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Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 147-152

Knowledge and practice of community pharmacists toward dispensing of cough medications for children Khartoum State: A cross-sectional study

1 Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Omdurman, Sudan
2 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan

Date of Submission15-Dec-2019
Date of Decision20-Feb-2020
Date of Acceptance04-Mar-2020
Date of Web Publication9-Apr-2020

Correspondence Address:
Bashir Alsiddig Yousef
Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, Khartoum 11111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_120_19

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INTRODUCTION: Cough is one of the common symptoms that alert patients to seek medical attention from physicians, which may lead to an increase in the cost of health-care services. The pharmacist is one of the medical professionals to whom parents can go for consultation and request cough medications for their children. The study aimed to assess the knowledge and practice of community pharmacists toward dispensing of cough medication for children.
MATERIALS AND METHODS: A cross-sectional study was carried out among 325 community pharmacists using a pretested, standardized questionnaire. A stratified random sampling method was used to select the participants. The knowledge and practice were assessed, and then the associations between knowledge and practice with different demographic variables were assessed using Chi-square test and analyzed using the Statistical Package for the Social Sciences.
RESULTS: Of 325 participants, the majority of them were females (74.2%) with B. Pharm (73.5%) and experienced <5 years (68.6%). About 53.8% of pharmacists were showed to have moderate knowledge, whereas 35.7% and 10.5% of them had a high and low level of knowledge, respectively. Regarding practice, 56.6% was found to show a fair level of practice, whereas 11.4% and 32% showed a good and poor level of practice, respectively. The majority of pharmacists still dispense cough medications for children <2 years despite the lack of efficacy and safety. Antibiotics were dispensed by pharmacists to children with cough without prescription, in the presence of fever and cough for a long period.
CONCLUSION: More than half of the participants showed moderate knowledge and practice toward dispensing of cough medication in children, no significant association between knowledge and demographic variables, but practice showed a significant association with participants' qualifications.

Keywords: Children, community pharmacists, cough medications, knowledge, practice

How to cite this article:
Ibrahim M, Badi S, Yousef BA. Knowledge and practice of community pharmacists toward dispensing of cough medications for children Khartoum State: A cross-sectional study. Int J Health Allied Sci 2020;9:147-52

How to cite this URL:
Ibrahim M, Badi S, Yousef BA. Knowledge and practice of community pharmacists toward dispensing of cough medications for children Khartoum State: A cross-sectional study. Int J Health Allied Sci [serial online] 2020 [cited 2023 May 30];9:147-52. Available from: https://www.ijhas.in/text.asp?2020/9/2/147/282131

  Introduction Top

Cough is one of the common symptoms that alert patients to seek medical attention from physicians, which may lead to an increase in the cost of health-care services.[1] Cough in children could cause significant anxiety to parents as it could disturb sleeping and daily activities of their children, while persistent cough is the most common sign that may need referring the patient to a pediatrician or a chest physician.[2]

Cough medications are considered as one of the most consumed over-the-counter (OTC) medications.[3] In the literature, there is a lack of evidence toward the effectiveness of cough medications.[4],[5],[6] The systematic review done by Schroeder and Fahey indicated that cough medications effectiveness is as placebo in alleviating the cough symptoms; therefore, it should not be used as a first-line treatment for the resolution of acute cough in children that may lead to unnecessary expenses for the health-care consumer.[7] Furthermore, cough medications should not be administered for children <2 years,[8] as many reports indicated that cough medications increased the emergency department visit due to their adverse events[9],[10] which had been reduced after the removal of cough medications from pharmacy shelves.[11] Community pharmacists should have a crucial role in providing patient counseling regarding cough management, and their performance concerning this role is profoundly affected by their knowledge and practice.[12] Even though there are many warnings regarding the use of cough medications in children, many pharmacists supported behind the counter condition as the survey had been done by Huston et al. in Georgia showed that the majority of pharmacists are comfortable in recommending cough medication.[13]

As the cough medication-related problems are expected to be increased, especially in children, due to the ease of purchase of these medications from community pharmacies and the overuse of these medications in children by their parents.[14],[15] Thus, pharmacists must be knowledgeable regarding the pharmacological and nonpharmacological cough management in children, especially cough syrups and the referral criteria of cough in children to the hospital. Thus, this study aimed to assess the knowledge and practice of community pharmacists working in Khartoum State toward the dispensing of cough medications for children.

  Materials and Methods Top

Study setting

This study was a descriptive cross-sectional study. The study samples were the registered community pharmacists in Khartoum State, Sudan. The study was conducted in the period from January to March 2017.

Inclusion and exclusion criteria

Registered pharmacists working in the community pharmacies, who agreed to participate and fill the questionnaire were included in the study, while those who refused to participate were excluded from the study.

Sample size and sampling technique

The Ministry of Health reported that there are 1869 community pharmacies in Khartoum state. By using Solvin's equation,[16] the sample size (n = 330) was calculated from the known population as follows:

Where N = total target population attending the center. n = sample size e = margin of error (0.05) at 95% confidence level. There were five participants refused to participate in the study, so the response rate was 98%. We used a stratified sampling method, as Khartoum State was divided into three areas (Khartoum, Omdurman, and Khartoum North), we considered each area as stratum, and then within each stratum, pharmacists were selected randomly using the simple random sampling technique.

Data collection method

A pilot study was carried out in a similar area for testing the validity of the questionnaire, and all questionnaires that were used in the pilot study were excluded. The data were collected using a self-administered questionnaire. The questionnaire consisted of three parts as follows: the first part consisted of demographic characteristics of the pharmacists. The second part was investigated the pharmacist's knowledge regarding the cough syrup ingredient and the high dose effect. The third part was used to assess the practice regarding cough medications.

The collected data were checked for completeness, manually scored and finally coded before the analysis, for each question in the knowledge section, a score of one was given for a correct answer, whereas a zero score was given for incorrect. Questions were rated, and a total score was obtained, as described in the Yong study.[17] The total knowledge scores were 9; therefore, those with a total score[1],[2],[3] were classified as having a low level of knowledge,[4],[5],[6] as moderate level, and[7],[8],[9] were considered having a high level of knowledge. Concerning the practice, the total score was 13. Those with a total score[1],[2],[3],[4],[5] were classified as having a poor practice,[6],[7],[8],[9] as fair practice, and[10],[11],[12],[13] were considered having good practice.

Data analysis

Data were analyzed using the International Business Machines (IBM). The Statistical Package for the Social Sciences for Windows, version 23.0 software (Armonk, NY, USA: IBM Corp). The data were demonstrated as tables for the descriptive statistics. A Chi-square test was used for testing the significant difference between variables. P < 0.05 was considered statistically significant.

Ethical consideration

The study was approved by the Ethical Committee of Faculty of Pharmacy (FPEC), University of Khartoum (FPEC-05-2017). From the pharmacists who agreed to participate in the study, verbal consent was obtained. All questionnaires were coded, and confidentiality was ensured throughout the study.

  Results Top

Out of 325 community pharmacists participated in this study, most of them hold a bachelor's degree (73.5%), females were the major (74.2%), and (68.6%) of them were practicing of experience <5 years [Table 1].
Table 1: Demographic characteristics of community pharmacists (n=325)

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Regarding the knowledge of participants about the cough syrups, 58.2% of them knew that ammonium chloride is an expectorant, and just 14.2% knew that bromhexine is a mucolytic, while 65% and 58% recognized that guaiphenesine and ammonium chloride are expectorants, respectively. Moreover, 90% recognizes that diphenhydramine is an antihistamine; only 12% knew that dextromethorphan is categorized as an antitussive [Table 2]. However, 60% of the community pharmacists said that high dextromethorphan dose is produce convulsion, and (44.9%) answered with no when asked about the high dose of expectorant can produce vomiting.
Table 2: Knowledge of community pharmacists about cough syrup ingredients and high dose adverse effects (n=325)

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After calculating the overall knowledge score, 53.8% of community pharmacists were found to have a moderate level of knowledge, whereas community pharmacists with a high level of knowledge just represented 35.7%, and low knowledge represented 10.5%. Using the Chi-square test, no statistically significant association (P < 0.05) was found between the knowledge and the sociodemographic characteristics of the pharmacist.

As shown in [Table 3], 72.9% of the community pharmacists dispense cough syrup for children aged <2 years, whereas 27.4% of them dispense cough syrup due to co-patient insisting. Furthermore, antibiotics were dispensed for the management of cough in children without prescription by 47.4% of community pharmacists. The three main reasons for dispensing antibiotics were the presence of fever (46.2%), cough more than 2 weeks (25.2%), and breathing difficulties (18.5%).
Table 3: Practice of community pharmacists regarding dispensing of cough syrup to children (n=325)

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Using the scoring system, the practice of participants indicated a fair level of practice in 56.6% of the pharmacists, while a good level and poor level of practice were represented in 11.4% and 32% of participants, respectively. Chi-square test revealed a statistically significant association between practice and qualification (P = 0.015), but no statistically significant association is revealed between practice and other sociodemographic characteristics (P < 0.05) or between the knowledge and practice of the participants (P = 0.09).

  Discussion Top

The findings of this study attempted to assess the knowledge level and practice of community pharmacists toward dispensing of cough medication in children in Khartoum State. The predominated group (68.6%) found to have <5 years practice experience and only 3.7% have more than 10 years of experience, this may be due to the fact that, the majority of pharmacists are seeking to get a position at medical companies, pharmaceutical factories or migrate aboard rather than rising their experience at community pharmacies, this in line with A. Ibrahim and Scott who stated that predominant practice experience in community pharmacies was from 0 to 5 years.[18] Melton and Lai showed that he community pharmacists provide good dispensing performance and a positive patient perception with subsequent patient satisfaction with the services.[19]

Assessing the knowledge of the pharmacists revealed that: more than half of the participants were classified as having a moderate level of knowledge, this may be due to a shortage in university curriculum regarding pharmacy practice, especially the OTC dispensing for children, as cough medications, and/or the lack of interest of pharmacists, postgraduation, to be updated with concern to pharmacotherapy. Statistical analysis revealed that there is no significant association between demographic data and knowledge; this in line with another study, which showed no significant association between knowledge and demographics data.[20]

About 72.9% of responding pharmacists dispense cough syrup for children aged <2 years despite lack of safety and efficacy, this is maybe due to the lack of knowledge toward Food and Drug Administration warning about the prevention of cough medication for children who aged <2 years, also the desire to avoid the pressure of the pharmacy owner by increasing the income of pharmacy. Furthermore, the current result revealed that 27.4% of the pharmacists dispense cough syrup due to the co-patient request to achieve customer satisfaction; this is compatible with that reported by Huston et al.[13] While there are no studies or guidelines support the use of mucolytic drugs in children, 67.4% of community pharmacists in Sudan dispense mucolytic to children with cough after expectorant fail to produce a good effect.[21]

While the use of antibiotics for the treatment of cough have no benefits in acute cough treatment and may be associated with increased adverse effects, increased bacterial resistance and can lead to money-wasting, the current results showed that 47.4% of community pharmacists dispense antibiotics without prescription for the management of cough in children, this indicates that pharmacists play an essential role in antibiotic self-medication and thereby increase the risk of bacterial resistance alongside money wasting, this is consistent with Togoobaatar et al. study which reported that: the increase in the use of nonprescribed antibiotic for young children leads to spread resistance to antibiotics and related health problems.[22] The study also documented that: the presence of fever, cough for more than 2 weeks and breathing difficulties is prober reason to dispense antibiotics without prescription as it may be signs of bacterial infection, but nevertheless, the antibiotics should not be dispensed without prescription by the pharmacist for any reason; putting in mind that fever is one of the signs of infection whether bacterial or viral, but viral infection do not need antibiotic use, that's why fever is not enough reason for dispense antibiotic by pharmacist, and if the child presented with cough more than 2 weeks or difficulty in breathing should be referred to pediatrician for further investigation rather than using nonprescribed antibiotics as reported by Marshall.[23] Interestingly, we found 61.5% of pharmacist recommend use of honey in children with cough because honey is very useful in relieving cough frequency and severity in children; since it has antioxidant and antimicrobial properties also improve the sleep when administer before the bedtime as well as reduce the use of ineffective OTC cough drugs.[24]

The assessment of pharmacists' practice showed fair practice as more than half (56.6%) of participants, while only 11.4% have a good practice. This may be due to lack of knowledge, lack of professional training with qualified staff also ignorance, and unawareness of parents who insist on taking specific drugs regardless of the opinion of the pharmacist. Cross tabulation proved to have a significant association between practice and qualification. However, there were no significant associations that exist between knowledge and practice scores; this result is inconsistent with the Mehralian et al. results, which they reported that knowledge has a significant effect on practice.[25]

The limitations of the current study are as the cross-sectional design may not allow generalization of the findings to all populations in Sudan. Further researches may be needed in rural areas of Sudan to assess the knowledge and practice of community pharmacists toward dispensing of cough medications for children. Despite these limitations, our study is novel and provided the first study to evaluate the knowledge and practice of community pharmacists towards dispensing of cough medications for children in Sudan. Physicians and pharmacists do need to work together to increase the level of knowledge about this issue.

  Conclusion Top

This study concluded that more than half the participants showed moderate knowledge and practice towards dispensing of cough medication in children, no significant association between knowledge and demographic variables, but practice showed a significant association with participants' qualifications. Thus, great efforts are required to improve the knowledge and practice of community pharmacists toward OTC medications, especially cough medications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Chang AB, Landau LI, van Asperen PP, Glasgow NJ, Robertson CF, Marchant JM, et al. Cough in children: Definitions and clinical evaluation. Med J Aust 2006;184:398-403.  Back to cited text no. 2
Chang AB. Cough: Are children really different to adults? Cough 2005;1:7.  Back to cited text no. 3
Smith SM, Schroeder K, Fahey T. Overthecounter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev 2014;24;(11):CD001831.  Back to cited text no. 4
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  [Table 1], [Table 2], [Table 3]

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