Palestinian pharmacists’ knowledge of issues related to using psychotropic medications in older people: a cross-sectional study

Purpose The purpose of this study was to assess the knowledge of pharmacists practicing in Palestine of issues related to using psychotropic medications in older people. Methods The study was conducted with a cross-sectional observational design using a questionnaire. A total of 400 pharmacists responded to a 19-statement knowledge test related to the use of psychotropic medications in older people. The study was conducted from July 2016 to February 2017. The reliability and internal consistency of the study tool was assessed using the test-retest method and the Cronbach alpha. Categorical groups were compared using the chi-square test and the Spearman rank correlation. Results On the 19-statement knowledge test, the median score was 55.3% with an interquartile range of 21.9%. In a comparison of the demographic and practice-related variables of the pharmacists who scored ≥ 50% on the 19-statement knowledge test with those who scored < 50%, age, gender, and having taken a course on psychotropic medications were found to be significantly associated with performance, as shown by the chi-square test and Spearman correlation. Conclusion Pharmacists practicing in Palestine possess less than optimal knowledge of issues related to the use of psychotropic medications in older people. Continuing educational interventions and/or training might be helpful in improving pharmacists’ knowledge of issues related to using psychotropic medications in older people.


Introduction
The provision of healthcare services has reduced mortality rates and increased life expectancy around the world. Consequently, the world's population is aging and the number of older people is incre asing dramatically. Older people often suffer chronic mental disor ders and consequently utilize psychotropic medications. Recently, the utilization of psychotropic medications by older people was re ported to be increasing [1]. Pharmacists are trusted and easily acces sible healthcare professionals who are expected to provide healthcare for patients, including older people, who use psychotropic medica tions. As experts in medication use, pharmacists can play an indis pensable role in caring for patients, including older people, promot ing the rational use of psychotropic medications, and helping patients obtain the best benefits from their medications. To provide optimal healthcare services, pharmacists are expected to have an adequate knowledge of medications. Assessing pharmacists' knowledge of vari ous aspects of medications could be a part of licensing examinations and can serve as a quality measure in practice [24]. The purpose of this study was to assess the knowledge of pharmacists practicing in Palestine of issues related to using psychotropic medications in older people.

Study design
The study was conducted among practicing Palestinian pharma cists with a crosssectional observational design using a questionnaire. The study questionnaire was based on previous studies conducted elsewhere [5,6]. Participants responded to a 19statement knowledge eISSN: 1975-5937 Open Access Palestinian pharmacists' knowledge of issues related to using psychotropic medications in older people: a cross-sectional study http://jeehp.org J Educ Eval Health Prof 2017; 14: 8 • https://doi.org/10.3352/jeehp.2017. 14.8 test related to psychotropic medication use in older people. Respon dents had to choose either 'true,' 'false,' or 'I don't know' for each item. Respondents were awarded one point for each correct answer and zero point for choosing the 'I don't know' option. If the respondent selected the wrong answer, half a point was deducted as a penalty for guessing [7]. Final scores were calculated for the 19statement knowl edge test as the percentage correct, which ranged from 0% to 100%.
Demographic and practicerelated details such as age, gender, place of residence, academic degrees, number of years in practice, and prac tice settings were also collected from each participant. Additionally, participants were asked if they had taken a course on psychotropic medications during their pharmacy degree programs. The study par ticipants completed the questionnaire in privacy in their workplaces in approximately 25 minutes. This study was conducted without any financial incentives.

Study subjects
The sample size required for this study was estimated using a sam ple size calculator (www.raosoft.com). The estimated population of pharmacists in Palestine is approximately 6,000. Using a confidence interval (CI) of 95% and a margin of error of 5%, a sample size of about 360 pharmacists was required for this study. In this study, 500 pharmacists were approached and invited to respond to the question naire. The inclusion criteria were as follows: (1) having a basic or ad vanced degree in pharmacy, (2) being licensed to practice in Palestine, and (3) being willing to complete the study questionnaire. Pharmacy assistants and trainees were excluded. Pharmacists were visited in their workplaces by field researchers who explained the study objectives to potential participants and obtained verbal consent. In Palestine, a pharmacist can obtain a license to practice pharmacy after complet ing either a bachelor's (BSc) degree in pharmacy or a doctor of phar macy (PharmD) degree and passing a licensing examination [7]. To ensure representativeness, pharmacists were recruited from different regions of the West Bank of Palestine. A convenience sampling tech nique was used to recruit the sample required for this study. The study was conducted from July 2016 to February 2017.

Reliability of the study questionnaire
To test the stability of scores over a short period of time, the test retest method was used. Questionnaires were completed by a group of 25 pharmacy graduates twice after allowing a time interval of 30 minutes to 1 hour between each administration. Correlations among the score percentages obtained by the same persons in both adminis trations were evaluated using Pearson correlation analysis. As in pre vious studies, a Pearson correlation coefficient of > 0.80 was set a pri ori as indicative of acceptable testretest reliability [4,7,8]. The Cron bach alpha was used to ensure that the questionnaire was internally consistent. Cronbach alpha values in the range of 0.70-0.95 were considered acceptable.

Statistics
The statistical analysis was performed using IBM SPSS for Win dows ver. 21.0 (IBM Corp., Armonk, NY, USA). The normality of the distribution was assessed using the KolmogorovSmirnov test. As the data were not normally distributed, medians were used, with the lower (Q1) and upper quartiles (Q3). To calculate the interquartile range (IQR), Q1 was subtracted from Q3. Pharmacists were consid ered to have passed the 19statement knowledge test if they scored ≥ 50%. The Pearson chisquare test was used to compare categorical groups. The Spearman rank correlation was used to correlate vari ables with score percentages. Pvalues ≤ 0.05 were considered to in dicate statistical significance.

Ethical approval
This study was reviewed and approved by the institutional review board of AnNajah National University (IRB approval no. May27 2016).

Results
The testretest reliability of the questionnaire was excellent, as in dicated by a Pearson's correlation coefficient of 0.95 (95% CI, 0.90 to 0.97) with a Pvalue of < 0.01. The Cronbach alpha of this ques tionnaire was 0.74, indicating good internal consistency of the items used. Raw data were available from Supplement 1.  The questionnaire was completed by 400 of the 500 pharmacists initially invited, giving a response rate of 80%. The demographic and practice details of the pharmacists who took part in this study are shown in Table 1.
A total of 330 (82.5%) of the pharmacists who participated in this study were younger than 35 years old and 201 (50.3%) were men. The vast majority of them had a basic degree in pharmacy, and 234 (58.5%) of the pharmacists stated that they had taken a course on psychotropic medications during their pharmacy degree program (Table 1).
On the 19statement knowledge test, the median score was 55.3%, with an IQR of 21.9%. On some questions, a considerable percent age of the pharmacists responded with 'I don't know' instead of guess ing the answer incorrectly. Details of the response distribution for each item of the 19statement knowledge test are shown in Table 2.
In a comparison of the demographic and practicerelated variables of the pharmacists who scored ≥ 50% on the 19statement knowl edge test with those who scored < 50%, age, gender, and having tak en a course on psychotropic medications were found to be significant ly associated with performance, as shown by the chisquare test and Spearman correlation analysis. The associations of the demographic and practicerelated variables with knowledge are shown in Table 3.
Other demographic and practicerelated variables, such as place of residence, academic degrees, number of years in practice, and practice setting, were not significantly associated with knowledge (Table 3).

Discussion
In this study, pharmacists' knowledge of issues related to pharma cotherapy using psychotropic medications in older people was assessed.
http://jeehp.org Our results extend previous assessments of pharmacists' knowledge of issues related to excipients, the pharmacotherapy of epilepsy, wom en's issues in epilepsy, and autism [3,4,7,8]. To the best of our knowl edge, this study is the first assessment of pharmacists' knowledge of psychotropic medication use in older people in Palestinian pharmacy practice. In this study, a reliable and internally consistent tool was used. Our results showed that the statements included in the knowl edge test varied in the level of difficulty, as shown by the answers of the participants. The sample included participants from both gen ders and different age groups, geographical locations, experience, and practice settings (Table 1). This ensured representativeness of the com munity of Palestinian pharmacists.
Pharmacists are trained as experts in medications, and in modern healthcare systems they are indispensable sources of information who are supposed to help patients make better use of their medications.
To do so, pharmacists should be knowledgeable about issues related to pharmacotherapy; in our study, this was assessed in terms of using psychotropic medications in older people. Although the median score on the 19statement knowledge test used in this study was modest (55.3% with an IQR of 21.9%), some areas of good knowledge can be highlighted.
When asked about the dosage of psychotropic medications ( Table  2, statements 1-4), 286 (71.5%) of the pharmacists knew that the dose of antipsychotics or benzodiazepines should be reduced in older people due to altered metabolism rate and higher sensitivity. Of the pharmacists, 279 (69.8%) knew the recommended daily dose of ris peridone in older people with severe behavioral disorders in demen tia, and a similar percentage knew that lowdose hypnosedative medi cations given over the short term might reverse the physiological chang es in sleep patterns in older people. However, only 159 (39.8%) could correctly answer the statement on the recommended daily dosage of olanzapine in older people with severe behavioral disorders in demen tia. In general, the pharmacists surveyed in this study gave more cor rect answers than the nurses in the study of Wauters et al. [6] in Bel gium. Today, the role of the pharmacist goes beyond merely dispens ing medications. Pharmacists can play an important role in helping physicians select the appropriate dosage, as it has been reported that pharmacistdirected interventions promoted dose optimization [9,10]. However, lack of knowledge can limit the potential role of pharma cists in caring for patients and might jeopardize the health of their patients.
The performance of the pharmacists on statements related to the selection of appropriate psychotropic medications varied by state ment (Table 3, statements 5-11). Of the pharmacists surveyed, 339 (84.8%) knew that when nonpharmacological therapies fail, hyp nosedatives are to be used for the treatment and minimization of anxiety disorders, 298 (74.5%) knew that antipsychotics can have a place in the treatment of delirium, 294 (73.5%) knew that hypnosed atives should be administered for a short period of time in old peo ple, 288 (72%) knew that antipsychotics reduce delusions and hal lucinations, 256 (64%) knew that antipsychotics are preferred to benzodiazepines for sedating older patients with severe agitation or delirium, 222 (55.5%) knew that antipsychotic medications are pre ferred over behaviororiented therapy in older people with dementia, and 212 (53%) knew that diazepam is not appropriate for use in older people. Again, the pharmacists in this study performed better than the Belgian nurses in the study of Wauters et al. [6]. Pharmacy as a profession is evolving. Pharmacists are often consulted by physi cians in selecting the most appropriate medications for patients [9]. Therefore, the knowledge of pharmacists should be optimized. Fail ing to help physicians choose the appropriate psychotropic medica tion for an older patient might have severe negative consequences on the health of the patient concerned. Many pharmacy schools have realized this and revised their pharmacy curricula accordingly, in an attempt to acquaint pharmacy graduates with an optimal level of knowledge [11].
In this study, the performance of pharmacists on statements relat ed to the dosage and selection of the appropriate psychotropic medi cations was better than their performance on statements related to the side effects of psychotropic medications (Table 3, statements [13][14][15][16][17][18][19]. Of the pharmacists, 334 (83.5%) knew that antipsychotics are associated with anticholinergic side effects, 314 (78.5%) knew that hypnosedatives can lead to dependence, 303 (75.8%) knew that ben zodiazepines impair memory in older people, 268 (67%) knew that atypical antipsychotics can lead to weight gain, 251 (62.8%) knew that haloperidol was associated with akathisia and antipsychotics in creased the prevalence of falls, 237 (59.3%) knew that antipsychotics cause postural hypotension, and 217 (54.3%) knew that antipsychot ics increase the risk of cerebrovascular accidents. Despite gaps in knowl edge, again, pharmacists in this study showed better knowledge than those reported in nurses in the study of Wauters et al. [6]. As experts on medications, pharmacists need to be knowledgeable of side effects and drugdrug interactions, including those of psychotropic medica tions. If well acquainted, pharmacists can play a prominent role in resolving medicationrelated problems [9]. Pharmacists' inability to alert patients as well as their physicians of the potential side effects of psychotropic medications might severely impact the health of the patients and might limit the role that pharmacists could play in car ing for patients.
Interestingly in this study, younger pharmacists had better knowl edge than their older counterparts (Table 3). This could be attribut ed to the inclusion of more information about psychotropic medica tions in current pharmacy curricula [11]. Female pharmacists also performed better than their male peers. In previous studies, gender was shown to be associated with knowledge among pharmacy stu dents. Contrary to our findings, Umair Khan et al. [12] showed that male pharmacy students were more knowledgeable than their female peers about the side effects of medications. In the same study, phar macy students were more knowledgeable of side effects of medica tions and reported more positive attitudes regarding their capacity to handle and report these side effects than medical students. In this study, taking a course on psychotropic medications during the phar macy degree program was significantly associated with scoring 50% or above on the knowledge test (Table 3). Our results were concor dant with those previously reported among pharmacists in Palestine [4]. Pharmacists who had taken courses on antiepileptic medications were more knowledge of issues in the pharmacotherapy of epilepsy. Designing courses on psychotropic medications and incorporating issues related to the use of these medications in older people might enhance pharmacists' knowledge. Incorporating practical sessions in pharmacology and pharmacotherapy might have positive effects on the knowledge, attitudes, and skills of pharmacists [13]. Recently, it has been reported that practical training programs increased learning motivation among pharmacy students [14]. Similarly, using comput er simulations was shown to enhance knowledge of medications and pharmacology [15].
Our results should be interpreted with some limitations in mind. First, a convenience sampling strategy was used. However, a repre sentative sample was included in this study, and a sample size calcu lator was used to determine the sample size. The sample included participants from both genders, different age groups, locations, and practice settings, which might have promoted representativeness and reduced bias. Second, respondents had to choose 'true,' false,' or 'I don't know' for each test item. The use of this tool could have un derestimated or overestimated the knowledge of pharmacists, as their performance could have been different if the test was based on mul tiplechoice questions [3]. Third, the test included questions in the form of statements. Respondents' performance could have been dif ferent if casebased scenarios were included in the test [4]. However, the study tool used in this study was previously used in another set ting [6]. Again, the tool was tested for testretest reliability and inter nal consistency before the study was conducted. Finally, we deducted half a point for each wrong answer. This could be viewed as conser vative and might have resulted in underestimating pharmacists' knowl edge of psychotropic medications.
In conclusion, our findings suggest that despite some areas of good knowledge, pharmacists possess less than optimal knowledge in issues related to the use of psychotropic medications in older people. Phar macists who were females, less than 35 years of age, and had taken a course on psychotropic medications during their pharmacy degree program possessed better knowledge that their male, older peers who had not taken a course on psychotropic medications during their phar macy degree program. Future studies should explore the potential of continuing education or training interventions to improve knowledge about psychotropic medication use in older people.