Knowledge of Pharmacists about Nuclear Pharmacy Services in Saudi Arabia

Goal: The knowledge of nuclear pharmacy is essential in pharmacy practice. In addition, the nuclear pharmacy services demand various diagnoses and drug therapy management. In this study, we aimed to explore pharmacists’ knowledge about nuclear pharmacy in the Kingdom of Saudi Arabia. Methods: This is a cross- sectional qualitative study. In this study, we distributed an electronic validated reliability questionnaire to all pharmacists and pharmacy interns. Students were excluded from this study. The survey collected demographic data of the responders and the knowledge of pharmacists about nuclear pharmacy, radioactive drugs, and resources of nuclear pharmacy. Data were analyzed using Statistical Package of Social Science (SPSS), Microsoft Excel, and Survey Monkey system. Results: A total of 235 pharmacists responded to the survey questionnaire. Of them, 142 (63.96%) were male, and 80 (36.04%) were female, with a statistically significant difference between them (p<0.001). About two-thirds of the pharmacists had earned a Bachelor’s degree (149 (63.40%)) and Diploma in Pharmacy (75 (31.91%)), with statistically significant differences among all qualifications (p<0.001). The average score for pharmacists’ knowledge of nuclear pharmacy services was 1.61, with high scores obtained for the elements—knowledge of the nuclear pharmacist has additional salary in Saudi Arabia (1.76) and radiation safety considerations (1.73). The average score was obtained for knowledge of radiopharmaceutical products (1.63), and the highest score on knowledge was obtained for 131 I-Sodium Iodide capsule five mCi (for thyroid therapy) (1.8) and 201 Tl-Thallium solution five mCi (for cardiac imaging) (1.8). The resources used to access information about nuclear pharmacy services were drug information resources (93 (40.09%)), scientific literature (83 (35.78%)), and the internet (83 (34.48%)). Conclusion: The pharmacist’s knowledge of nuclear pharmacy services and radiopharmaceutical products was poor. Therefore, to expand nuclear medicine, including pharmacy-related nuclear services, we recommend implementing the education and training program on nuclear pharmacy in Saudi Arabia.


INTRODUCTION
Nuclear pharmacy is defined as "a specialty area of pharmacy practice involved with the preparation of radioactive materials to improve and promote health through the safe and effective use of radioactive drugs to diagnose and treat specific disease states. ". [1] Radiopharmaceutical is the radioactive material or radioactive drug used in therapeutic and diagnostic procedures. [1] A radiopharmacy is "the place where radioactive drugs are prepared and dispensed. The radiopharmacy also serves as a depot for the storage of radioactive materials and nonradioactive supplies". [1,2] The main job of the pharmacist is to procure and prepare radiopharmaceutical products with highquality procedures and follow up compliance with the handling of hazardous material. Besides, providing radiopharmaceutical-related information, monitoring patients undergoing radioactive treatment, and preventing radioactiverelated problems, included distributive and clinical pharmacy activities. [1,3,[4][5][6][7][8][9] So far, more than 100 radioactive drugs are used to treat various disorders, including cancer and thyroid gland disorders; they are also used in pain management and diagnosis. Most radiopharmaceutical products are used for primary diagnosis, whereas other products are used in disease management. [10] The history of nuclear pharmacy began more than 30 years ago. In Saudi Arabia, the nuclear pharmacy was started in 1983 at King Faisal Hospital and Research Center under the Research and Development of radiopharmaceuticals. [11] The Saudi Society of Nuclear Medicine, founded in 2006, deals with radiopharmaceutical products and their diagnostic and therapy protocols. Moreover, the Saudi Food and Drug Authority released various guidelines for manufacturing and preparing radioactive medications. So far, more than 50 nuclear medicine departments have used radioactive drugs or radiopharmaceutical products. [11] As a result, the knowledge of dealing with radiopharmaceutical products is essential. Nuclear pharmacy education has been a part of the Diploma in Pharmacy in various colleges of pharmacy in Saudi Arabia and the rest of the world. [12,5,13,14] However, the knowledge of nuclear pharmacy for graduated pharmacists is needed in the nuclear pharmacy practice.
To the best of our knowledge, information is lacking about the knowledge or perception of nuclear medicine with practical nuclear pharmacy. [15] Other studies have discussed the use of nuclear pharmacy services. [16,17] However, there are no studies conducted on the assessment of knowledge in nuclear pharmacy in Saudi Arabia, the Gulf, or the Middle Eastern countries, and in the rest of the world. Therefore, in this study, we aimed to assess pharmacists' knowledge in nuclear pharmacy in the Kingdom of Saudi Arabia.

METHODS
This is a cross-sectional survey on knowledge of pharmacists about nuclear pharmacy in Saudi Arabia. This is a self-reported electronic survey with pharmacists (both interns to consultants) and pharmacy specialists in Saudi Arabia. All non pharmacists and students and noncompleted surveys will be excluded from the study. The survey collected respondents' demographic information and their knowledge of selected nuclear pharmacy elements and radiopharmaceutical products in pharmaceutical care. The references of nuclear pharmacy elements in practice. We used the 5-point Likert response scale system with closed-ended questions to obtain responses. Based on the population size, the sample was calculated with a confidence level of 95% and z score of 1.96, the margin of error of 5-6.5%, the population percentage of 50%, and a dropout rate of 10%. Thus, the sample size was calculated as 251-432 with a power of study of 80%. [18][19][20] The response rate required for the estimated sample size was at least 60-70 %. [20,21] The survey was distributed through social media such as WhatsApp and Telegram. After around 1-2 weeks, a reminder message was sent. Expert reviewers and pilot testing validated the survey. Moreover, various reliability tests such as McDonald's ω, Cronbach's α, Gutmann's λ2, and Gutmann's λ6 were analyzed. The data were collected through the Survey Monkey system. They were analyzed using the Statistical Package of Social Sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft excel sheet version 16. We performed descriptive and frequency analysis, good of fitness test, and correlation analysis. In addition, we performed inferential analysis of factors affecting the knowledge of pharmacists about nuclear pharmacy and radiopharmaceutical products, as well as linear regression. The STROBE (strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guided the reporting of the results of this survey. [22,23]

RESULTS
A total of 235 pharmacists responded to the survey questionnaire, with most of the responses obtained from the southern (82 (34.89%)), central (49 (20.85%)), and western region (47 (20%)) with statistically significant differences among the regions (p<0.001). Of them, 142 (63.96%) were male, and 80 (36.04%) were female responders, with statistically significant differences between them (p<0.001). Most of the responders were in the age group of 24-30 years (115 (48.94%)), followed by 31-35 years (57 (24.26%)), with statistically significant differences between all ages groups (p<0.001). About two-thirds of the pharmacists had obtained Bachelor's degree (149 (63.40%)) and Diploma in Pharmacy (75 (31.91%)), with statistically significant differences between all pharmaceutical degrees (p<0.001). Most pharmacists were staff pharmacists (119 (51.29%)) and interns (43 (18.53%)). The majority of the pharmacists had an experience of ≤ 3years (124 (52.99%)), with the majority of them practicing at the outpatient (26 (29.89%)) and inpatient pharmacy (19 (21.84%)), with statistically significant differences between them (p<0.001). There was a strong positive correlation between age (years) and years of experience at the pharmacy center, with Kendall's tau_b (0.705) and Spearman's rho (0.784) showing statistically significant differences between them (p>0.05). However, there was a negative medium correlation between position and years of experience at the pharmacy center, with Kendall's tau_b (−0.505) and Spearman's rho (−0.592) showing statistically significant differences between them (p>0.05) (Tables 1  and 2). The total average scores of knowledge of pharmacists about nuclear pharmacy services was 1.61, with high scores obtained for elements "knowledge of the nuclear pharmacist has additional salary in Saudi Arabia" (1.76), "radiation safety considerations" (1.73), and "heard about the concept of a nuclear pharmacist's job" (1.86). In contrast, low scores were obtained for elements such as "familiar with King Abdulaziz City for sciences and technology regulations of radiopharmaceutical products" (1.48) and "off-labeled or nonapproved radiopharmaceutical products" (1.54). Moreover, elements such as "the preparation of nonsterile radiopharmaceutical products" (1.55) and "the resources of nuclear pharmacy" (1.55) and showed statistically significant differences between their responses (p<0.001) ( Table 3). The average score of elements "knowledge of radiopharmaceutical

Factors influencing the basic knowledge of nuclear pharmacy and radiopharmaceutical products
Various factors influence the basic knowledge of nuclear pharmacy. Five geographical locations might affect the knowledge of nuclear pharmacy. The West region had the lowest average knowledge score (1.4590) with statically significant differences (p=0.003). Six levels of age affected the knowledge. The age (24-30 years) lowest average score of knowledge (1.4704) with statically significant differences (p=0.012). Five levels of a position affected the knowledge with pharmacy intern's lowest average knowledge score (1.4574) with statically significant differences (p=0.036). There were no statistically significant differences in the basic knowledge of nuclear pharmacy versus gender (p=0.054) and years of experience (p=0.320). Furthermore, various factors might influence the knowledge of radiopharmaceutical products. Six levels of age affected the knowledge. The age (24-30 years) lowest average score of knowledge (1.4941) with statically significant differences (p=0.003). Five levels of a position affected the knowledge. The pharmacy supervisor had the highest average knowledge score (2.2756) with statically significant differences (p=0.004). There were no statically significant differences between location (p=0.056), gender (p=0.482), and years of experience (p=0.161) ( Table 6). This study demonstrated the relationship between basic knowledge of nuclear pharmacy and factors affecting it, such as location, age (years), gender, position held, and years of experience at the pharmacy center. The multiple regression model considered the    Table 7). The relationship between radiopharmaceutical products knowledge and factors location, age (years), pharmacist gender, position held, and years of experiences in a pharmacy career. It was demonstrated through a multiple regression model and considered the nuclear pharmacy basic knowledge dependent factors were regarded as the expletory variable. There is a weak relationship (R=0.219; p=0.062) between knowledge of radiopharmaceutical products and factors affecting it with nonstatistically significant differences between them (p>0.05). Moreover, no factors had a relationship by using the Standardized Coefficients Beta, considered non-statistically significant (p>0.05) and through multiple regression model. It was confirmed by the Bootstrap model (Table 8).

DISCUSSION
For the past 30 years, there was expanding nuclear medicine science founded in Saudi Arabia, the first center in 1983. [11] Currently, several healthcare organizations use nuclear medicine in the central, western, and eastern provinces of Saudi Arabia. Each center had a consultant nuclear medicine physicians, and technicians, nurses, and a few pharmacists. [11,17,24,25] The pharmacy college has upgraded its curriculum degrees from Bachelor to Pharm D, [12] including the nuclear pharmacy courses. The knowledge of nuclear pharmacy was mandated to increase the professionalism of nuclear pharmacists in nuclear medicine and prepare the pharmacists to work and provide better services in the field of nuclear medicine. The current investigation is to tackle the target knowledge of pharmacists in nuclear pharmacy science. The study was a cross-section design with a convenient sample. Moreover, the survey conducted in this study was validated with a high-reliability score. The majority of the pharmacists responded from the southern region as the author of this article resides there. Therefore, it is easy for the pharmacists belonging to this region to respond from the southern region. There were different samples between sites, which is expected because it was a convenient sample, not a cluster sample, which is accepted in the research. [18][19][20] Most of the responders were male, which might be because it was easy for the authors to communicate with the male pharmacists. Most of the responders were a young group of 24-30. Furthermore, pharmacists with a Bachelor's degree or Diploma had less experience and were in low positions in employment. There was a strong correlation between age and expected experiences; passing more years of age will get more experiences. However, there was a negative correlation between the experience of the pharmacist and his/her position. Some pharmacists were hired as managers even though they had limited experience. The average score of pharmacists' knowledge about nuclear pharmacy was low, with only 30% of the responders having particular knowledge. Most pharmacists were not working at nuclear medicine centers, consistent with previous studies. [24,25] On the other hand, the responders had the highest knowledge of the nuclear pharmacy field; mainly, the nuclear pharmacist jobs got more additional salary and the radiation safety concept. Moreover, they knew about a nuclear pharmacist's job, that's expected because the responders were familiar with pharmacists employment regulations, and might the pharmacists had experienced with medications safety services or even had medication safety education during the school of pharmacy study. [12][13][14]5] Moreover, most healthcare providers, including pharmacists, are not familiar with the nuclear pharmacist jobs as there are only a few pharmacists who work in the department of nuclear medicine. [11,17,24,25] The previous study also reveals less awareness among healthcare providers about nuclear pharmacists' jobs. [7] In contrast, they had the lowest score knowledge about local guidelines or preparation of parenteral radioactive medications or the absence of nuclear pharmacy resources. That's related to might few pharmacists working at nuclear medicine departments, or the pharmacy department did not provide nuclear pharmacy services. [24,25] In this study, pharmacists' knowledge regarding radiopharmaceutical products is inferior, as reported by a previous study. (7) The highest knowledge with commonly used radioactive drug-like 131-Sodium Iodide 201 TI-Thaluim solution might be different from radioactive drugs used in an earlier study. [16] Most of the responders used drug information resources (e.g., PubMed) and scientific literature from the internet on nuclear pharmacy, which shows that the pharmacists were more familiar with drug information resources and online resources. Another study showed that the availability of nuclear pharmacy at healthcare organizations is only 16%. [7] In this study, pharmacist's knowledge of nuclear medicine was affected by various factors, such as location. The southern region scored the lowest about knowledge of nuclear pharmacy, which may be because the pharmacists were not properly working in nuclear medicine or did not provide nuclear pharmacy services at their healthcare institutions. That is declaring that's any place that any place does not has the nuclear medicine practice properly. Thus, their and nuclear pharmacy services they will be familiar with the radioactive drug. However, our results showed no positive or negative correlation between pharmacist knowledge of nuclear pharmacy services or radioactive drug knowledge and the five factors (location, age, gender, position, and years of experience). However, there was some difference in the knowledge-based on the aforementioned factors.

LIMITATION
This study has some limitations. First, the unequal distribution of responders knowledge of nuclear pharmacy will be poor. Other factors that might affect the knowledge of pharmacists of nuclear pharmacy were age and position held. The pharmacy interns or newly graduated pharmacists scored the lowest, expected because they have not practiced nuclear pharmacy services yet. The gender or number of years of experience did not influence the pharmacist knowledge because the male or female graduates from the same school of pharmacy did not practice nuclear pharmacy regardless of the period of experience.
However, the supervisor had the highest knowledge of medicines because they might participate in the procurement and reporting of radioactive pharmaceuticals by following the medication's usage or documenting radioactive medication safety for drug-related problems. [26,27] Some factors might influence the radioactive drug knowledge, such as location or gender, or years of experience because the nuclear pharmacy services have not existed in their regions. There was a correlation between knowledge of nuclear pharmacy services and radiopharmaceutical products, which was expected because of the pharmacy practice International Journal of Pharmacology and Clinical Sciences, Vol 10, Issue 2, Apr-Jun, 2021 between locations and the unequal number of responders between males and females. Second, the unequal distribution of age, position held, and years of experience. The majority of the responders were young with less experience, that's shows the representative of their knowledge about nuclear pharmacy. Third, although the number of samples did reach an optimal level with an appropriate effect size, more sampling was needed to get 400 responders in further studies. Finally, it was not easy to compare the current results with previous studies because they did not exist.

CONCLUSION
In conclusion, pharmacists' knowledge about nuclear pharmacy services and radioactive medications is deficient in the Kingdom of Saudi Arabia. Furthermore, the knowledge of pharmacists is varied, which is due to various factors. For example, pharmacists of a particular location or young people had less knowledge of nuclear pharmacy. However, there is no correlation between specific characteristics, for instance, location, age, gender, positions, and experiences. Therefore, we recommend further studies with large sample size and nuclear pharmacy-related issues in Saudi Arabia.