the pandemic, pharmacists in Bulgaria were also in charge of additional administrative issues regarding the reporting of new paperless prescription forms, socalled "S blanks", for patients who were treated with medication prescribed with special protocols and paid by the National Health Insurance Fund (NHIF) [54]. The purpose of this was for chronically ill patients to avoid visiting their general practitioners and specialists for the issuing of a new protocol [54]. This led to an extra workload for pharmacies.

The pharmacy owners from both European countries were obliged to ensure protective gloves, safety goggles and masks for all pharmacists [52,54]. However, the Bulgarian Pharmaceutical Union (BPU) and other non-profit associations, such as the Bulgarian Medicines Verification Organization, provided some quantity of protective equipment for BPU members [54]. No governmental help was ensured, since pharmacists work in the private sector.

Further follow-up studies conducted in both countries would be informative for the society and their results could be compared with the period analyzed in the current study. The inclusion of further neighboring countries in such a comparison might bring added value and could present a broader picture of how the COVID-19 pandemic has affected community pharmacists' quality of life.
