The Practice of Pharmacy Infection Control by Pharmacists in Saudi Arabia

Objectives: In this study, we aimed to illustrate the practice of pharmacy infection control by pharmacists in the Kingdom of Saudi Arabia. Methods: In this cross- sectional study, we aimed to assess the practice of pharmacy infection control by pharmacists in Saudi Arabia. We used a self-reported electronic survey questionnaire and distributed it to pharmacists from interns to consultants and specialists in Saudi Arabia. The survey collected demographic information of the pharmacists and about the implemented pharmacy infection control practices. The practice of pharmacy infection control and pharmacy infection control responsibilities among the types of healthcare professionals. We used 5-point Likert response scale system with close-ended questions to obtain responses. The data were λ 6 was 0.973, and Greater Lower Bound was 0.990. Conclusion: In this study, pharmacists’ practice of pharmacy infection control was found to be inadequate in Saudi Arabia. Therefore, implementing infection control in pharmacy practice is required to prevent drug-related infection control problems. In addition, we recommend improving the infection control practice in pharmacy services in Saudi Arabia.


INTRODUCTION
Infection control is an essential concept for healthcare professionals, including pharmacists. [1][2][3][4][5][6] The pharmacist needs to prevent the infection before or during dispensing of medications. The pharmacist needs to follow hand hygiene regularly to avoid any transmission of infection. [7] Moreover, infection control needs to be periodically practiced at different pharmacy services, including inpatient pharmacy, outpatient pharmacy, and clinical pharmacy services. [1][2][3][4][5][6] It is required for the pharmacy environment, workplaces, equipment, and pharmacy staff. Pharmacists distribute and dispense hand sanitizer and disinfectant solutions to various healthcare sections in their organization. There are different standards of infection control for medical and nursing care. [1][2][3][4][5][6] However, only a few studies have talked about complete pharmacy infection control programs or guidelines, and some have focused their research on one type of pharmacy service during the mass gathering. [8][9][10][11][12][13] Various practices of pharmacy infection control should be addressed such as vision, mission, strategic plan, and policies and procedures in addition to the competency of pharmacy infection control, surveillance-monitoring, immunization for pharmacy staff and trainees, and medications storage. [1][2][3][4][5][6] However, to the best of our knowledge, there are no studies, especially on pharmacy practice of pharmacy infection control. [14][15][16] Therefore, in this study, we aimed to assess the practice of pharmacy infection control in the Kingdom of Saudi Arabia.

METHODS
It was a cross-sectional study that explored the practice of pharmacy infection control during pharmaceutical care in Saudi Arabia. We used an electronic and self-reported survey questionnaire and distributed it to pharmacists from interns to consultants and all pharmacy specialties in Saudi Arabia. All non-pharmacists, students, and incomplete surveys were excluded from the study. The survey collected demographic information of the pharmacists and data regarding the practice and implementation of pharmacy infection control and pharmacy infection control (to authorities) responsibility of types of healthcare professionals. We used a 5-point Likert response scale system with close-ended questions to obtain responses. Based on the previous literature with unlimited population size, the sample was calculated for this crosssectional study with a population percentage of 50%, the confidence level of 95%, a z score of 1.96, and a margin of error of 5-6.5%, and drop-out rate of 10%. Thus, the calculated sample size was around 251-432 with a power of study of 80%. [17][18][19] The response rate required for the calculated sample size was at least 60-70%. [19,20] The survey was distributed through social media such as WhatsApp and Telegram apps. In addition, a reminder message was sent once every 2-3 weeks. The expert reviewers and pilot testing validated the survey data. Moreover, the test of reliability Gutmann's λ6, Gutmann's λ2, McDonald's ω, and Cronbach's α were calculated. The data were analyzed through the Survey Monkey system, and we used Statistical Package of Social Sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel (version 16) software for data analysis. We performed descriptive and frequency analysis, the goodness of fit analysis, correlation analysis, and inferential analysis of factors affecting medication safety practice. The STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guided the reporting of the results of this study. [21][22][23]

RESULTS
A total of 435 pharmacists responded to the survey. Of them, one-quarter were from the central region (97 (22.35%)) and northern area (92 (21.2%)), and there were no statistically significant differences between the provinces (p=0.637). Of those, most of the responders were from a community pharmacy (81 (18.62%)), Ministry of Health (MOH) hospitals (69 (15.86%)), and military hospitals (49 (11.26%)), with statistically significant differences between worksites (p=0.000). Of the total responders, 212 (48.96%) were female, and 221 (51.04%) were male, and there was no statistically significant difference between them (p=0.665). Most of the responders were in the age group of 24-30 years (151 (34.87%)) followed by 36-40 years (101 (23.33%)), with statistically significant differences between all age groups (p=0.000). Most of the pharmacists were pharmacy staff (192 (44.55%)) and pharmacy supervisors (104 (24.13%)), with statistically significant differences between all levels of qualifications (p=0.000). The majority of the responders held Bachelor in Pharmacy degree (281 (64.75%)), Master in Pharmacy degree (94 (21.66%)), and Diploma in Pharmacy (90 (20.74%)). Most pharmacists have work experience of 7-9 years (117 (27.08%)) and 4-6 years (116 (26.85%)), with statistically significant differences between all levels of experience (p=0.000). Almost one-fifth of the pharmacists practiced at the clinical pharmacy (62 (18.08%)), outpatient pharmacy (61 (17.78%)), and inpatient pharmacy (555 (16.03%)), with statistically significant differences between all sites of pharmacy practice (p=0.000). There is a strong positive correlation between age (years) and years of experience in pharmacy career based on Kendall's tau_b (0.576) and Spearman's rho (0.701), with statistically significant differences between them (p<0.001) (Tables 1  and 2). The average score for the implemented items for pharmacy infection control practice was 3.07, with high scores obtained for the elements "the vision of pharmacy infection control" (3.79), "mission of pharmacy infection control" (3.55), "infection control pharmacy and drug quality reporting systems" (3.37), and "the strategic plan of pharmacy infection control" (3.35). In contrast, low scores were obtained for the elements "infection control pharmacy competency" (2.51), "Infection control pharmacy and quality management" (2.65), and "policies and procedure of pharmacy infection control" (2.77), with significant statistical differences between all responses (p=0.000) ( Table 3). The average score for the elements of pharmacy infection control practice implementation was 3.47, with high scores obtained for the elements "the pharmacist share in infection control committee" (4.37) and "the pharmacist was always a staff member of infection control or pharmacy departments" (3.84). In contrast, the lowest score was obtained for the element "the attendance of several courses or workshops about pharmacy infection control" (3.17) and "there are electronic pharmacy infection control performances" (3.34), with a statistically significant difference between all the answers in all aspects in pharmacy practice (p=0.000) ( Table 4). The highest scores of pharmacy infection control (to authorities) were obtained for the element "the responsibility of types of healthcare professionals was an infection control pharmacist" (3.95) and "infection control doctors" (3.94). In contrast, the lowest score was obtained for the element "infectious diseases doctors" (3.29) and "infection control nurses" (3.37), with statistically significant differences between the responses (p=0.000) ( Table 5). The score for the single-test reliability analysis of McDonald's ω was 922, Cronbach's αwas 0.919, Gutmann's λ2 was 0.930, Gutmann's λ6 was 0.973, and Greater Lower Bound was 0.990.

Factors influencing the pharmacist's practice of pharmacy infection control
In this study, we performed independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests to obtain adjusted significant values, which are as follows. The factors that might affect pharmacists' practice of pharmacy infection control include location, worksite, gender, age, practice area, current position held, and years of experience. Gender alone did not affect the knowledge of storage, with a non-statistically significant difference between males and females (p>0.05). Five locations affected the practice of pharmacy infection control by pharmacists. The western region showed the lowest scores (2.8144), with a statistically significant difference between all regions (p=0.000). Fourteen levels of the working site showed low scores, in which case private hospitals obtained the lowest score (2.4963), with a statistically significant difference between them (p=0.000). Six different age groups affected the practice of pharmacy infection control. The lowest score (2.7477) was obtained for the age group of 24-30 years, with a statistically significant difference between all age groups (p=0.000). Twelve practice areas showed a low score (2.4762), and the area of pharmaceutical companies showed a statistically significant difference (p=0.000). Five career positions affected the practice of pharmacy infection control, with the lowest score (2.7767) obtained for the intern position, which was statistically significant (p=0.013). Six levels of years of experience affected the practice of pharmacy infection control. The lowest score (2.7478) was obtained for <1 year of experience, followed by 1-3 years of experience (2.7578) and >12 years of experience (2.7474), and the differences were statistically International Journal of Pharmacology and Clinical Sciences, Vol 10, Issue 4, Oct-Dec, 2021      hospital (3.8653), and the differences were statistically significant (p=0.000). Six different age groups affected the practice of infection control implementation, and the lowest score (3.3547) was obtained for the age group of 31-35 years, with a statistically significant difference (p=0.001). Five different current positions held affected the practice of infection control implementation, and the highest score (3.7485) was obtained for pharmacy staff, and the differences were statistically significant (p=0.000). Six groups of work experiences affected the practice of infection control implementation, and the lowest score (3.3481) was obtained for 1-3 years of experience, with statistically significant differences between all age groups (p=0.000). The relationship between pharmacy infection control implementation  between pharmacy infection control practice and factors affecting it. All factors did not show significant differences (p>0.05). However, a single factor (i.e., current position) explained 26% of the positive relationship in variation to the implementation of pharmacy infection control, with a statistically significant difference between them (p=0.014). The non-existence of multi-collinearity verified the relationship with the years of experiences factor with variance inflation factor (VIF=1.410) less than three or five [24][25][26] (Table 7).

DISCUSSION
The practice of pharmacy infection control is highly essential in the field of pharmacy. [1][2][3][4][5][6] Various sections of the pharmacy section require infection control tools, which include the IV admixture, compounding sterile and non-sterile medications, and extemporaneous preparation in addition to the preparation and dispensing of medicines at inpatients and outpatient pharmacies. [7,[27][28][29] Therefore, exploring the pharmacy infection practice is highly suggested to resolve any defect. This study, with a validated and highly reliable survey of all types of site pharmacists in different regions with appropriate sample size, was found to be better than that of previous studies. [14][15][16] It was mainly in terms of community pharmacies, MOH hospitals, and military healthcare organizations. In this study, there were non-significant differences in the number of male and female responders. The responders had obtained a Bachelor's degree in Pharmacy or Diploma in Pharmacy, and most of them practiced in various specialties and outpatient and inpatient pharmacies. Moreover, most respondents who had good work experience also practiced pharmacy infection control. Unfortunately, the pharmacy infection control practice by the respondents was inadequate. Most pharmacists had a vision; the mission of pharmacy infection control was expected, especially from common pharmacy practice. However, some essential practices have not been established, such as competency of the pharmacist, pharmacy infection control, or unclear policies and procedures, which lead to malpractice of pharmacy infection control. Moreover, pharmacists participated in the infection committee in this study and sometimes worked at the infection control department, similar to a previous study. [15] However, education and training programs for pharmacy infection control were seldom practiced or were absent. Moreover, there are no available electronic pharmacy infection control activities. That was expected because it was a new program, and it will take time to become the electronic version. In this study, the pharmacists agreed that pharmacy infection control should be the responsibility of the department of pharmacy, followed by the medical doctors. Pharmaceutical companies emphasizing the administration offices might rarely implement or apply the infection control program inside the administration offices. Our results showed that only a single dependent factor (i.e., age) explained 20% of the positive response in the pharmacy infection control practice, which is expected because the pharmacy infection control needs experience in practice On the contrary, some factors affected the pharmacy infection control implementation, such as location. In this study, we found that the southern region showed the lowest score of performance related to inadequate infection control system inside the pharmacy and insufficient education and training during undergraduate and postgraduate levels. Furthermore, the worksite was another factor that affected the pharmacy infection control implementation. University and military healthcare organizations were the most practiced worksites where there was implementation infection control system. This result was expected because the university provides education and training on pharmacy infection control in a proper setting. Moreover, military hospitals have a very restricted system that prevents the transmission of infection among soldiers. Moreover, both of them should implement pharmacy infection control in practice in a healthcare setting.
Age is an additional factor that affected the pharmacy infection control implementation, particularly pharmacists in the age group of 31-35 years with a work experience of 1-3 years because the pharmacy staff was not in positions responsibilities for implementation pharmacy infection control program. In comparison, higher positions had the authority to implement the pharmacy infection control. However, only a single dependent factor positively affected (26%) the implementation of pharmacy infection control, which was expected because the higher position has the authority to implement pharmacy infection control.

Limitations
The results of this study are informative with high-reliability data and acceptable sample size. Moreover, the demographic data of location and gender were equally distributed. However, there were some limitations to this study. For example, there was an unequal distribution of age, worksite, practice area, years of experience, and current position. In addition, there were not many studies to compare with them. Therefore, we recommend further studies with comparable demographic data.

CONCLUSION
The practice of pharmacy infection control by pharmacists in Saudi Arabia was found to be insufficient. Various factors might affect infection control practice, such as young age, low experience, and lower position. In addition, other factors such as geographic location, gender, worksite vary in the practice. Therefore, essential key performance indicators are highly suggested to improve the implementation of pharmacy infection control in Saudi Arabia.