|Year : 2016 | Volume
| Issue : 3 | Page : 318-322
Knowledge and attitudes of pharmacists regarding sugar content in medicine in Bengaluru city: A questionnaire study
Hitendra Ramesh Jain1, Vanishree Nanjundaiah2, Shivalingeshswamy Hiremath3, Chaitra Nagesh3, Jeswin Jacob4, Keerthi Prasad2
1 Department of Public Health Dentistry, S.M.B.T. Dental College and Hospital, Sangamner, Maharashtra, India
2 Department of Public Health Dentistry, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka, India
3 Department of Public Health Dentistry, The Oxford Dental College and Hospital, Bengaluru, Karnataka, India
4 Department of Public Health Dentistry, Dayanand Sagar College of Dental Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||28-Jul-2016|
Hitendra Ramesh Jain
Department of Public Health Dentistry, S.M.B.T. Dental College and Hospital, Sangamner - 422 608, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Most pediatric medicines are prescribed in a liquid form that includes sugar in the formulation. Accumulating evidence, on a clinical and experimental basis, shows a significant association between the intake of sucrose-based medication and an increased incidence of dental caries. Objective: The aim of this study is to assess the knowledge and attitude of pharmacists regarding sugar content in medicine in Bengaluru city. Materials and Methods: A descriptive, cross-sectional survey was conducted among a sample of the pharmacists in Bengaluru city. A sample of 140 retail pharmacist shops were selected randomly from the total list of retail pharmacist shop registered at the Drug Control Department, Bengaluru. Data regarding their knowledge and attitude in relation to sugar content in medicine was obtained using a questionnaire. Results: Around 67.9% of the pharmacists agreed that sugar-containing medicines taken long-term could lead to dental problems. Only 12.9% of pharmacists believed that patient prefer sugar-free medicine. Most of the pharmacists (72.9%) felt that they themselves have an important role in educating people about sugar containing medicine. Conclusions: Pharmacists requires further knowledge about sugar-free medicine. The expansion of the pharmacist role in oral health promotion would be of value to patients/customers. Various methods should be adopted to increase pharmacist knowledge about dental health.
Keywords: Medicine, pharmacist, sugar-free
|How to cite this article:|
Jain HR, Nanjundaiah V, Hiremath S, Nagesh C, Jacob J, Prasad K. Knowledge and attitudes of pharmacists regarding sugar content in medicine in Bengaluru city: A questionnaire study. J Indian Assoc Public Health Dent 2016;14:318-22
|How to cite this URL:|
Jain HR, Nanjundaiah V, Hiremath S, Nagesh C, Jacob J, Prasad K. Knowledge and attitudes of pharmacists regarding sugar content in medicine in Bengaluru city: A questionnaire study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Nov 13];14:318-22. Available from: http://www.jiaphd.org/text.asp?2016/14/3/318/187177
| Introduction|| |
Dental health professionals have long been concerned about the harmful effects of sugar containing medicines on teeth. A regular intake of sugar greatly increases the risk of dental caries. The sugar contained in medicines is just as harmful to teeth as sugar in sweets. Studies show a positive association between intake of these drugs and dental caries. This represents a cause for concern for children's oral health since many studies have shown increased prevalence of the disease and its relationship with the habitual intake of these liquid formulations. In spite of adequate alternatives to medicines sweetened with sugar, their substitution has been slow.
The dental profession has recommended that medicines be sugar-free. Because of the bitter taste of most medications, sugar is combined with other ingredients to give a more pleasant taste to the medications to increase acceptance and treatment compliance of patients, especially children. Although there are artificial substitutes, such as sodium saccharine, sodium cyclamate, aspartame, and sorbitol, sucrose is most widely used. It is thus an additional source of sugar for pediatric patients, especially those chronically ill, who receive a greater sugar load from liquid medications than healthy children do and consequently, have high caries prevalence. Antibiotics and cough medicines are the most common sugar-containing medicines regularly used by young children, and although the latter are brought on an over-the-counter basis they may still be used over relatively long periods.
Pharmacist act as the providers of drugs, including those recommended and/or prescribed by hospitals and general medical practitioners as well as those purchased over-the-counter. There are a variety of ways by which the pharmacist can take a frontline approach to oral disease prevention, identification, assessment, management, and referral including the dispense of sugar-free medicine. Most studies addressing this core issue have helped policy decision makers and health professionals to implement legislation and surveillance systems to control, avoid or replace sugar in medicines for noncariogenic sugar, and showed promising results.
There has not been a previous study of the knowledge and attitude of pharmacists in Bengaluru city in regards to sugar–free medicine. Hence, this baseline study was carried out to assess the knowledge and attitude of pharmacist regarding sugar content in medicine in Bengaluru city.
| Materials and Methods|| |
This study was a cross-sectional survey among a sample of pharmacists in Bengaluru city. Ethical approval was obtained from Institutional Review Board. Written informed consent was obtained from the pharmacists who agreed to participate in the survey and were assured of confidentiality.
Data of the total number of retail pharmacist shops in Bengaluru city were obtained from Drug Control Department, Bengaluru city. There were an approximate total of 7000 retail pharmacist shop registered at the Drug Control Department. A sample of 140 retail pharmacist shops were selected randomly from the total list.
Data regarding pharmacist's knowledge and attitudes toward sugar content in medicine were obtained using a questionnaire. The questionnaire comprised initially of 17 questions that had been earlier pretested on a group of pharmacists which finally reduced to 14 questions after checking for validity of the questionnaire. The questionnaire was divided into three sections; Section 1 regarding knowledge, the attitude of pharmacists regarding sugar-free medicine. Section 2 focused regarding perceived barrier to use of sugar-free medicine as view by pharmacists. Section 3 dealt with assessing the view of pharmacists regarding utilization of sugar-free medicine.
A pilot study was carried out on 10% of the desired population to check the feasibility and relevance of the prepared format. The questionnaire was tested for its validity and reliability before the main study. The content validity was assessed by a panel of six experts, 4 of dental educators and 2 of the legal representatives. Initially, 17 individual items were proposed for the questionnaire. Total Aiken's V value was initially not satisfactory. Individual 3 items which had low Aiken's V value were excluded and 14 items were retained to obtain overall Aiken's V value of 0.94. To assess internal consistency of questions, Cronbach's alpha was calculated and found out to be 0.81.
For the purpose of the study, Bangalore city was divided into 5 zones - North, West, East, South and central Bangalore. From each zone, 28 pharmacists were randomly selected to get sample size of 140 pharmacists. The survey was held during day time as there will be less customer during early part of the day, thus, devoting time for filling questionnaire. The pharmacists were explained about the questionnaire before they answered the questions. Each pharmacist was given approximately 10–15 min to fill the questionnaire. The completed questionnaire was collected by the same investigator after it is filled, on the same day. Statistical analysis of the collected data was performed using the Statistical analysis of the collected data was performed using the SPSS 17, IBM Chicago.
| Results|| |
In the study population of 140 pharmacists, 47.8% of the pharmacists had a work experience of 1–5 years, 47.8% with 5–10 years, and 4.3% with >10 years of work experience, respectively [Table 1]. Many pharmacists (62.1%) agreed that sugar in formulation has an effect on oral health. Almost, 81 pharmacists (57.9%) agreed that sugars are an essential ingredient in the formulation of most medicine.
|Table 1: Distribution of the study population according to the years of experience|
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In this study, 78 pharmacists (55.7%) wished that all long-term medicine should be made sugar-free. Only 18 (12.9%) out of 140 participating pharmacists agreed that patient actually prefer sugar-free medicine. Few participating pharmacists (37.1%) agreed that wherever possible a sugar-free medicine should always be prescribed when starting new medicine course [Table 2]. Very few pharmacists (18.6%) believed that they have the total autonomy of dispensing sugar-free or sugar containing prescribed medicines. Around 59% of the pharmacists agreed that they should decide on the formulation of long-term medicines and 67 pharmacists (47.9%) agreed that they should recommend sugar-free medicines when counter-prescribing over-the-counter products.
|Table 2: Distribution of the study population according to knowledge, attitude regarding sugar-free medicine|
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Many pharmacists (67.9%) agreed that sugar-containing medicines taken long-term could lead to dental problems while 79 out of 140 pharmacists (56.4%) agreed that patients do not understand the threat of frequent sugar intake to their dental health. Very few pharmacists (19.3%) agree that sugar-free medicines are generally more expensive than those with sugar.
Only 7.1% of the participating pharmacists believed that the use of sugar-free medicines reduces compliance and 9.2% pharmacists are of the opinion that sugar-free medicines produce adverse side effects if consumed for a long period [Table 3].
Most pharmacists (72.9%) agreed they should play an important role in educating patients about dental health, 70 out of 140 pharmacists (50%) agreed that pharmacist should advise prescribers about which medicines are available sugar-free [Table 4]. Most study pharmacists (80.7%) agreed that dental professionals should educate other health professionals about the potential risks to dental health through the use of sugar-containing medicines. Majority pharmacists (86.4%) agreed that dentists should be responsible for the promotion of the use of sugar-free medicines, whereas 67.9% of the study pharmacists are of the opinion that government should subsidise the production of sugar-free medicines.
|Table 4: Perceptions of pharmacists regarding utilization of sugar-free medicine|
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| Discussion|| |
Previous studies of the pharmacists' role in sugar-free medicines have concentrated on the stocking of over-the-counter products while their sources of learning and their provision of sugar-free medicines and its influencing factors are emphasized in this study. The results are generally encouraging and indicate a reasonable awareness of the problem among pharmacists. Most of the pharmacists in this study appear to have fairly positive attitudes toward sugar-free medicines.
Most pharmacists in this study have a work experience of 1–10 years accounting for approximately 96%. Most of the responding pharmacists (62.1%) agreed that sugar in formulation has an effect on oral health, which as in agreement with study conducted by McVeigh and Kinirons  (90%) and Mackie et al. (77%) Regular intake of sugar greatly increases the risk of dental caries. However, not many pharmacists in our study are confident about the role of sugars on oral health as compared to other countries representative sample.,
More than half of the respondents (57.9%) agreed that sugar is an essential ingredient in the formulation of most medicine. This is in contrast with previous studies, conducted by Baqir and Maguire which stated that most respondents were in agreement that sugar is not essential in the manufacture of pharmaceuticals.
More than half of the respondent pharmacists (55.7%) in our study agreed that all long-term medicine should be sugar-free, which is in agreement with previous studies done by McVeigh and Kinirons  and Baqir and Maguire. It has been suggested that all long-term medicines should be used sugar-free to avoid the adverse effect of sugar on oral health.,
Very few of the responding pharmacists (12.9%) believed that patients prefer sugar-free medicine, which is in agreement with a previous study (11.3%). This shows that pharmacists believed that still patients are unaware of the benefits of sugar-free medicine. Most subjects leave the decision as to what is prescribed to by the doctor. The doctor is still the dominant party in the doctor-patient relationship. Patient's role in the decision-making process for prescribed medicines is very limited.
In this study, 37.1% of the responding pharmacists agreed that all new drug treatments initiated should be sugar-free, which is very less as compared to the previous study conducted by Baqir and Maguire (85%). However, 58.6% of the pharmacists in this study believed that consultant should prescribe sugar-free medicine when starting a new treatment which is agreement with the study conducted by Baqir and Maguire (55%). Many pharmacists believed that general medical or dental practitioner mostly have the autonomy of choosing the type of medication, and should always prescribe sugar-free medicine for a patient. However, lack of knowledge as to whether a medicine is available as a sugar-free formulation as well as promotion by drug companies may affect their decision.
Very few of the responding pharmacists (18.6%) were of the belief that the decision to use a sugar-free or sugar containing prescribed medicines should rest with the pharmacist. This result is in agreement with a previous study (26.3%). However, 47.9% responding pharmacists are of the view that they should recommend sugar-free medicines when counter – prescribing over-the-counter products. Studies carried out by Baqir and Maguire  showed agreement among 88.4% of respondents on this issue. Since most of the consumer/patient were unaware of the advantages of sugar-free medicine, pharmacists were of the opinion that they should prescribe themselves this product while counter prescribing over-the – counter, which is more common practice in India.
Earlier studies like done by Baqir and Maguire have shown that almost 90% of respondents believed that sugar-containing medicine taken for long time could lead to dental problems. In this study, around 68% of respondents agreed in this view. On particularly relating sugar medicine intake for long time with dental problems, a good proportion is aware of the fact. Sweetening agents such as sucrose are included in the formulation to mask the bitter taste of the medicine's active ingredient. Sucrose and other acidogenic sugars in the diet are the primary cause of dental caries, and a positive link has been shown between the long-term use of sugar-containing medicines and dental caries.
The majority of respondents (61%) in our study were unsure whether sugar-free medicines were more expensive, compared to other previous studies (conducted by Baqir and Maguire) where pharmacist felt that they were expensive. This indicate that pharmacists in our study are not much aware of the sugar-free medicines regarding their cost as compared to sugar containing medicine.
In this study, mostly 81.4% of respondents were unsure whether sugar-free medicine reduces compliance, compared to a previous study (conducted by Baqir and Maguire) where 54% of respondent disagreed with the above statement. Mostly, it has been seen in studies conducted that sugar-free medicines are also well tolerated and have a good compliance in respect to patients. Some artificial sweetners are many fold times sweeter than normal sucrose, and are noncaloric which are useful in diabetic patients.
More than half of the respondent (56.4%) agreed that patient do not understand the threat of frequent sugar intake to their dental health, which is in agreement with the previous study (conducted by Baqir and Maguire) where 64.8% of pharmacists also believed the same. The use of sugar-free medicines was a matter of convenience. Patients prioritized the short-term benefits of medicines over the long-term effects.
Only 12% of the respondent pharmacists in our study agreed that sugar-free medicine produce adverse side effects if consumed for a long period. In literature, sugar-free medicines have seen to be better tolerated and had a good compliance except for few case of osmotic diarrhea seen in consumption for a very long period. However, overall they are good compliance and better alternative as compared to sugar-containing products.,,
Similar to other study; in our study almost 80% of the respondents have the view that dental professionals should educate other health professionals about the potential risks to dental health through the use of sugar-containing medicines, and 86.4% agrees that dentist should be responsible for the promotion of the use of sugar-free medicines. A study conducted by McVeigh and Kinirons explained that doctors were held in high esteemed by most of the subjects and were seen less approachable than pharmacists due to their busy appointment schedules and high consultancy charges. Patients report that they rarely asked their doctors for a specific prescription, as they feel reluctant to interfere in the professional decision and believed that doctor automatically will prescribe a sugar-free medicine.
Our research shows that half of the respondents sample wished to advise prescribers about which medicine are available sugar-free, as compared to 83% in a study conducted by Baqir and Maguire  More than half of the respondent pharmacists (73%) are of the view that pharmacists should play a role in educating patients about dental health, which is in agreement to study conducted by Baqir and Maguire (87%). The general agreement that the pharmacists should have a role in educating and informing the public about dental health reinforces the role seen for pharmacists in the future. The pharmacist is in an ideal position at the interface between the patient and other health professions where they can pass on health advice and information to patients.
Our research shows that 68% of respondent pharmacists are of the view that government should subsidise the production of sugar-free medicines as compared to 51% agreement seen in the previous study conducted by Baqir and Maguire  Most of the pharmacists believe that on subsidising these products, will increase the sale and usage of these products.
One of the limitations of this cross-sectional study was low sample size covering only 140 pharmacists. There is a need for a more multi-professional approach to the education of health professionals, health-care providers, manufacturers, and regulators with regard to sugar control in medicines use and related regulatory issues.
| Conclusions|| |
Most pharmacists lack sufficient knowledge about sugar-free medicine and its good effects. Some pharmacists are even unsure of the advice regarding oral health and sugar-free medicine, and would benefit from further education on this matter.
Hence, there is a definitive need for training of pharmacists and providing them with access to information on available dental services. The dental profession should take the initiative in the promotion of sugar-free medicines and in the provision of the necessary education for pharmacists at the undergraduate and postgraduate level as well as during continuing professional education.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McVeigh N, Kinirons MJ. Pharmacists' knowledge, attitudes and practices concerning sugar-free medicines. Int J Paediatr Dent 1999;9:31-5.
Bentley E, Mackie I, Fuller SS. The rationale, organisation and evaluation of a campaign to increase the use of sugar-free paediatric medicines. Community Dent Health 1997;14:36-40.
Mackie IC, Worthington HV, Hobson P. An investigation into sugar-containing and sugar-free over-the-counter medicines stocked and recommended by pharmacists in the north western region of England. Br Dent J 1993;175:93-8.
Mackie IC, Hobson P. Factors affecting the availability of sugar-free medicines for children – A survey in the UK. Int J Paediatr Dent 1993;3:163-7.
Durward C, Thou T. Dental caries and sugar-containing liquid medicines for children in New Zealand. N
Z Dent J 1997;93:124-9.
Menezes VA, Cavalcanti G, Mora C, Garcia AF, Leal RB. Pediatric medicines and their relationship to dental caries. Braz J Pharm Sci 2010;46:1.
Peres KG, Oliveira CT, Peres MA, Raymundo Mdos S, Fett R. Sugar content in liquid oral medicines for children. Rev Saude Publica 2005;39:486-9.
Baqir W, Maguire A. Doctors' and pharmacists' attitudes to the use of sugar-free and sugar containing medicines in the elderly. Int J Pharma Pract 2001;9:177-84.
Cavalcanti AL, De Sousa RI, Clementino MA, Vieira FF, Cavalcanti CL, Xavier AF.In vitro
analysis of the cariogenic and erosive potential of paediatric antitussive liquid oral medications. Tanzan J Health Res 2012;14:139-45.
Priya S, Madan Kumar PD, Ramachandran S. Knowledge and attitudes of pharmacists regarding oral health care and oral hygiene products in Chennai city. Indian J Dent Res 2008;19:104-8.
Maunder PE, Landes DP. An evaluation of the role played by community pharmacies in oral healthcare situated in a primary care trust in the north of England. Br Dent J 2005;199:219-23.
Hastings G, Hughes K, Lowry R. Promoting sugar-free medicines: Parents' views. Br J Gen Pract 1997;47:823-4.
Bradley M, Kinirons M. A survey of factors influencing the prescribing of sugar-free medicines for children by a group of general medical practitioners in Northern Ireland. Int J Paediatr Dent 1996;6:261-4.
Bradley M, Kinirons MJ. Provision of sugar-free medicines for young children: The views of a sample of parents in Northern Ireland. J Ir Dent Assoc 1998;44:70-3.
[Table 1], [Table 2], [Table 3], [Table 4]