Analyzing Community Pharmacists’ Knowledge and

Behavior Regarding the Sale of Functional Foods at

Pharmacy Retailers in the Mekong Delta, Vietnam
Huong V.T.M. Vo
Can Tho university of medicine and pharmacy
Hung P.N. Nguyen (  [email protected] )
Can Tho university of medicine and pharmacy
Vinh N. P
Ho Chi Minh City Medicine and Pharmacy University
Minh N.T.T. Nguyen
Can Tho university of medicine and pharmacy
Minh T.N. Tang
Can Tho University
Toan P.T. Pham
Can Tho university of medicine and pharmacy

Research Article

Keywords: Selling behavior, functional foods, knowledge, attitude, behavior, factor analysis

Posted Date: January 18th, 2024

DOI: https://doi.org/10.21203/rs.3.rs-3857829/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Additional Declarations: No competing interests reported.

 ANALYZING COMMUNITY PHARMACISTS’ KNOWLEDGE AND
BEHAVIOR REGARDING THE SALE OF FUNCTIONAL FOODS AT
PHARMACY RETAILERS IN THE MEKONG DELTA, VIETNAM

Huong V.T.M.1, Hung P.N.2*, Vinh N.P3, Minh N.T.T.4, Minh T.N.5, Toan P.T.6

1
Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Can Tho University of
Medicine and Pharmacy, Can Tho, Viet Nam
2
Department of Pharmaceutical management, Faculty of Pharmacy, Can Tho University of
Medicine and Pharmacy, Can Tho, Viet Nam
3
Ho Chi Minh City Medicine and Pharmacy University, Dinh Tien Hoang, District 1, Ho Chi
Minh city, Viet Nam
4
Department of Foreign languages, Faculty of Basic Sciences, Can Tho University of Medicine
and Pharmacy, Can Tho, Viet Nam
5
Can Tho University, Can Tho, Viet Nam
6
Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam

*Corresponding author: Hung Phuc Nguyen, Department of Pharmaceutical management,

Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam, 84;
E-mail: [email protected]; Phone number: (+84)909754664

ORCIDs:
− Huong Vo Thi My: 0000-0002-9904-7719
− Hung Phuc Nguyen: 0000-0003-3747-2776

ABSTRACT

Background: After the Covid-19 pandemic, there has been a notable increase in people's
demand for and usage of functional foods at pharmacy retailers. Consequently, the role of drug
sellers in providing guidance and recommendations for the use of functional foods has become
increasingly significant. However, the knowledge of drug sellers about functional foods remains
limited, often resulting in inaccurate or inappropriate advice to consumers. Objectives: The
study was conducted to analyze the knowledge and behavior of drug sellers in selling functional
foods at pharmacy retailers in the Mekong Delta, Vietnam. Subjects and methods: A cross-
sectional descriptive study was conducted through a survey of drug sellers at pharmacy retailers
in the Mekong Delta during the period from June 2022 to March 2023. The questionnaire was
constructed using the following factors based on the theory of planned behavior (TBP) model,
consisting of 32 observed variables. Results: Of the 575 drug retailers participating in the study,
drug sellers with good knowledge accounted for 52%. The scale exhibited reliability, with both
Cronbach's Alpha coefficients exceeding 0.7 and variable-total correlation surpassing 0.3.
Exploratory Factor Analysis indicated that the constructed scale is of high quality. Multivariate
regression analysis showed that “Perceived behavioral control” affects the selling behavior of
functional foods among drug sellers at drug retailers. Conclusion: Considering the selling
behavior of functional foods by drug sellers during their professional practice is vital to ensure
the health benefits of consumers and promote the development of the functional food market.

Keywords: Selling behavior, functional foods, knowledge, attitude, behavior, factor analysis.

I. Introduction

Currently, functional foods are one of the industries with strong growth in most countries
in the world [1]. According to a report by Precedence Research, the market size of functional
foods accounted for $305.4 billion in 2020 and is predicted to reach $597.1 billion by 2032 [2].
Developed countries like the United States, the United Kingdom, and Denmark report that 35-
60% of adults use functional foods [3]. Further studies indicate that in some countries such as
Palestine, Jordan, Spain and Sweden, the use of functional foods has become very popular in
community health care [1, 4].

In Vietnam, functional foods defined in the Law on Food Safety are foods used to support
the function of the human body, create a comfortable condition, increase resistance, reduce the
risk of disease, including supplements, health protection foods, nutraceutical foods [5]. Since the
Covid-19 pandemic, the functional food market has shown robust growth in terms of both
quantity and quality. According to statistics of the Food Safety Administration, in Vietnam, there
are approximately 30.000 functional food products with registered and self-declared numbers in
circulation [6]. In 2021, in the report of the Functional Food Association, more than 80% of the
Vietnamese population consumed functional foods, including health foods, supplements, and
fortified foods. It can be seen that the demand for functional foods has increased significantly in
public health care in Vietnam today.

The Mekong Delta holds a crucial position in our country's socio-economic development
strategy and represents a potential market for the business and distribution of functional foods.
Unfortunately, the provision of inaccurate information and excessive advertising about the use
of functional foods from drug sellers at some pharmacy retailers not only hinders the
achievement of optimal results but also poses serious health risks to individuals. For instance, it
can lead to an increased risk of bleeding due to vitamin E overdose or teratogenic effects from
prolonged overdose of vitamin A. Although functional foods can be effective in certain clinical
conditions, such as blood cancer treatment [7], their improper use can result in severe public
health consequences, for example, liver toxicity associated with the use of turmeric-based
functional foods [8]. Therefore, drug sellers play an important role in providing advice and
guidance for the safe, sensible, and effective utilization of functional foods [9].

Following this, the present study aimed to analyze the knowledge, attitude, and behavior
of drug sellers concerning the sale of functional foods at pharmacy retailers in the Mekong Delta.
II. Subjects and Research methods

2.1. Research design: A cross-sectional descriptive study collected data through a survey
conducted with drug sellers at various pharmacy retailers across the Mekong Delta region. The
participants willingly agreed to take part in the study by completing an online questionnaire via
the Google Forms platform from June 2022 to March 2023.
2.2. Research methods.

2.2.1. Developing a set of research questions:

The study conducted a comprehensive review of literature concerning drug sellers'

behavior in selling functional foods [10-12]. Subsequently, the researchers synthesized and
carried out preliminary research using qualitative research methods and interview techniques.
We engaged in discussions with a group of five experts, including individuals from state health
management agencies in Vietnam, university lecturers, and hospital pharmacists. Preliminary
interviews were also conducted with over 10 drug sellers. The objective was to discuss,
supplement, remove inappropriate scales and adjust the content of each comment to align with
the research objectives. The study focused on drug sellers at drug retailers in the Mekong Delta,
Vietnam. Afterward, the study proceeded with an initial survey involving 70 drug sellers in
pharmacy retailers.

After collecting the data, Cronbach's alpha and Exploratory Factor Analysis (EFA) were
used to remove unreasonable items. Cronbach's alpha value of 0.6 or higher is considered
satisfactory for use [13] and EFA was assessed using the following indicators: (i) Factor loading
> 0.3; (ii) Kaiser–Meyer–Olkin coefficient (0.5 ≤ KMO ≤ 1); (iii) Bartlett test is statistically
significant (Sig. < 0.05); and (iv) Percentage of variance > 50%. Additionally, a preliminary
evaluation of the scale's convergence value and differentiation value was conducted
simultaneously.

The study obtained a formal scale consisting of 61 questions (variables), distributed

across 5 components, namely: (1) Knowledge of functional foods (K); (2) Attitudes about the
sale of functional foods (A); (3) Subjective norms (SN); (4) Perception of behavioral control
(PBC); (5) Intention (I).

The contents of the survey questions include:

- General information:

General information about pharmacy retailers (13 questions): types of pharmacy, number
of functional foods sold per day, geographical location.

Information about drug sellers (10 questions): gender, professional level of pharmacy,
job position of drug sellers.
 - Knowledge of functional foods (22 questions) is assessed using a set of questions with
a total score of the composite knowledge score (22 questions). Each correct answer is awarded
1 point, and the scores are classified into three levels [14]: Poor (<50% of the total score or less
than 4 points), Average (50% - 70% of the total score, ranging from 4 to 5 points), Good (>70%
of the total score, equivalent to 6 points or more).

Method of evaluation: To calculate the percentage of consumers in the knowledge group,

divide the number of consumers who answered the right number of questions in the knowledge
group by the total number of consumers surveyed, and then multiply by 100.

- Attitude (11 items); Subjective norms (11 items); Perception of behavior control (10
items); and Intention (3 items) are evaluated using the Likert-5 scale, a commonly used scale in
scientific research questionnaires for assessing individual opinions, behaviors, and perceptions.
In this study, responses to the questions were scored as follows: 1 = 'Strongly disagree', 2 =
'Disagree', 3 = 'Partially agree', 4 = 'Agree', 5 = 'Strongly agree'.

2.2.2. Sample size and sampling method:

To conduct Exploratory Factor Analysis (EFA), the sample size must be large and
determined based on the minimum size and the number of measurement variables included in
the analysis. According to Serena Carpenter, the minimum measurement variable ratio is 5:1;
that is, 1 measurement variable needs a minimum of 5 observation samples. Given that the scale
of this study, after calibration, consists of 61 questions, the minimum sample size required is
305. In this study, we gathered a sample of 575, which is suitable based on the required sample
size conditions [15].

Sampling Method: The sampling method employed was convenience sampling. The
research subjects were interviewed using either a printed questionnaire or Google Forms. The
target was to interview 45 drug sellers per province in the 13 provinces of the Mekong Delta.

Selection criteria:

Pharmacies and pharmacy counters are selling functional foods and are operational
during the study period.

Exclusion criteria:

+ Pharmacies, pharmacy counters belonging to medical establishments, pharmaceutical

enterprises, regional polyclinics.

+ Drug sellers who respond in a specific order or do not complete the survey in full or
decline participation in the study.

2.2.3. Research model: The research uses a model with five variables and 61 questions based on
Ajzen's "Theory of Intended Behavior" (TPB) (1991) to predict actual behavioral determinants
with high accuracy, including: Knowledge (K): drug sellers' understanding of functional foods,
the role of nutritional supplements, positive effects, undesirable effects, and drug interactions
associated with the use of functional foods; Attitude (A): evaluation and perception of functional
food sellers; Subjective noms (SN): the sale of functional foods by drug sellers affected by factors
such as revenue and profitability of pharmacy retailers; Perception of behavioral control (PBC):
belief in the positive influence of functional food sales and control of issues related to the sale
of functional foods; Intent (I): (The intention of drug sellers to sell functional foods) [16]. (Figure
.1)

Knowledge (K)

Attitude (A)

Subjective norm (SN) Perceived Behavioral

Control (PBC)

Intention
(I)

Behavior (B)

Figure. 1. Study model

2.2.4. Data analysis

Cronbach's Alpha test, invented by Lee Cronbach in 1951, is a very common tool in
scientific studies used to measure the reliability of a scale. The value varies from 0 to 1.
According to the theory, this coefficient is proportional to the scale's reliability. However, if it is
0.95 or higher, it suggests that some items are redundant; they essentially ask the same question
but in different forms, indicating a duplication in the scale. Conversely, if the value is low, it
may be due to a small number of questions, and poor relationships between the items (which can
be improved by modifying or removing some items). The acceptable value is typically in the
range of 0.7 to 0.95. A value greater than or equal to 0.3 is considered [17, 18].

Exploratory Factor Analysis (EFA) is a multivariate statistical method that reduces a

large number of variables or factors into a smaller set, establishing the basic dimensions between
the measured factors and the underlying structures. The criteria in EFA analysis include assessing
the suitability of the sample size by using the Kaiser–Meyer–Olkin (KMO) coefficient, which
should range from 0.5 to 1 to be considered reasonable. Additionally, Bartlett's test must be
significant (p < 0.05), and the distribution load factor (Factor loading) should be at least 0.3 or
higher. If the load factor is 0.5 or higher, it indicates that the observed variable is statistically
significant. Furthermore, the total variance extracted should be greater than or equal to 50%, and
structures with eigenvalues greater than 1 should be retained for interpretation. The most
commonly used rotation method for EFA analysis is the rotation method developed by
Thompson (2004) [19, 20].

Kolmogorov–Smirnov test is used to test and compare the distribution of sample data with
the theoretical distribution. In this study, the K–S test is employed to check the normal
distribution of the set of average values of functional food sellers' intention to sell [21].

Confirmatory Factor Analysis (CFA) is a statistical method used to assess the suitability
of a measurement model with actual data. Factor analysis confirms that CFA is a quantitative
analysis method that helps determine how certain latent variables (factors) contribute to
explaining the variation in a group of observed variables (indicators). This method enhances the
reliability and validity of the measurements, improves the appropriateness of the models, and
aids in deriving more accurate conclusions and solutions in the study [22, 23].

Structural Equation Modeling (SEM) is a second-generation statistical analysis technique

developed to analyze the multidimensional relationship between multiple variables in a model24.
Multiple relations between variables can be represented in a series of single and multiple
regression equations. The linear structural modeling technique uses a combination of quantitative
data and correlational assumptions (cause-effect) into the model.

With SEM, researchers can visually examine the relationships that exist between
variables of interest. The measurement model clearly shows the relationship between latent
variables and observed variables. It provides information about the measurement properties of
the observed variable (reliability, validity). The structural model clearly indicates the relationship
between latent variables to each other. These relationships can describe the theoretical
predictions that researchers are interested in [25].

2.3 Research ethics

This study has been approved by the Ethics Council in Biomedical Research of Can Tho
University of Medicine and Pharmacy (Approval Number 22.002.Teacher/PCT- HDDD dated
May 10, 2022). The survey process is based on voluntary participation, ensuring participant
anonymity.
III. RESULTS

3.1. Characteristics of the study sample.

The characteristics of drug sellers and pharmacy retailers are shown in Table 1.

Table 1. Describe the characteristics of drug sellers and pharmacy retailers

Frequency
CHARACTERISTIC Proportion(%)
(n=575)
DRUG SELLERS
Male 180 31.3%
Gender
Female 395 68.7%
Professional degree Post-Graduate 39 6.8%
Undergraduate 237 41.2%
Intermediate 257 44.7%
42 7.3%
Druggist

Pharmacy’s owner 305 53.0%

Employee 178 31.0%
In charge of 83 14.4%
Role of the drug seller
professional affairs
Internship 7 1.2%
others 2 0.3%
PHARMACY RETAILERS
Private Pharmacy 550 95.7%
Type of pharmacy
Chain Pharmacy 25 4.3%
<5 242 42.1%
Number of functional foods
5 –10 255 44.3%
sold daily
> 10% 78 13.6%
City 174 30.3%
Geographical location Suburb 189 32.9%
Countryside 212 36.9%

The research noted the characteristics of drug sellers as follows: female account for
68.7%, while male account for 31.3%. Additionally, 44.7% have an intermediate level of
pharmacy training, and 53.0% are pharmacy’ owners. Regarding pharmacy retailers, 95.7% are
private pharmacies; 44.3% of these establishments sell 5-10 functional foods per day, and 36.9%
of them are located in countryside.

3.2. Characteristics relevant to knowledge, attitude, and behavior of drug sellers in selling
functional food at pharmacy retailers in the Mekong Delta

3.2.1. Characteristics relevant to knowledge of drug sellers

3.2.1.1. The percentage of drug sellers who accurately answered knowledge questions about
functional food

A description of the proportion of drug sellers who answered correctly knowledge

questions about functional foods is shown in (Table 2).

Table 2. A description of the proportion of drug sellers who answered correctly knowledge
questions about functional foods
True False
Questions
n % n %
Functional food is not medicine. 568 98.8% 7 1.2%
Functional food cannot replace drug treatment. 548 95.3% 27 4.7%
Only pharmacies can sell functional food. 206 35.8% 369 64.2%
Functional food is solely sold at pharmacies or pharmacy
267 46.4% 308 53.6%
counters.
The pharmacy has a separate area for selling functional food. 547 95.1% 28 4.9%
Employees who directly sell dietary supplements must wear
separate protective clothing and are not permitted to smoke or 376 65.4% 199 34.6%
spit in the business area.
Functional food is not necessary for individuals who are already
280 48.7% 295 51.3%
in good health.
Functional food must be used at the correct dosage and time. 468 81.4% 107 18.6%
It's advisable to start by using functional food with a low dosage
313 54.4% 262 45.6%
at first use.
Do not use many functional foods at the same time. 473 82.3% 102 17.7%
Unless prescribed by a doctor, do not use functional foods on a
475 82.6% 100 17.4%
regular and long-term basis.
Functional food cannot replace daily food. 100 17.4% 475 82.6%
Functional food is appropriate for anyone. 170 29.6% 405 70.4%
It's important to use functional food under the advice and
512 89.0% 63 11.0%
guidance of a doctor, pharmacist, or the person in charge.
Functional food can cause undesirable side effects, even
493 85.7% 82 14.3%
threatening life if improperly used.
Functional food causes allergies. 493 85.7% 82 14.3%
Functional food can potentially cause adverse interactions with
486 84.5% 89 15.5%
drugs that are being used.
Customers should visit a doctor before using functional food. 427 74.3% 148 25.7%
Customers can improve their health issues by changing their
living mode, nutrition, and lifestyle instead of using functional 501 87.1% 74 12.9%
food.
Acid folic (vitamin B9) helps reduce the risk of congenital
498 86.6% 77 13.4%
defects in pregnant women.
 Excess iron causes nausea, vomiting, and even damage to the
514 89.4% 61 10.6%
liver and other organs of the body.
Interaction between vitamin K and anticoagulants (warfarin)
214 37.2% 361 62.8%
leads to consequences.
The study recorded that the percentages of drug dispensers who accurately answered
questions regarding dietary supplements. Notably, 98.8% correctly identified that functional
foods are not medicines, 1.2% acknowledged their lack of knowledge about dietary supplements,
and 95.3% accurately stated that functional foods can’t replace drug treatment.
3.2.1.2. Reality of community pharmacists' knowledge of functional food
A description of the current state of knowledge of pharmacists about functional foods is
presented in Table 3.
Table 3. A description of the current state of knowledge of pharmacists about functional foods
Feature Quantity (n=575) Proportion (%)
Poor 49 8.5%
Knowledge Average 227 39.5%
Good 299 52.0%
The study found that drug sellers had the highest proportion of good knowledge about
functional foods (52.0%) and poor knowledge accounted for the lowest proportion at 8.5%.
3.2.1.3. Factors affecting knowledge scores about functional food among drug sellers
A description of the total knowledge score according to the characteristics of the research
sample is shown in Table 4.
Table 4. A description of the total knowledge score according to the characteristics of the
research sample
Interquartile Range Average
Feature p
(IQR) rank*
1. Feature of medicine sellers
Male 16.00 (8.00) 269.66
Gender 0.073
Female 16.00 (7.00) 296.36
Post-gruadate 15.00 (6.00) 230.72
Undergraduate 16.00 (8.00) 278.93
Qualification
Intermediate 18.00 (8.00) 309.43 0.013
on Pharmacy
Druggist 16.00 (7.00) 261.25
Others 0.00 (0.00) 0.00
Pharmacy’s owner 18.00 (7.50) 291.30
Employee 17.00 (8.00) 302.75
Role of
In charge of 251.64
medicine 0.039
professional affairs 15.00 (7.00)
dealers
Internship 15.50 (15.00) 168.64
Others 0.00 (0.00) 397.50
2. Feature of medicine retail facilities
Types of Private Pharmacy 16.00 (7.00) 292.12
0.005
Pharmacy Chain Pharmacy 12.00 (12.00) 197.42
<5 16.00 (8.00) 279.48 0.012
 Numbers of 5 – 10 18.00 (8.00) 308.13
functional 248.63
foods sold >10
daily 15.00 (8.00)
City 15.00 (6.25) 270.42
Geographical
Suburb 17.00 (7.00) 274.12 0.012
Location
Countryside 16.50 (8.00) 314.81
* The average rank is the mean value of the rank of all observed variables in each sample.
A higher score in a group indicates a greater impact of that group on knowledge.
The study examined the total knowledge scores based on characteristics of the study
sample, including types of pharmacies, numbers of functional foods sold daily, geographical
locations, professional degrees, and the roles of medicine dealers and drug sellers, revealing
statistically significant differences (P ≤ 0.05). These features influence the knowledge of drug
sellers regarding functional foods.
3.2.2. Characteristics relevant to the reliability of the scale assessed by Cronbach’s Alpha
coefficients.
Characteristics relevant to the reliability of the scale assessed by Cronbach’s Alpha
coefficients are presented in Table 5.
Table 5. Characteristics relevant to the reliability of the scale assessed by Cronbach’s Alpha
coefficients
Cronbach’s
Variable - Alpha
Cronbach’s
total coefficients
Survey variables Alpha
correlation when
coefficients
coefficients excluded
variables
ATTITUDE
A1. Almost all functional foods are properly
0.486 0.799
consulted by medicine sellers.
A2. Almost all functional foods are properly used
0.573 0.793
by customers.
A3. A medicine seller is a person who has an
important position (skills and knowledge) to
0.480 0.800
provide advice and consultation on the use of
functional foods to customers.
0.815
A4. Currently, the sale of functional foods
0.671 0.785
supports the improvement of public health issues.
A6. The customer's condition may become more
0.322 0.812
serious if they do not use functional foods.
A7. Selling functional foods helps customers
0.509 0.797
avoid side effects from using drugs.
A8. Selling functional foods along with medicine
0.619 0.789
helps patients get quick treatment results.
A9. Selling drugs without dietary supplements
makes customers distrust the quality of drug 0.374 0.808
sellers at the pharmacy or pharmacy counter
A10. If customers do not use functional foods,
they will have to use more medicine to recover 0.351 0.810
from the disease.
A11. Selling functional foods helps me have
more experience to consult for my customers in 0.650 0.787
the future.
A13. Selling functional foods improperly reduces
the reputation of the pharmacy or pharmacy 0.430 0.804
counter.
SUBJECTIVE NORMS
SN2. If I refuse to sell functional foods, many
0.628 0.848
other places will also sell them.
SN3. Customers’pressure forced me to sell
0.548 0.853
functional foods to them.
SN4. Customers do not object to me selling
0.612 0.849
functional foods to them.
SN5. Many other pharmacists sell functional
0.662 0.845
foods like me.
SN6. The pharmacy’s owner required me to sell
0.650 0.846
functional foods when customers requested it.
SN7. The functional food supplier wants me to
0.543 0.853
sell more functional foods.
0.864
SN8. If the pharmacies refuse to sell functional
foods, customers will not return to the pharmacies 0.464 0.858
or pharmacy counters again.
SN9. Selling functional foods helps increase the
revenue and profits of pharmacies or pharmacy 0.664 0.845
counters.
SN10. Many medicine experts recommend not
0.558 0.852
abusing functional foods.
SN11. My professors recommend not to abuse
0.455 0.858
functional foods.
SN12. Newspapers and television warn against
0.400 0.862
abusing functional foods.
PERCEIVED BEHAVIORAL CONTROL
PBC1. I have sufficient knowledge to proactively
consult and supply functional foods to customers 0.611 0.914
when they request them. 0.918
PBC2. I have sufficient knowledge to proactively
0.680 0.910
consult and supply functional foods for customers
 to use along with medications to support disease
treatment.
PBC3. Functional foods customers require are
0.583 0.916
safe and suitable for most users.
PBC4. Functional foods I dispense are safe and
0.723 0.908
suitable for most users.
PBC5. No one objected to me selling functional
0.684 0.910
foods when customers requested them.
PBC6. During my practice, I regularly sold
functional foods when customers requested them 0.702 0.909
and had no bad feedback about them.
PBC7. I have proactively consulted customers
about using those functional foods and achieved 0.744 0.907
effective results in similar cases.
PBC8. Customers have used those functional
foods and achieved effective results in similar 0.764 0.906
cases.
PBC9. I have used those functional foods and
0.742 0.907
achieved effective results in similar cases.
PBC10. The functional foods that I supply to my
customers are always available at pharmacies or 0.711 0.909
pharmacy counters.
INTENTION
I2. I will sell functional foods if the customer is
0.721 0.733
an acquaintance.
I3. I will sell functional foods if the customer is
0.774 0.704 0.818
also a healthcare professional.
I4. I will sell functional foods if the customer has
0.720 0.731
economic conditions.
After checking the reliability level using Cronbach's Alpha, 4 variables were excluded
(A5, A12, SN1, I1), the remaining 35 observed variables had a variable-total correlation
coefficient > 0.3 and a reliability coefficient. Cronbach's Alpha > 0.6 is satisfactory, so we
continue to undergo exploratory factor analysis (EFA).
3.2.3. Results of exploratory factor analysis (EFA)
3.2.3.1. Results of exploratory factor analysis (EFA) for independent variables
The results of the exploratory factor analysis (EFA) for independent variables are shown
in Table 6.
Table 6. Results of exploratory factor analysis (EFA) for independent variables
Factors
Observed variables
1 2 3
A3 0.981
A9 0.980
A10 0.977
 A6 0.974
A7 0.974
A8 0.970
A1 0.969
A13 0.968
A4 0.965
A2 0.962
A11 0.950
SN8 0.940
SN11 0.931
SN12 0.930
SN10 0.930
SN4 0.886
SN9 0.876
SN5 0.872
SN6 0.865
SN3 0.863
SN2 0.859
SN7 0.847
PBC9 0.911
PBC5 0.901
PBC1 0.876
PBC8 0.832
PBC7 0.766
PBC4 0.753
PBC2 0.729
PBC10 0.674
PBC6 0.661
PBC3 0.610
Eigenvalue 4.357
Extracted variance(%) 81.730%
KMO 0.949 (0.5 ≤ KMO ≤ 1)
The study recorded that the extracted variance value reached over 70% (81.730%); KMO
coefficient = 0.949 (0.5 ≤ KMO ≤ 1); and Sig value (significance level) of the Bartlett test (0.000
< 0.05: satisfies the condition); three groups of factors extracted at Eiganvalue = 4.357 (>1) all
satisfied the conditions. Accordingly, the subsections are redivided into 03 new factors based on
the correlation between the subsections and the factors. Thus, the variables retained after EFA
analysis all satisfy the condition that the loading factor is greater than 0.5, so convergent and
discriminant validity are achieved.
3.2.3.2. Results of exploratory factor analysis for the dependent variable
Include the 3 observed variables of the Intention factor in the EFA analysis and the results
are presented in Table 7.
Table 7. Description of exploratory factor analysis (EFA) results for the dependent variable
 Observed variables Factors
I2 0.928
I3 0.907
I4 0.860
Eigenvalues 2.424
Extracted variance(%) 80.801%
KMO 0.716
The study recorded satisfactory results with KMO = 0.716. Barlett's test with Sig value
= 0.000, Eigenvalue = 2.424 (> 1), and one factor was extracted. Total variance extracted =
80.801%, which is greater than 50%, satisfying the condition. The EFA analysis was conducted
using observed variables of the dependent component "(I): Intention".

3.2.4. Confirmatory factor analysis (CFA) results

Confirmatory factor analysis results are shown in Figure 2. and Table 8.

Figure 2. Confirmatory factor analysis results (CFA)

 Table 8. Standardized factor loadings confirmatory factor analysis results (CFA)
CMIN/DF GFI CFI TLI RMSEA p AGFI
2.056 0.911 0.987 0.984 0.043 0.000 0.809
The study recorded CFA results indicating that the model achieved TLI = 0.984, CFI =
0.987, GFI = 0.911 (> 0.9). Furthermore, RMSEA = 0.043 (< 0.08) and Chi-square/df = 2.056
(< 3), all of which are consistent with actual data.
The results of testing convergent validity and discriminant validity are presented in Table 9.

Table 9. Description of results of testing convergent validity and discriminant validity

CR AVE MSV MaxR(H) A SN PBC I
A 0.997 0.968 0.171 1 0.984
SN 0.97 0.748 0.206 0.998 0.062 0.865
PBC 0.927 0.563 0.254 0.933 0.413*** 0.281*** 0.751
I 0.886 0.722 0.254 0.906 0.165*** 0.454*** 0.504*** 0.85

The study notes that concepts exhibit AVE > MSV and √AVE is greater than the
correlation between concepts, confirming their distinctiveness. In addition, the scale of the
concepts all achieved convergent validity, with values of CR ranging from 0.808 to 0.916 (>
0.7). The research model is consistent with market data and suitable for subsequent CB-SEM
analysis.
3.2.5. SEM test results
Description of SEM test results is shown in Fig 3. and Table 10.
 Figure. 3. Description of SEM test results

Table 10. Standardized factor loadings of SEM test results

CMIN/DF GFI CFI TLI RMSEA p AGFI
1.757 0.924 0.991 0.989 0.036 0.000 0.900
The study recorded the results of testing the theoretical model with 479 degrees of
freedom, chi-square = 841.732 (p = .000) and CMIN/DF = 1.757 < 3. The indices TLI = 0.989,
GFI = 0.924 (values from 0 to 1 are good values) and CFI = 0.991, all greater than 0.08, signify
a good model fit. Besides, since these coefficients are greater than 0.9, the model is considered
satisfactory. The RMSEA value was 0.036, less than the acceptable threshold of 0.08, indicating
that the model fits the data well.
IV. Conclusion
4.1. The characteristics of the research sample

In the study conducted between 2022 and 2023, a total of 575 drug sellers who met the
research criteria were included in the analysis. Among them, the proportion of female drug sellers
(68.7%) is higher than that of males (31.3%). This proportion aligns with the findings of Langer
B. and Kunow C. (2019) in [26] and Al-Taani GM et al [27] illustrating a notable difference in
the male-to-female ratio. This difference can be attributed to the nature of drug retailing, which
demands meticulousness, care, and patience-qualities that women often possess in abundance,
making them well-suited for the job. In addition, women often seek employment in more stable
and less volatile work environments compared to men. Regarding professional qualifications,
the majority of drug sellers hold an intermediate level of qualification (44.7%). This finding
contrasts with studies on the knowledge, attitudes, and behaviors of drug sellers like the one
conducted by Budh Sitrakool [28], where the majority of drug sellers possessed university
pharmacist degrees. This variation can be ascribed to Vietnam Pharmacy Law No.
105/2016/QH13, issued on April 6, 2016, which regulates pharmacy policies in Vietnam [29].
The law permits intermediate pharmacists to establish pharmacy counters in districts, communes
and suburbs of provinces and centrally run cities. Consequently, the number of intermediate-
level pharmacists in the Mekong Delta provinces accounts for a large number. Moving on to job
position, the highest proportion (53%) of drug sellers are pharmacy owners, a pattern consistent
with P.N. Hung and colleagues' findings in Can Tho City, Vietnam (2023) [30]. This correlation
can be explained by the prevalence of private pharmacy retailers in Vietnam.

The study observed that the majority of pharmacies (95.7%) are privately owned, which
is similar to a study conducted by Brunelli L. and colleagues in Italy [31]. The high prevalence
of private pharmacies can be attributed to the increasing demand for public healthcare services,
which public facilities are unable to fully satisfy. Therefore, the development of private drug
retail facilities is very necessary. Considering geographical location, pharmacy retailers
concentrated in rural areas make up the largest share (36.9%), differing from the findings of
Shakya, Sujyoti et al [32] who reported a higher concentration of pharmacy retailers in urban
areas (54.2%). Such disparity arises from the specific characteristics of national policies,
geographical locations, and the socio-economic development of each region worldwide.
4.2. The knowledge, attitudes, and behaviors of drug sellers regarding functional foods
4.2.1. The characteristics of drug sellers' knowledge about functional foods

The study found that a high percentage of drug sellers have good knowledge about
functional foods (52%), which is similar to the findings by Emiru, Y. K., and colleagues in 2019
(66.7%) [33] and Bukic J. et al. in 2021 [10]. Among them, the question to which most drug
sellers responded correctly was that functional foods are not drugs (98.8%), stemming from the
provisions of the Pharmacy Law 2016 (Law No. 105/2016/QH13) and Food Safety Regulation
(Decree No. 15/2018/ND-CP) in Vietnam. These regulations provide specific distinctions
between functional foods and drugs. In addition, Circular 02/2018/TT-BYT, dated January 22,
2018, which regulates Good Practices for pharmacy retailers [34], provides instructions on the
proper arrangement of separate areas for functional foods and medications to prevent any
confusion. This outcome indicates the effective implementation of pharmacist training programs
and regulations pertaining to the sale of functional foods in Vietnam.

The study revealed that drug sellers who own pharmacies tend to have higher levels of
knowledge compared to their counterparts who are employees. A study conducted by Emiru, Y.
K., and colleagues in Ethiopia [33] also corroborated these findings. This is due to the fact that
pharmacy owners must meet specific expertise, qualifications, and regulatory requirements for
knowledge updates in order to open and operate a drug retail facility, aligning with government
regulations [34].
4.2.2. The reliability characteristics of the scale through Cronbach's Alpha coefficient and the
results of exploratory factor analysis, confirmatory factor analysis, and linear structure (SEM)

The study developed a comprehensive scale to assess the knowledge, attitudes, and
behavioral factors of drug sellers involved in the sale of functional foods at pharmacy retailers
in the Mekong Delta based on Ajzen's 'Theory of Planned Behavior' (TPB) [16] and relevant
published studies [10, 27, 31-33, 35 ]. The obtained test results demonstrate high reliability, as
evidenced by the robust Cronbach's Alpha values: Attitude (α = 0.815), Subjective Norms (α =
0.864), Perceived Behavioral Control (α = 0.918), and Intention (α = 0.818). In EFA analysis,
the factors achieved convergent and discriminant validity, so all variables were retained.
Compared to previous studies on the behavior of drug sellers selling functional foods, for
example, those conducted by Emiru, Y. K. et al in Ethiopia (2019) [33] and Altamimi M.,
Hamdan M. et al. in Palestine (2021) [35], the present study performed a more in-depth analysis
of key factors, including the Subjective Norm, Perceived Behavioral Control, and Intention. The
developed scale evaluates various aspects related to drug sellers' intention to sell functional foods
with a relatively high level of reliability when compared to previous studies. Using a 5-level
Likert scale proves to be a practical, accessible, and time-saving method of data collection. This
scale enables drug retailers to have objective information, aiding them in formulating appropriate
and effective strategies to improve community health.
The sample size for the study during the questionnaire and scale evaluation stage consists
of 305 samples, meeting the necessary criteria based on Cronbach's Alpha and EFA testing.
However, it's important to note that this sample size may not fully represent the entire population.
In the survey and analysis of the behavior of drug sellers involved in the sale of functional foods,
a substantial sample size of 575 participants was utilized, which is larger than that used in some
previous studies. This sample included a diverse range of professional qualifications, subjects,
and working positions within pharmacy retailers. Nevertheless, the sampling approach was not
stringent and should be made more specific and clear.

The discriminant value testing of component concepts within each concept reveals strong
discrimination between these concepts. The CFA results exhibit favorable indices, with TLI,
CFI, and GFI all exceeding 0.9, indicating the model's suitability and compatibility with real
data. Furthermore, the RSMEA index < 0.08 and CMIN/FD < 3 demonstrate the model's
appropriateness and its reflection of scale unidimensionality. These findings match with prior
research by [36, 37].

According to Bentler and Bonett (1980) and Kline (2023), the closer the TLI, CFI, and
GFI index values are to 1, the more suitable the model is considered. The model's TLI, CFI, and
GFI indices are 0.924, indicating a good fit. At the same time, RMSEA > 0.08 is satisfactory
with 95% confidence. This result is completely consistent with the research theory presented in
the theoretical basis of the study. In summary, the intention to sell functional foods is influenced
by attitudes, subjective norms, and perceived behavioral control, and these effects are all positive
and statistically significan [38, 39].
4.3. Strengths and limitations of the study
 Currently, there's a scarcity of studies analyzing the knowledge, attitudes, and behaviors
of drug sellers engaged in the sale of dietary supplements at retail establishments in the Mekong
Delta. Therefore, the findings from this study can serve as a foundational database for future
research. However, the research was halted at the questionnaire development stage, focusing on
investigating the situation of functional food sales by drug sellers. As a result, a deeper analytical
exploration is essential to comprehend how various factors influence drug sellers' intentions to
sell functional foods. Furthermore, this research was time-constrained. Hence, further studies by
researchers and policymakers should aim to acquire more insights from drug sellers, pharmacy
retailers, and related factors to supplement this study.
Conclusion
The study developed a scale that comprises one dependent factor (Intention) with three
observed variables and three independent factors (Attitude, Subjective Norm, Perceived
Behavioral Control) with a total of 32 observed variables. The test results show that the scale has
high reliability and validity. This scale can serve as a trustworthy reference for future surveys on
the dietary supplement selling behavior of drug sellers in other areas.
Declaration
Ethical approval and consent to participate
This study has been approved by the Ethics Council in Biomedical Research of Can Tho
University of Medicine and Pharmacy (Approval Number 22.002.Teacher/PCT- HDDD dated
May 10, 2022). The survey process is based on voluntary participation, ensuring participant
anonymity.
Consent for publication
N/A.
Availability of data and materials
The data is provided within the manuscript.
Competing interests
The authors declare there are no competing interests related to this paper.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial,
or not-for profit sectors.
Authors' contributions
Huong V.T.M., Hung N.P.:, methodology, validation, investigation, resource; Minh N.T.T.:
writing- review and editing; Toan P.T.: investigation, resource; Vinh N.P.: conceptualization,
project administration; supervision, methodology; Minh N.T.: methodology, validation, formal
analysis.
Acknowledgement
The authors would like to express sincere thanks to Can Tho University of Medicine and
Pharmacy, together with state management agencies of Mekong Delta. Without their persistent
support, this paper would not be thoroughly possible.
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