Level of knowledge, attitudes and perspectives
The association between categorical variables, such as knowledge level, attitude level, and practice level, and binary response variables (i.e., Yes/No responses to community pharmacists who have received training in antimicrobial stewardship) was assessed using Pearson's chi-squared test (Table 5). A small proportion of the pharmacists (n = 16, 8.4%) demonstrated a good level of knowledge. Among the untrained participants, seven (5.9%) had a good level of knowledge compared with nine (12%) trained participants. Overall, 175 (92%) participants showed poor knowledge, with a higher percentage in the untrained group (94%) than that in the trained group (88%). The association between knowledge level and the trained and untrained groups was not statistically significant (p = 0.12). Overall, 44 pharmacists (23%) had negative attitudes, with a significantly higher proportion in the untrained group (34%) than that in the trained group (5.5%). Overall, 147 participants (77%) displayed positive attitudes. Among them, 66% were untrained, whereas 95% of the trained group had a positive attitude. A statistically significant association (p < 0.001) was found between the trained and untrained groups. Overall, 82 participants (43%) showed a good level of practice. The difference between trained (59%) and untrained (33%) pharmacists is notable. Overall, 109 (57%) pharmacists had poor practice, with a higher percentage in the untrained group (67%) than that in the trained group (41%). A statistically significant association (p < 0.001) was found in practice based on training status.
Table 5
Level of knowledge, attitude and practices among community pharmacists who have received training.
Characteristic | Overall, N = 1911 | No, N = 1181 | Yes, N = 731 | p-value2 |
Knowledge Level | | | | 0.12 |
Good | 16 (8.4%) | 7 (5.9%) | 9 (12%) | |
Poor | 175 (92%) | 111 (94%) | 64 (88%) | |
Attitude Level | | | | < 0.001 |
Negative | 44 (23%) | 40 (34%) | 4 (5.5%) | |
Positive | 147 (77%) | 78 (66%) | 69 (95%) | |
Practice Level | | | | < 0.001 |
Good | 82 (43%) | 39 (33%) | 43 (59%) | |
Poor | 109 (57%) | 79 (67%) | 30 (41%) | |
1n (%) |
2Pearson's Chi-squared test |
(Table 5. Level of knowledge, attitude and practices among community pharmacists who have received training)
Factors associated with knowledge, attitudes, and practices score among community pharmacists in the univariate regression analysis
In the univariate linear regression analysis assessing the impact of demographic characteristics on knowledge, attitudes, and practices, several significant associations were identified (Table 6). Male pharmacists demonstrated a substantially positive association with both attitude (β = 2.6, 95% CI [1.1, 4.1], p = 0.001) and practice (β = 1.9, 95% CI [0.43, 3.3], p = 0.011). All the age groups highlighted significant positive association with the training and practice (30–39 years: β = 0.93, 95% CI [0.37, 1.5], p = 0.001; 40–49 years: β = 1.0, 95% CI [0.39, 1.6], p = 0.002; 50–59 years: β = 1.2, 95% CI [0.42, 1.9], p = 0.003; 60 years or above: β = 1.9, 95% CI [0.44, 3.3], p = 0.011), attitude (40–49 years: β = 0.80, 95% CI [0.12, 1.5], p = 0.021; 50–59 years: β = 0.83, 95% CI [0.01, 1.7], p = 0.048; 60 years or above: β = 1.7, 95% CI [0.13, 3.3], p = 0.036). In the case of attitude (β = 0.31, 95% CI [-0.31, 0.92], p = 0.33), only the 30–39 age group did not show a positive association compared to those age group 20–29 years. However, the study found no significant association between age and knowledge.
Educational background, specifically holding a Pharmacy Certificate Registration Course, was significantly associated with enhanced attitudes (β = 1.0, 95% CI [0.05, 2.0], p = 0.040) and practices (β = 1.5, 95% CI [0.54, 2.4], p = 0.002) compared with those with a B. Pharm degree. Two other educational level participants (Diploma in Pharmacy: β = 1.2, 95% CI [0.09, 2.4], p = 0.036; other: β = 1.3, 95% CI [0.41, 2.2], p = 0.005) showed a significant association only with practices.
Role differentiation within the pharmacy environment revealed that pharmacy owners were more likely to exhibit good knowledge (β = 1.6, 95% CI [0.51, 2.8], p = 0.005) and positive attitudes (β = 2.5, 95% CI [1.4, 3.6], p < 0.001) and practices (β = 1.2, 95% CI [0.10, 2.2], p = 0.033). Pharmacy managers and staff pharmacists also revealed a positive attitude (pharmacy manager: β = 1.4, 95% CI [0.04, 2.7], p = 0.044; staff pharmacist: β = 1.8, 95% CI [0.60, 3.0], p = 0.003), and staff pharmacists had better knowledge (β = 1.3, 95% CI [0.13, 2.5], p = 0.031) compared to pharmacy managers and others. Experience also played a pivotal role, with pharmacists with different years of experience showing a positive association with knowledge (16–20 years: β = 0.90, 95% CI [0.11, 1.7], p = 0.026; > 20 years: β = 0.99, 95% CI [0.19, 1.8], p = 0.016) and practice (11–15 years: β = 1.0, 95% CI [0.30, 1.7], p = 0.006; 16–20 years: β = 0.12, 95% CI [0.35, 1.9], p = 0.005; > 20 years: β = 1.0, 95% CI [0.27, 1.8], p = 0.009). Furthermore, the analysis revealed a significant correlation between antimicrobial stewardship training and an increase in knowledge (β = 0.56, 95% CI [0.08, 1.0], p = 0.024), attitudes (β = 1.1, 95% CI [0.61, 1.6], p < 0.001), and practice (β = 1.1, 95% CI [0.68, 1.6], p < 0.001). The frequency of dispensing antibiotics did not significantly influence these practices.
Table 6
Univariate analysis of covariates associated with knowledge, attitudes, and practices scores among community pharmacists.
| Knowledge | Attitude | Practice |
Characteristic | Beta | 95% CI1 | p-value | Beta | 95% CI1 | p-value | Beta | 95% CI1 | p-value |
Gender | | | | | | | | | |
Female | — | — | | — | — | | — | — | |
Male | 0.35 | -1.1, 1.8 | 0.64 | 2.6 | 1.1, 4.1 | 0.001 | 1.9 | 0.43, 3.3 | 0.011 |
Age | | | | | | | | | |
20–29 years | — | — | | — | — | | — | — | |
30–39 years | 0.39 | -0.21, 0.99 | 0.20 | 0.31 | -0.31, 0.92 | 0.33 | 0.93 | 0.37, 1.5 | 0.001 |
40–49 years | 0.46 | -0.20, 1.1 | 0.17 | 0.80 | 0.12, 1.5 | 0.021 | 1.0 | 0.39, 1.6 | 0.002 |
50–59 years | 0.52 | -0.28, 1.3 | 0.21 | 0.83 | 0.01, 1.7 | 0.048 | 1.2 | 0.42, 1.9 | 0.003 |
60 years or above | 1.2 | -0.35, 2.7 | 0.13 | 1.7 | 0.13, 3.3 | 0.036 | 1.9 | 0.44, 3.3 | 0.011 |
Education | | | | | | | | | |
B. Pharm | — | — | | — | — | | — | — | |
B. Pharm Professional | -0.36 | -1.8, 1.1 | 0.63 | -0.16 | -1.7, 1.3 | 0.83 | 0.93 | -0.46, 2.3 | 0.19 |
Diploma in Pharmacy | -0.54 | -1.8, 0.66 | 0.38 | 0.46 | -0.77, 1.7 | 0.46 | 1.2 | 0.09, 2.4 | 0.036 |
No Formal Education | -1.9 | -5.3, 1.6 | 0.29 | -0.79 | -4.3, 2.7 | 0.66 | -0.57 | -3.8, 2.7 | 0.73 |
Others | -0.15 | -1.1, 0.80 | 0.76 | 0.26 | -0.71, 1.2 | 0.60 | 1.3 | 0.41, 2.2 | 0.005 |
Pharmacy Certificate Registration Course | -0.49 | -1.5, 0.48 | 0.32 | 1.0 | 0.05, 2.0 | 0.040 | 1.5 | 0.54, 2.4 | 0.002 |
Role | | | | | | | | | |
Other | — | — | | — | — | | — | — | |
Pharmacy manager | 1.3 | -0.06, 2.6 | 0.062 | 1.4 | 0.04, 2.7 | 0.044 | 0.32 | -0.94, 1.6 | 0.62 |
Pharmacy owner | 1.6 | 0.51, 2.8 | 0.005 | 2.5 | 1.4, 3.6 | < 0.001 | 1.2 | 0.10, 2.2 | 0.033 |
Staff pharmacist | 1.3 | 0.13, 2.5 | 0.031 | 1.8 | 0.60, 3.0 | 0.003 | 0.29 | -0.82, 1.4 | 0.61 |
Experience | | | | | | | | | |
0–5 years | — | — | | — | — | | — | — | |
11–15 years | 0.46 | -0.26, 1.2 | 0.21 | 0.27 | -0.50, 1.0 | 0.50 | 1.0 | 0.30, 1.7 | 0.006 |
16–20 years | 0.90 | 0.11, 1.7 | 0.026 | 0.66 | -0.17, 1.5 | 0.12 | 1.1 | 0.35, 1.9 | 0.005 |
6–10 years | 0.48 | -0.13, 1.1 | 0.12 | 0.45 | -0.19, 1.1 | 0.17 | 0.42 | -0.16, 1.0 | 0.16 |
More than 20 years | 0.99 | 0.19, 1.8 | 0.016 | 0.73 | -0.11, 1.6 | 0.091 | 1.0 | 0.27, 1.8 | 0.009 |
Dispense Antibiotics | | | | | | | | | |
Frequently (3–5 times a week) | — | — | | — | — | | — | — | |
Occasionally (1–2 times a week) | 0.22 | -0.50, 0.94 | 0.55 | 0.23 | -0.51, 0.97 | 0.54 | 0.58 | -0.11, 1.3 | 0.10 |
Rarely (less than once a week) | 0.27 | -0.72, 1.3 | 0.59 | 0.81 | -0.21, 1.8 | 0.12 | 0.46 | -0.50, 1.4 | 0.35 |
Very frequently (more than 5 times a week) | 0.22 | -0.43, 0.87 | 0.50 | 0.80 | 0.13, 1.5 | 0.020 | 0.18 | -0.44, 0.81 | 0.57 |
Have you received training in antimicrobial stewardship? | | | | | | | | | |
No | — | — | | — | — | | — | — | |
Yes | 0.56 | 0.08, 1.0 | 0.024 | 1.1 | 0.61, 1.6 | < 0.001 | 1.1 | 0.68, 1.6 | < 0.001 |
(Table 6. Univariate analysis of covariates associated with knowledge, attitudes, and practices scores among community pharmacists)
Factors associated with knowledge, attitudes, and practices among community pharmacists in the multivariate linear regression analysis
We conducted multivariate linear regression analysis using Ordinary Least Squares (OLS) estimation to assess the combined influence of demographic characteristics on the knowledge score. This analysis included variables such as sex, age, education level, professional role, years of experience, frequency of antibiotic dispensing, and antimicrobial stewardship training. (Table 7). The results revealed that male pharmacists had a non-significant negative association with knowledge (β = -0.84, 95% CI: [-2.6, 0.90], p = 0.34) and a non-significant positive association with attitudes (β = 1.3, 95% CI: [-0.37, 2.9], p = 0.13) and practices (β = 0.82, 95% CI: [-0.72, 2.4], p = 0.30). Interestingly, no statistically significant associations were found across age groups in any of the three areas of knowledge, attitudes, or practices. In terms of educational background, those holding a Pharmacy Certificate Registration Course exhibited a significant negative association with knowledge (β = -0.82, 95% CI: [-1.9, 0.25], p = 0.13) and a non-significant negative association with practice (β = 0.89, 95% CI: [-0.05, 1.8], p = 0.064). Conversely, other specified education levels demonstrated no significant associations with knowledge but a significant positive association with practice (β = 0.96, 95% CI: [0.05, 1.9], p = 0.039). Roles within the pharmacy manager showed no significant correlation with knowledge, attitudes, or practices but pharmacy owner and staff pharmacist showed positive correlation with knowledge (pharmacy owner: β = 1.6, 95% CI: [0.23, 3.0], p = 0.023; staff pharmacist: β = 1.6, 95% CI: [0.19, 2.9], p = 0.026) and attitude (pharmacy owner: β = 1.9, 95% CI: [0.57, 3.2], p = 0.005; staff pharmacist: β = 1.5, 95% CI: [0.24, 2.8], p = 0.020).
Similarly, the number of years of experience did not significantly affect these dimensions. The frequency of antibiotic dispensing was also found to be non-influential. Notably, pharmacists who received training in antimicrobial stewardship displayed a non-significant positive association with knowledge (β = 0.46, 95% CI: [-0.07, 1.0], p = 0.090) and a highly significant positive association with both attitudes and practices (Attitude: β = 0.90, 95% CI: [0.40, 1.4], p < 0.001; Practice: β = 0.90, 95% CI: [0.43, 1.4], p < 0.001).
Table 7
Multivariate analysis of covariates associated with knowledge, attitudes, and practices scores among community pharmacists.
| Knowledge | Attitude | Practice |
Characteristic | Beta | 95% CI1 | p-value | Beta | 95% CI1 | p-value | Beta | 95% CI1 | p-value |
Gender | | | | | | | | | |
Female | — | — | | — | — | | — | — | |
Male | -0.84 | -2.6, 0.90 | 0.34 | 1.3 | -0.37, 2.9 | 0.13 | 0.82 | -0.72, 2.4 | 0.30 |
Age | | | | | | | | | |
20–29 years | — | — | | — | — | | — | — | |
30–39 years | 0.20 | -0.49, 0.90 | 0.57 | -0.20 | -0.86, 0.46 | 0.54 | 0.60 | -0.02, 1.2 | 0.058 |
40–49 years | 0.35 | -0.51, 1.2 | 0.42 | 0.20 | -0.61, 1.0 | 0.62 | 0.63 | -0.14, 1.4 | 0.11 |
50–59 years | 0.12 | -0.87, 1.1 | 0.81 | 0.33 | -0.60, 1.3 | 0.48 | 0.73 | -0.14, 1.6 | 0.10 |
60 years or above | 0.84 | -0.91, 2.6 | 0.34 | 1.1 | -0.58, 2.7 | 0.20 | 0.92 | -0.63, 2.5 | 0.24 |
Education | | | | | | | | | |
B. Pharm | — | — | | — | — | | — | — | |
B. Pharm Professional | -1.2 | -2.9, 0.56 | 0.18 | 0.24 | -1.4, 1.9 | 0.77 | 0.32 | -1.2, 1.8 | 0.68 |
Diploma in Pharmacy | -0.67 | -1.9, 0.61 | 0.30 | 0.65 | -0.55, 1.9 | 0.29 | 0.92 | -0.21, 2.1 | 0.11 |
No Formal Education | -0.18 | -4.0, 3.6 | 0.93 | 1.1 | -2.5, 4.7 | 0.54 | -0.38 | -3.8, 3.0 | 0.82 |
Others | -0.28 | -1.3, 0.75 | 0.59 | 0.15 | -0.82, 1.1 | 0.77 | 0.96 | 0.05, 1.9 | 0.039 |
Pharmacy Certificate Registration Course | -0.82 | -1.9, 0.25 | 0.13 | 0.79 | -0.22, 1.8 | 0.12 | 0.89 | -0.05, 1.8 | 0.064 |
Role | | | | | | | | | |
Other | — | — | | — | — | | — | — | |
Pharmacy manager | 1.5 | 0.00, 3.1 | 0.050 | 1.1 | -0.34, 2.6 | 0.13 | -0.29 | -1.6, 1.1 | 0.67 |
Pharmacy owner | 1.6 | 0.23, 3.0 | 0.023 | 1.9 | 0.57, 3.2 | 0.005 | 0.11 | -1.1, 1.3 | 0.86 |
Staff pharmacist | 1.6 | 0.19, 2.9 | 0.026 | 1.5 | 0.24, 2.8 | 0.020 | 0.14 | -1.1, 1.3 | 0.82 |
Experience | | | | | | | | | |
0–5 years | — | — | | — | — | | — | — | |
11–15 years | 0.33 | -0.50, 1.2 | 0.43 | -0.24 | -1.0, 0.54 | 0.54 | 0.55 | -0.18, 1.3 | 0.14 |
16–20 years | 0.57 | -0.36, 1.5 | 0.22 | -0.28 | -1.2, 0.59 | 0.53 | 0.37 | -0.45, 1.2 | 0.38 |
6–10 years | 0.34 | -0.34, 1.0 | 0.33 | 0.04 | -0.60, 0.67 | 0.91 | 0.10 | -0.49, 0.69 | 0.74 |
More than 20 years | 0.66 | -0.31, 1.6 | 0.18 | -0.25 | -1.2, 0.66 | 0.58 | 0.47 | -0.39, 1.3 | 0.28 |
Dispense Antibiotics | | | | | | | | | |
Frequently (3–5 times a week) | — | — | | — | — | | — | — | |
Occasionally (1–2 times a week) | 0.12 | -0.66, 0.91 | 0.76 | -0.06 | -0.79, 0.68 | 0.88 | 0.56 | -0.13, 1.3 | 0.11 |
Rarely (less than once a week) | 0.16 | -0.93, 1.2 | 0.78 | 0.62 | -0.41, 1.6 | 0.23 | 0.12 | -0.84, 1.1 | 0.80 |
Very frequently (more than 5 times a week) | 0.00 | -0.71, 0.71 | > 0.99 | 0.63 | -0.05, 1.3 | 0.067 | 0.08 | -0.55, 0.71 | 0.80 |
Have you received training in antimicrobial stewardship? | | | | | | | | | |
No | — | — | | — | — | | — | — | |
Yes | 0.46 | -0.07, 1.0 | 0.090 | 0.90 | 0.40, 1.4 | < 0.001 | 0.90 | 0.43, 1.4 | < 0.001 |
1CI = Confidence Interval |
(Table 7. Multivariate analysis of covariates associated with knowledge, attitudes, and practices scores among community pharmacists)