Pharmaceutical Care in Children Self-reported knowledge , attitudes and competency of final-year pharmacy students in Jordan

Objectives
Pharmacists require a baseline level of knowledge in paediatric pharmaceutical care in order to be able to adequately care for paediatric patients and counsel their families. This study aimed to explore the self-reported knowledge, attitudes and competency of final-year pharmacy students in Jordan regarding paediatric pharmaceutical care.


Methods
This study took place in Jordan between November 2016 and May 2017. A 28-item questionnaire was designed and administered to 400 students from all pharmacy programmes in Jordan during their final year of training.


Results
A total of 354 students agreed to take part in the study (response rate: 88.5%). Most respondents (95.2%) were aware of the term 'paediatrics'. However, almost one-third of the respondents (30.5%) reported never having taken paediatric dose calculation courses and more than half (55.6%) were unfamiliar with the term 'off-label medicines'. Moreover, most respondents (65.1%) had low knowledge scores (≤2 out of 5) when presented with realistic paediatric case scenarios. There were no significant differences in knowledge and attitudes between undergraduate and doctoral students or between those from public or private universities (P >0.05).


Conclusion
The findings of this study highlight an alarming deficiency in paediatric pharmaceutical knowledge among final-year pharmacy students in Jordan. As such, paediatric-related content should be emphasised in the pharmacy curricula of Jordanian universities so that pharmacy students receive more formalised education and more extensive training in this area.


C
2][3][4] Due to advances in paediatric medicine, the increasing complexity of childhood diseases and unique dosing and pharmacokinetic challenges, there is growing need to educate pharmacists in basic paediatric competencies.Furthermore, it is estimated that the use of prescription medications among paediatric patients is substantial; according to the Centers for Disease Control and Prevention, 14-20% of patients under 19 years old surveyed in 2008 reported having used at least one prescription drug in the preceding month. 5,6As a result, pharmacy curricula should emphasise a minimum level of paediatric pharmacotherapy competence; this could potentially help to lower the rate of paediatric medication errors. 1,7he provision of pharmaceutical care to children can be challenging, especially with regards to the appropriate drug, dosage and route of administration.Because of their relative lack of chronic ailments, children usually require fewer medications compared to adults; this, compounded with the various ethical and logistical barriers to studying the effects of medications among children, means that there are very few medications licensed for use among children. 4Medications without the proper marketing authorisation are referred to as 'unlicensed' , while off-label medications indicate licensed medicines which are prescribed or used in a manner not consistent with recommendations, for instance in terms of dose, route of administration or recommended age.
According to the United Nations, 37.7% of the population in Jordan is under 14 years old. 8Moreover, pharmacists in Jordan often act as primary care providers as, for financial reasons, they are often the first and only port of call for healthcare advice and medicine use by patients.Wazaify et al. also reported that pharmacists in Jordan often dispense non-prescribed medications, including antibiotics. 9As such, it is imperative that pharmacists in Jordan have the necessary knowledge to provide safe and adequate care to paediatric patients, including the information needed to dispense medications and counsel paediatric patients or their guardians. 7,10owever, due to a lack of national guidelines regarding paediatric care, pharmacists often rely on knowledge received during their education and training.The present study aimed to explore the self-reported knowledge, attitudes and competency of final-year pharmacy students in Jordan regarding paediatric pharmaceutical care, including assessment, treatment and dosage.To the best of the authors' knowledge, this is the first study to directly explore pharmacy students' perceptions and attitudes regarding this topic.

Methods
This study took place in Jordan between November 2016 and May 2017 and involved all 400 final-year undergraduate (Bachelor of Science) and postgraduate (Doctor of Pharmacy) students from all pharmacy programmes in Jordan.Only students who had completed ≥85% of the credit-hours required for graduation at their specific university were included.A survey was designed to assess the students' knowledge, attitudes and competency regarding paediatric pharmaceutical care.2][13][14][15][16][17] Subsequently, the survey was examined by experts in the fields of clinical pharmacy, pharmacy practice and paediatrics to determine the fitness for purpose and face and content validity of the instrument.The final version of the questionnaire was then tested in a pilot group of 50 final-year pharmacy students who were not included in the full study.The instrument was deemed valid, with a Cronbach's alpha coefficient of 0.87 for internal consistency.
The final English-language questionnaire consisted of 28 items and was divided into four sections.The first section (items 1-7) collected the participants' demographic information to allow for the examination of variability in responses according to various characteristics.Section two (items 8-14) aimed to explore respondents' knowledge of paediatric treatment and dosing.The third section (items 15-22) explored respondents' perceptions of their abilities regarding paediatric treatment and dosing.The final section (items 23-28) consisted of five realistic case scenarios covering common paediatric complaints [Table 1].These case scenarios were chosen based on the recommendations of colleagues specialising in paediatric therapeutics and were assessed by a panel of experts prior to their inclusion in the survey.For each case scenario, the participants had to choose the single correct response out of five multiple-choice options; each correct answer received one point while wrong answers were scored as zero.The total knowledge score for the section was calculated by summing the correct answers, with five being the highest score, indicating perfect knowledge, and zero the lowest, indicating a complete lack of knowledge.
The students were invited to take part in the survey at the end of specific lectures, as determined by appropriate members of the administration at each university.Before distributing the questionnaire, one of the researchers introduced the study to the students and briefly described the contents and purpose of Pharmaceutical Care in Children Self-reported knowledge, attitudes and competency of final-year pharmacy students in Jordan e470 | SQU Medical Journal, November 2018, Volume 18, Issue 4 the survey.Students were informed that completion of the questionnaire would take approximately 10 minutes In order to avoid duplicate responses, all students who had previously completed the questionnaire were asked to leave the room.The questionnaires were collected as soon as they were completed.
Following data collection, the survey responses were coded and entered into a customised database using the Statistical Package for the Social Sciences (SPSS), Version 21.0 (IBM Corp., Armonk, New York, USA).Descriptive results were presented as means and standard deviations for continuous variables and percentages for qualitative variables.A simple linear regression analysis was performed to identify factors significantly affecting knowledge scores.All tests were two-tailed.A P value of ≤0.05 was considered statistically significant.
This study received ethical approval from the Institutional Review Board of King Abdullah University Hospital, Ar Ramtha, Jordan (#20160191).All students were informed that participation in the study was voluntary in nature.All participants provided informed written consent before completing the questionnaire and were assured of the anonymity and confidentiality of their data.

Results
A total of 354 students took part in the study (response rate: 88.5%).The majority were female (81.1%) and Jordanian (78.8%).In addition, most students (76.3%) were enrolled in public universities, such as the University of Jordan (37%) and the Jordan University of Science & Technology (39.3%).As students in Jordan are able to register for more credit-hours in order to graduate earlier, there was a range of fourth-, fifth-and sixth-year students [Table 2].
Most respondents (95.2%) were aware of the term 'paediatrics' , with 86.7% reporting having gained this knowledge during their pharmacy education.However, almost one-third of the respondents (30.5%) reported having had no exposure to paediatric dosing or dose calculation courses during their education.Moreover, 55.6% were unfamiliar with the concept of off-label or unlicensed paediatric medicine use.Overall, the majority of the students (81.1%) reported that there was a need for more paediatric-related topics to be incorporated into the curriculum [Table 3].In terms of their perceived ability to deal with and treat paediatric patients after graduation, many respondents were either unsure or believed that they would not be able to recommend treatment for paediatric patients (55.7%), calculate paediatric doses (40.1%), counsel the parents or guardians of paediatric patients (44.9%) or monitor side-effects in children (49.2%) [Table 4].
With regards to their responses to realistic paediatric case scenarios, most students scored either one (33.9%)or two (28.2%) points out of five [Figure 1A].In addition, there was a greater percentage of incorrect compared to correct responses for each case scenario, except for the case scenario involving fever [Figure 1B].Overall, there were no significant differences in the students' knowledge, attitudes or competency according to type of degree or university attended (P >0.05).

Discussion
The present study sheds light on the self-reported knowledge, attitudes and competency of final-year pharmacy students in Jordan regarding paediatric pharmaceutical care, including assessment, treatment and dosage.Although a previous study investigated the paediatric content of pharmacy curricula in different countries, the current study is, to the best of the authors' knowledge, the first to directly explore pharmacy students' perceptions and attitudes regarding this topic. 18Overall, the current study exposed a perceived lack of paediatricrelated content in the pharmacy curricula of Jordanian universities, with most students highlighting the need for the inclusion of more paediatric-related topics in their courses.This raises concerns regarding the ability of newly-graduated pharmacists to deal with paediatric cases.Pharmacists should be sufficiently knowledgeable of paediatric pharmaceutical care so as to ensure that paediatric patients are prescribed suitable, safe and effective medications. 194][25] Generally, the majority of pharmacy-related errors occur when a pharmacist is not able to identify prescription errors, gives incorrect drug administration instructions or mislabels a medication. 26There is considerable evidence to suggest that a well-trained pharmacist can reduce the rate of medication errors, specifically in younger children, for whom such errors can be fatal. 27,28n the current study, more than half of the students reported being unfamiliar with the concept of off-label or unlicensed paediatric medicine use during the course of their education.0][31] A previous study in Scotland found that 30% of pharmacists were unaware of off-label medicine use in children, with the majority of respondents having gained such knowledge in clinical practice rather than during their formal education. 30Both general practitioners and paediatricians have reported receiving insufficient information regarding off-label and unlicensed medicine use in children during undergraduate education. 29,31lmost one-third of respondents in the current study reported not having taken any paediatric dose calculation courses during their education.][34] Compared to adults, dosing in paediatric patients is individualised and may depend on different factors for each case. 35Accordingly, extra caution should be taken when dealing with paediatric dosages, especially when dispensing medications with a narrow therapeutic index. 36verall, respondents in the current study had grave concerns regarding their ability to deal with and treat paediatric patients.This highlights the importance of covering such topics in pharmacy courses.][31] Pharmacy students should therefore be trained to deal with paediatric patients and their parents in communication courses.Furthermore, dose calculations and adjustments should be covered extensively in pharmacokinetics courses to ensure that future pharmacists are able to dispense medicine in accurate doses and reduce the frequency of dosing errors in children.Another important factor is the ability to monitor side-effects in children; previous research has shown that pharmacists often fail to detect and report adverse drug reactions. 37urther education regarding pharmacovigilance, specifically in paediatric patients, will optimise the role of future pharmacists in paediatric pharmaceutical care.Another suggestion is to mandate postgraduate certification courses in paediatrics prior to actual practice.
Worldwide, there is growing recognition that pharmacy education needs to be developed and improved so as to better prepare graduates to provide paediatric pharmaceutical care. 11,38In the current study, most respondents had low knowledge scores when faced with basic real-life paediatric scenarios.Alarmingly, although the cases covered only simple ailments which are very common in paediatric care (e.g.diaper rash, teething, constipation, etc.), most students were unable to answer *For each of the five case scenarios, correct responses were given a score of one, with total scores of zero and five corresponding to no or perfect knowledge, respectively.
correctly.Moreover, such students were in their final year of study and would very soon be registered pharmacists.This finding is therefore of major concern and highlights the importance of hands-on paediatric training along with formal education. 39A didactic educational approach that fails to include a research component and incorporates only minimal hands-on training may lead to pharmacists lacking real-world experience and being unable to deal with general and primary care cases. 40,41ne obstacle in Jordan may be the large number of students per class in pharmacy schools, especially in public universities.The implementation of a pre-registration year of practice for pharmacy graduates may positively influence their ability to deal with different patient populations, such as children. 41n the present study, no significant differences in knowledge or attitudes were noted between final-year pharmacy undergraduate and doctoral students according to type of degree.This finding was unexpected as doctoral students undergo more specialised paediatric education in the form of a compulsory course in paediatric therapeutics and a hospital rotation in paediatric wards.Given this additional training, it might be supposed that such students should display greater knowledge or enhanced clinical abilities when faced with paediatric case scenarios. 42Furthermore, no significant differences were observed between pharmacy students at public or private universities.It should be noted that all university programmes and curricula in Jordan are subject to the guidelines and recommendations of the Accreditation and Quality Assurance Commission for Higher Education Institutions, thereby leading to similar curricula for the majority of pharmacy programmes in the country.
This study was subject to several limitations.Firstly, no measures were taken to ensure that students did not consult or refer to external sources when answering knowledge questions; however, this is unlikely considering the low knowledge scores.Secondly, the participants' knowledge was scored on a Likert rather than a binomial scale; the latter might have allowed for more in-depth analysis of the responses in comparison to the participants' demographic characteristics and potentially reduced bias.Thirdly, some of the questions may have been difficult to answer due to the wording, which could have been clearer; thus, clarity may have affected the validity of the findings.Furthermore, items in the questionnaire were perhaps too general-for example when inquiring about respondents' knowledge of the term 'paediatrics'-however, this was deemed necessary as the study took place in an Arabic-speaking country where laypeople may not be aware of such terms.Nevertheless, the current study was exploratory in nature and these findings could be considered a benchmark for further in-depth studies in paediatric pharmacy education.

Conclusion
Pharmacists play a vital role in assuring the safe and effective administration of medications to paediatric patients.The results of this study revealed that, according to final-year pharmacy students, the current pharmacy curricula taught during undergraduate and doctoral programmes in Jordan is insufficient with regards to paediatric pharmaceutical care.The students had low confidence regarding their ability to deal with paediatric patients, with most not able to make correct recommendations during basic case scenarios, counsel children and their parents/guardians or calculate correct drug dosages.Pharmacy students should therefore undergo more extensive education and training in these areas, perhaps during a mandatory pre-registration year of practice.

Figure 1 :
Figure 1: Distribution of (A) total knowledge scores* and (B) correct and incorrect responses among final-year pharmacy students in Jordan presented with realistic paediatric case scenarios (N = 354).
a c k n o w l e d g e m e n t s The preliminary version of this study was presented at the Health Services Research and Pharmacy Practice Conference on 12-13 April 2018 at the University of Newcastle, Newcastle upon Tyne, UK.An abstract of this oral presentation was published in the International Journal of Pharmacy Practice in March 2018, Volume 26, Issue S1, Pp. 9-10.

Table 1 :
Five realistic case scenarios to assess paediatric pharmaceutical knowledge among final-year pharmacy students in Jordan

Table 2 :
Demographic characteristics of final-year pharmacy students in Jordan (N = 354)

Table 3 :
Knowledge and attitudes of final-year pharmacy students in Jordan regarding paediatric pharmaceutical care (N = 354)

Table 4 :
Self-reported competency of final-year pharmacy students in Jordan regarding paediatric pharmaceutical care (N = 354) Pharmaceutical Care in Children Self-reported knowledge, attitudes and competency of final-year pharmacy students in Jordan e472 | SQU Medical Journal, November 2018, Volume 18, Issue 4