Thyroid disorders are a major public health problem. Pharmacists are pivotal in identification and management of thyroid disorders. Level of knowledge and perception of pharmacists have significant influence on the roles pharmacists play in identification and management of patients with thyroid disorders. This study was conducted to assess the knowledge and perception of pharmacists in Ghana on thyroid disorders. A cross-sectional study was carried out amongst registered pharmacists in Ghana from 8th-29th May, 2021. Data was collected using a validated online questionnaire. Participants’ socio-demographic characteristics and level of knowledge were summarized as frequencies and percentages. Roles pharmacists play in management were summarized in charts. Chi-square test was performed to determine association between level of knowledge, perception and independent variables. Magnitude and strength of association was determined for each variable and the level of knowledge by simple and multiple logistics regression analysis. A total of 430 pharmacists participated in the study. Most participants (392, 91.2%) had sufficient knowledge about thyroid disorders. Lectures on thyroid disorders in pharmacy school were the main source of information for a significant number of participants (332, 77.2%). About half of participants (217, 50.5%) felt they had fair knowledge about thyroid disorders. Again, a significant number of pharmacists (305, 70.9%) indicated that continuous professional development and clinical meetings could enhance their involvement in the management of thyroid disorders. Commonly mentioned role pharmacists play in management was patient counseling (233, 54.2%). Female participants were 63.2% less likely to have sufficient knowledge than males (p=0.008). Pharmacists who had an encounter with a patient with thyroid disorders are 152% more likely to have sufficient knowledge those who had not had an encounter with a patient with thyroid disorders (p=0.008). Ghanaian pharmacists demonstrated sufficient knowledge about thyroid disorders. Continuous professional development and clinical meetings can enhance pharmacists’ involvement in management. Gender and having had an encounter with a suspected or confirmed patient were significantly associated with level of knowledge.

Keywords

Knowledge, Perception, Pharmacists, Ghana, Thyroid disorders

Thyroid disorders are major public health problems worldwide (Alhazmi et al., n.d.; Shankar et al., 2020), and are also among the commonest known endocrine disorders (Diab et al., 2019).  These conditions are described as altered serum thyroid-stimulating hormone (TSH) levels with or without altered thyroid hormones (Aryal et al., 2010). Some risk factors that can influence the prevalence of thyroid disorders include age, sex, environmental factors, geographic factors, iodine intake and ethnicity (Sulejmanovic et al., 2019). Countries with iodine deficiency have the highest prevalence of thyroid disorders, and nearly one third of the population in the world live in areas with iodine deficiency (Sulejmanovic, Cickusic, Salkic & Bousbija 2019; Aryal et al. n.d.).

Studies have shown that 1.6 billion people are at risk of developing thyroid disorders in more than 110 countries worldwide (Rashad and Samir, 2020). Hypothyroidism, thyrotoxicosis, thyroiditis and iodine deficiency disorders are the most prevalent thyroid disorders in Africa (Asmelash et al., 2019) (Rashad & Samir 2020). Due to the high prevalence of thyroid disorders, assessment of thyroid function is an essential part of evaluation for all patients with thyroid diseases (Chaker, Bianco, Jonklaas & Peeters 2017; De Leo, Lee & Braverman 2016).

There is the need for a multidisciplinary approach to the management of thyroid disorders since untreated thyroid disorders affect the physical and mental well-being of the patients (Dew et al., 2018; Sethi et al., 2018). Studies have shown that pharmacists play a major role in identification and management of patients with thyroid disorders (Dong, 1990). Pharmacists engage in patient counseling, continuity of care, issue of reminders for blood tests, assessment of patient medications for medication interactions and prescription refills. Pharmacists also ensure easy access to prescriptions for patients (Dew et al. 2018; Dong 1990). Level of knowledge and perception of pharmacists on thyroid disorders have a significant influence the roles pharmacists play in identification and management of patients with thyroid disorders (Dew et al. 2018). This study was therefore conducted among pharmacists in Ghana to assess their knowledge and perception on thyroid disorders.

Study design and setting

A cross-sectional study was carried out amongst registered pharmacists across Ghana from 8th to 29th May, 2021 to assess the knowledge and perception of pharmacists on thyroid diseases.

Study population and sampling

This study population included pharmacists across Ghana present in the country at the time of the study. Pharmacists in this study included pharmacists practicing in various fields of pharmacy (community practice, hospital practice, regulatory, academia, research, entrepreneurship and industry). The number of registered pharmacists in good standing in Ghana was 2561 as at 31st December, 2020 according to the Pharmacy Council (PC), Ghana.

With a confidence level of 95%, margin of error of 5%, a Z score of 1.96 and an estimated population of interest (p) of 0.5, the sample size was calculated using the formula derived from the central limit theorem as given by Jaisingh (2006). The formula is

            N=p (1-p) (Z/E)2,      

Therefore, a minimum obligatory sample size of 385 pharmacists was required to fill the questionnaires. To cater for non-response, inappropriate responses and errors in filling the questionnaire, 10% of the sample size was calculated (39) making the final sample size of 424 pharmacists was required to fill the questionnaires. Pharmacists in good standing and thus were qualified by law to practice in Ghana were sampled using the convenience sampling technique. The questionnaires were converted to Google Forms via WhatsApp instant messaging. This was sent to pharmacists’ interest group pages to enable pharmacists in good standing according to the Pharmaceutical Society of Ghana (PSGH) and PC fill. Data collection was ended when a sample size of 430 pharmacists was achieved.

Data collection techniques

The questionnaire was converted to Google Forms and pre-tested on 10 pharmacists who did not take part in the study, subsequently. It was sent via WhatsApp instant messaging to pharmacists in good standing according to the PSGH and PC to fill. Data collection was ended when a sample size of 430 pharmacists was achieved. The questionnaire consisted of open- and close-ended questions as well as a brief introduction describing the purpose of study, anonymity and confidentiality statements.    

To affirm consent, participants were required to answer a yes-no question to indicate their willingness to participate in the study.

Data processing

Data from the Google forms were exported to Microsoft Excel 2016 after checking for completeness and accuracy of the information. The data was cleaned by identifying all wrong entries and the corrections were done using the codes in the questionnaire. Data exported was saved as Microsoft Excel file and exported to STATA for statistical analysis.

Data analysis

All analyses were done using STATA version 15.0. Descriptive statistics on socio-demographic characteristics of respondents were presented as frequencies in tables. The level of knowledge of pharmacists of thyroid disorders was summarized as frequencies and percentages. Roles pharmacists play in the management of thyroid disorders and factors that enhance the involvement of pharmacists in management of thyroid disorders were summarized as frequencies and percentages. A Chi-square test was used to test for association between level of knowledge and all the independent variables. The responses indicated that only two levels of knowledge on thyroid disorders were identified. As such this was treated as a binary outcome using simple logistic regression analysis to determine the magnitude and strength of association between each variable and level of knowledge. Multiple logistics model was used to determine demographics influencing level of knowledge after adjusting for confounders.

Ethical considerations

Ethical clearance was obtained from the Committee on Human Research Publication and Ethics (CHRPE), Kwame Nkrumah University of Science and Technology (KNUST) prior to the commencement of the study (CHRPE/AP/241/21).

Demographic characteristics of participants

A total of 430 pharmacists participated in this study with a response rate of 100%. Two hundred and twenty-two of the participants (51.6%) were males and 208 (48.4%) were females (Table 1).

Table 1: Demographic characteristics of participants

Area of pharmacy practice 

Community pharmacy practice (209, 48.6%) and hospital pharmacy practice (215, 50.0%) were the most common areas of practice for pharmacists in this study (Figure 1).   

Figure 1: Area of practice of pharmacists

Source of information for pharmacists on thyroid disorders

Lectures on thyroid disorders in pharmacy school (332, 77.2%), clinical meetings (228, 53.0%), and interaction with a patient with thyroid disorder (227, 52.8%) were the most common sources of information for pharmacists (Figure 2).

Figure 2: Sources of information on thyroid disorders for pharmacists in Ghana

Knowledge of pharmacist about thyroid disorders

All participants (430, 100.0%) had heard about thyroid disorders with significant number of participants (304, 70.7%) having an encounter with a suspected or confirmed case. Majority of participants knew thyroid goitre (407, 94.7%), thyroiditis (384, 89.3%), Graves’ disease (382, 88.8%), thyroid cancer (365, 84.9%) and Hashimoto’s disease (327, 76.0%) were types of thyroid disorders. Almost all the participants (421, 97.9%) knew that thyroid disorders are not managed through surgery only. Most participants (392, 91.2%) had sufficient knowledge about thyroid disorders (Table 3).

Table 2: Knowledge of pharmacists about thyroid disorders

Signs and symptoms of thyroid disorders.

Almost all the participants (407, 94.7%) knew that goitre was a symptom of thyroid disorders, and a significant number of participants (382, 88.8%) knew that fatigue was a symptom of thyroid disorders (Table 3).

Table 3: Signs and symptoms of thyroid disorders

Medications for management of thyroid disorders

Almost all the participants (424, 98.6%) knew that levothyroxine was used in the management of thyroid disorders. Almost two-thirds of the participants (273, 63.5) knew more than 3 medications used for the management of thyroid disorders (Table 4).

Table 4: Medications for management of thyroid disorders

Guidelines used by participants for management of thyroid disorders

The commonly used guidelines for the management of thyroid disorders by participants included the British National Formulary (BNF) (324, 75.3%) and Standard Treatment Guidelines (STG) (327, 76.0%). Other guidelines used included Medscape (110, 25.6%), applied therapeutics (87, 20.2%), American thyroid association guidelines (55, 12.8%) and online resources (47, 10.9%). The least commonly used guidelines were guidelines from workplaces (32, 7.4%) and UpToDate (19, 4.4%).

Perception of pharmacists about thyroid disorders

Two hundred and seventeen participants (217, 50.5%) indicated they had fair knowledge about thyroid disorders, and 6 (1.4%) felt they had very poor knowledge on the medications for management of thyroid disorders (Table 5).  

Table 5: Perception of pharmacists about thyroid disorders

 Factors that enhance pharmacists’ involvement in management of thyroid disorders.

Most participants (391, 90.9%) mentioned at least one factor that enhances pharmacists’ involvement in the management of thyroid disorders. Training of pharmacists during CPDs/Clinical meetings (305, 70.9%) and pharmacists’ involvement in ward rounds and case management (61, 14.2%) were identified as the commonest factors (Figure 3).

Figure 3: Factors that enhance pharmacists’ involvement in management of thyroid disorders

Roles pharmacists play in the management of thyroid disorders

Most participants (393, 91.4%) mentioned at least one role pharmacists play in the management of thyroid disorders. Patient counseling was the commonest mentioned role (233, 54.2%) (Figure 4).

 Figure 4: Roles pharmacists play in management of thyroid disorders

Association between level of knowledge of participants and demographic Characteristics

Gender (p=0.003) and having an encounter with a suspected confirmed case of a thyroid disorder (p=0.003) were significantly associated with the level of knowledge of participants on thyroid disorders. However, age, working experience and hearing about thyroid disorders were not significantly associated with the level of knowledge of participants on thyroid disorders (Table 5).

Table 6: Association of Level of Knowledge and Demographics

Female participants were 63.2% less likely to have sufficient knowledge on thyroid disorders than male participants (p=0.008). Pharmacists who had an encounter with a patient with thyroid disorders are 152% more likely to have sufficient knowledge those who had not had an encounter with a patient with thyroid disorders (p=0.008) (Table 6).

Table 7: Logistic regression of demographics associated with level of knowledge on thyroid disorders

A total of 430 pharmacists participated in the study with a response rate of 100%. More than half of the respondents were male. However, in a similar study conducted in the United Kingdom, most participants were female (75%) (Dew et al. 2018). Majority of the participants were within the ages of 21-30 years, which is in agreement with studies conducted in Ethiopia and Turkey where most participants were Pharmacists between the ages of 19 and 30 years (Kara, Demirkan & Ünal 2020; Tesfaye, Yismaw, Negash & Ayele 2020). A State of the nation’s health report confirms findings from this study, where most Ghanaian healthcare workers were identified to be between the ages of 18-34years (University of Ghana School of Public Health 2018). Over half of the participants in this study had less than 5 years working experience, similar to studies conducted in Jordan (45.9%) and Ethiopia (54.2%) where most participants had worked for 5years or less (Karasneh et al. 2021; Tesfaye et al. 2020). The present youthful age structure of pharmacists in Ghana implies that with several years of working experience ahead of them, measures must be put in place to empower them to be able to play key roles in patient management (University of Ghana School of Public Health, 2018).

Most pharmacists who participated in the study were into community and hospital pharmacy practice, in agreement with a similar study conducted in Jordan where majority of the pharmacists were into hospital and community practice (Karasneh et al., 2021). It is imperative that pharmacists in direct patient care are equipped with relevant information about medical conditions such as thyroid disorders to enable them make significant inputs and impact patient care.

Common sources of information on thyroid disorders for participants included lectures about thyroid disorders in pharmacy school, clinical meetings and continuous professional development (CPD) programs. This was in contrast with findings from a study conducted to identify pharmacists’ commonly used sources of information which revealed that drug information handbook, BNF and drug desk were commonly used (Wong et al., 2009). A Malaysian study also revealed that majority of pharmacists were more likely to source for information from the internet, professional peers, leaflets provided from company representatives and drug seminars organized by pharmaceutical companies (Hassali et al., 2010). It is important for patients with thyroid disorders to receive relevant and current information form healthcare workers. Thus, information on thyroid disorders from credible sources must be used by pharmacists in patient identification, management and counselling (Maheshwari et al., 2017).

In this study, all the participants had heard of thyroid disorders with majority (304, 70.7%) having an encounter with a suspected or confirmed case of a thyroid disorder, in contrast with findings from a study conducted in India to assess knowledge and awareness regarding thyroid disorders among women of a cosmopolitan city where 29.2% of participants had not heard the word “thyroid” before (Rai et al., 2016). Furthermore, in a similar study conducted in patients with hypothyroidism, very few participants (12%) had high awareness of the disease according to the scoring assessment criteria of the study (Sethi et al., 2018). In this study, 91.2% of participants had sufficient knowledge about thyroid disorders, which is not in agreement with findings from a similar study conducted in India where most participants (66.6%) had a low level of knowledge (Sethi et al., 2018), and findings from another study conducted in the United Kingdom which revealed that participants admitted to having inadequate knowledge. It is important that pharmacists and other health workers acquire sufficient level of knowledge on medical conditions such as thyroid disorders since this will help to optimize patient management, ensure continuity of care and reduce associated negative perceptions (Dew et al., 2018).

Less than half of the participants knew that being more than 60 years of age and having a medical condition such as diabetes mellitus and rheumatoid arthritis are risk factors for thyroid disorders, while 12.8% wrongfully chose male gender as a risk factor for thyroid disorders. In a similar study conducted in Riyadh, participants demonstrated a worrying lack of knowledge about risk factors for thyroid disorders, and lack of knowledge of educated individuals on thyroid disorders was an issue of concern (Aladwani et al., 2019). However, most participants were aware that family history of thyroid disease, iodine deficiency, previous medical history of thyroid disease and female sex were risk factors for thyroid disorders. Several studies have also confirmed that iodine deficiency and insufficient iodine intake are risk factors for thyroid disorders (Maharjan and Chhetri, 2015; Sethi et al., 2018).

Signs and symptoms identified by participants as associated with thyroid disorders were similar to findings from studies conducted in India and United Kingdom where constipation, dry skin, weight gain, fatigue and diarrhoea were identified as signs and symptoms for thyroid disorders (Dew et al., 2018; Maheshwari et al., 2017). Most participants demonstrated high level of knowledge about the medications used for management of thyroid disorders. From similar studies, participants were aware of the use of levothyroxine in management of thyroid disorders (Dew et al., 2018; Sethi et al., 2018). Research has confirmed that inadequate healthcare worker knowledge on medications for management of thyroid disorders has a negative impact on therapeutic outcomes (Dew et al., 2018). Pharmacists are healthcare workers who can actively participate in patient education to ensure appropriate patient outcomes are achieved. (Dew et al., 2018; Dong, 1990).

Guidelines used by most participants for the management of thyroid disorders included the BNF and the national STG. Findings from a similar study also indicated local guidelines were used by most participants. However, in contrast, others admitted to not using any guidelines (Dew et al., 2018). In a similar study in Singapore, pharmacists admitted to the use of guidelines such as drug information handbook and BNF as sources of information (Wong et al., 2009). The STG (the most recommended and comprehensive national guidelines for management of medical conditions) and  BNF are among the most frequently used guidelines in pharmacy schools as well as in practice thereby accounting for a relatively higher frequency of use  (Ministry of Health, 2010,  British National Formulary, 2021; Wong et al., 2009).

Less than a quarter of the participants felt they had a very good level of knowledge on thyroid disorders with regards to medications for management, familiarity with signs and symptoms, and ability to identify a suspected case of thyroid disorder. This was consistent with findings from studies conducted in the United Kingdom and India where participants admitted to low level of knowledge on medications for management and identification of patients at risk of developing thyroid disorders. Improving pharmacists’ knowledge and involvement in identification and management of thyroid disorders will lead to optimized patient outcomes (Dew et al., 2018; Sethi et al., 2018).

Participants in this study indicated that pharmacists' involvement in managing patients with thyroid disorders, CPDs/clinical meetings on thyroid disorders and, specialization of pharmacists in the management of thyroid disorders would encourage their participation   in management of thyroid disorders. This is in agreement with studies that have concluded that specialization, pharmacists’ involvement in CPDs and ward rounds enhanced their knowledge, ensured their continued competence in practice and improved their service provision (Bullock et al., 2019; Jung et al., 2018; Rouse et al., 2018; Terzaghi et al., 2020; Wheeler and Chisholm-Burns, 2018). Participants also indicated that pharmacists play diverse roles in the management of thyroid disorders, in agreement with other studies which confirmed that pharmacists are directly involved in ensuring medicines availability, patient management, pharmacovigilance, patient counseling and research on thyroid disorders (Dong, 1990; Kader Mohiuddin, 2020). In other studies, pharmacists have been noted to play additional roles such as preparation of parenteral forms of antithyroid medications for administration (Dong, 1990; Pokhrel et al., 2021). Pharmacists are well positioned to play important roles in multidisciplinary team efforts towards management of conditions such as thyroid disorders (Newman et al., 2019, Lott et al., 2021).

 This study indicates that, gender and having an encounter with a confirmed or suspected case of thyroid disorder were significantly associated with level of knowledge of participants. Male pharmacists and pharmacists who have had an encounter with a confirmed or suspected case of thyroid disorder demonstrated a higher level of knowledge. This is similar to findings from a study conducted in India where a high percentage of males had significant level of knowledge as compared to females (Sethi et al. 2018). However, in another study in Egypt, age and level of education were significantly associated with level of knowledge of participants (Wahed, Hefzy, Ahmed & Hamed 2020). It is important that pharmacists of various fields of practice demonstrate a high level of knowledge about thyroid disorders (Rouse et al., 2018; Wheeler and Chisholm-Burns, 2018).

Ghanaian pharmacists demonstrated sufficient knowledge about thyroid disorders, but only a few felt they had very good level of knowledge on thyroid disorders. Continuous professional development and clinical meetings can enhance pharmacists’ involvement in management of thyroid disorders.

It is important that community and hospital pharmacists who are readily accessible to patients and the general public have adequate knowledge on thyroid disorders. Since several sources of information on management of medical conditions exist, it is imperative that pharmacists access information from credible guidelines. Particularly references that provide extra information on pharmacokinetics, administration guidelines and side effects will be very effective. Since pharmacy practice is evolving from the traditional role of dispensing to a more patient-centred approach, pharmacists must be empowered to perform more roles in management of conditions such as thyroid disorders. When pharmacists who are readily available healthcare workers have access to opportunities such as educational programs and CPDs on thyroid disorders periodically, they will be abreast with current trends in management which will have a positive impact on their level of knowledge and perception.

Limitation

Although required number of participants was achieved, there was an inadequate representation of pharmacists from various sectors of pharmacy practice in Ghana. The use of online questionnaires excluded pharmacists in rural areas with internet connectivity problems.

Data availability

The data used to support the findings of this study are available from the corresponding author upon request.

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

Funding

The authors received no specific funding for this study.

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