an evaluation of pharmacists’ knowledge of women’s issues in epilepsy

4
An evaluation of pharmacists’ knowledge of women’s issues in epilepsy James W. McAuley a,b, * , Jynel Casey a , Lucretia Long b a College of Pharmacy, The Ohio State University, Columbus, OH, USA b College of Medicine, The Ohio State University, Columbus, OH, USA article info Article history: Received 22 September 2008 Revised 13 October 2008 Accepted 15 October 2008 Available online 26 November 2008 Keywords: Epilepsy Antiepileptic drugs Pharmacists Pharmacy Women’s issues Knowledge Education abstract Objective: Although epilepsy affects men and women equally, there are many women’s health issues in epilepsy. These issues challenge both the woman with epilepsy and the many health care professionals involved in her care. As antiepileptic drugs (AEDs) play a major role in the treatment of epilepsy, phar- macists can serve an important function in the health care of patients with this chronic disease. The goal of this educational project was to assess pharmacists’ knowledge of women’s issues in epilepsy using the Knowledge of Women’s Issues and Epilepsy II (KOWIE-II) questionnaire. Methods: In this cross-sectional study we used the valid and reliable KOWIE-II questionnaire, a 10-item questionnaire on women’s issues in general as well as pregnancy-related issues. A random sample of pharmacists registered in Ohio either were sent the KOWIE-II questionnaire or completed it prior to a live seminar. Demographic and practice-related data were collected. A percentage correct score was calcu- lated per pharmacist. Results: Our sample consisted of 152 completed surveys. On the questionnaire, the overall average cor- rect score was 60.3%. Nearly 75% of pharmacists had a correct score for the statement inquiring about the drug interaction between enzyme-inducing AEDs and contraceptives. Slightly less than 70% knew of the issue of AED-induced bone loss. Almost one-third (32.2%) of the respondents answered incorrectly when asked about the frequency of sexual dysfunction in women with epilepsy, though an even higher percentage chose ‘‘don’t know.” Most of the pharmacists (69.1%) stated ‘‘don’t know” when asked about the relationship between hormones and seizure control. More than 70% correctly answered four of the six pregnancy-related statements (folic acid = 77.0%, healthy babies = 82.9%, continued AED adherence dur- ing pregnancy = 86.8%, choice of AED during pregnancy = 71.1%). Fewer pharmacists knew about vitamin K supplementation (57.9%), and even fewer answered the question on breastfeeding correctly (33.6%). Pharmacists who interacted with the most patients per month had the highest scores. Conclusion: Pharmacists are in a key position to help women with epilepsy, and though there are some areas where pharmacists are generally knowledgeable about women’s issues in epilepsy, there are still gaps in knowledge where educational interventions are clearly needed. Ó 2008 Elsevier Inc. All rights reserved. 1. Introduction Although epilepsy affects men and women equally [1], there are many women’s health issues in epilepsy [2]. These women’s issues include choice of antiepileptic drug (AED) in women of childbear- ing age, teratogenicity, breastfeeding, hormonal influences (pre- and postmenopause), contraceptive drug interactions, sexual dysfunction, AED impact on bone, and more. These issues can chal- lenge both the woman with epilepsy and the many health care professionals involved in her care. Vazquez and colleagues recently reported results from a brief online survey of 440 women with epilepsy [3]. They gathered the patient’s perspective on the level of dialogue about women’s issues and whether patients perceived a need for more information from their physician. Interestingly, though women reported that their physician was the primary source of information on women’s is- sues in epilepsy, more than half of them (55%) reported the infor- mation was insufficient. Crawford and Lee reported similar findings from their survey of 1855 women [4]. Unfortunately, there are many examples in the literature dem- onstrating a lack of knowledge of women’s issues in epilepsy by health care professionals [5–7]. The Knowledge of Women’s Issues and Epilepsy II (KOWIE-II) questionnaire was developed to assess what health care professionals know about issues pertaining to women with epilepsy [8]. The validity and reliability of this tool, which can be used for clinical research and to assist with educa- tional interventions, have previously been established. Using the KOWIE-II, Long and Montouris evaluated the knowledge of wo- men’s issues in epilepsy of 202 health care professionals (mostly physicians) attending an American College of Physicians annual conference [9]. Collectively, these respondents were not 1525-5050/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2008.10.018 * Corresponding author. Fax: +1 614 292 1335. E-mail address: [email protected] (J.W. McAuley). Epilepsy & Behavior 14 (2009) 243–246 Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh

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Epilepsy & Behavior 14 (2009) 243–246

Contents lists available at ScienceDirect

Epilepsy & Behavior

journal homepage: www.elsevier .com/locate /yebeh

An evaluation of pharmacists’ knowledge of women’s issues in epilepsy

James W. McAuley a,b,*, Jynel Casey a, Lucretia Long b

a College of Pharmacy, The Ohio State University, Columbus, OH, USAb College of Medicine, The Ohio State University, Columbus, OH, USA

a r t i c l e i n f o

Article history:Received 22 September 2008Revised 13 October 2008Accepted 15 October 2008Available online 26 November 2008

Keywords:EpilepsyAntiepileptic drugsPharmacistsPharmacyWomen’s issuesKnowledgeEducation

1525-5050/$ - see front matter � 2008 Elsevier Inc. Adoi:10.1016/j.yebeh.2008.10.018

* Corresponding author. Fax: +1 614 292 1335.E-mail address: [email protected] (J.W. McAuley

a b s t r a c t

Objective: Although epilepsy affects men and women equally, there are many women’s health issues inepilepsy. These issues challenge both the woman with epilepsy and the many health care professionalsinvolved in her care. As antiepileptic drugs (AEDs) play a major role in the treatment of epilepsy, phar-macists can serve an important function in the health care of patients with this chronic disease. The goalof this educational project was to assess pharmacists’ knowledge of women’s issues in epilepsy using theKnowledge of Women’s Issues and Epilepsy II (KOWIE-II) questionnaire.Methods: In this cross-sectional study we used the valid and reliable KOWIE-II questionnaire, a 10-itemquestionnaire on women’s issues in general as well as pregnancy-related issues. A random sample ofpharmacists registered in Ohio either were sent the KOWIE-II questionnaire or completed it prior to a liveseminar. Demographic and practice-related data were collected. A percentage correct score was calcu-lated per pharmacist.Results: Our sample consisted of 152 completed surveys. On the questionnaire, the overall average cor-rect score was 60.3%. Nearly 75% of pharmacists had a correct score for the statement inquiring aboutthe drug interaction between enzyme-inducing AEDs and contraceptives. Slightly less than 70% knewof the issue of AED-induced bone loss. Almost one-third (32.2%) of the respondents answered incorrectlywhen asked about the frequency of sexual dysfunction in women with epilepsy, though an even higherpercentage chose ‘‘don’t know.” Most of the pharmacists (69.1%) stated ‘‘don’t know” when asked aboutthe relationship between hormones and seizure control. More than 70% correctly answered four of the sixpregnancy-related statements (folic acid = 77.0%, healthy babies = 82.9%, continued AED adherence dur-ing pregnancy = 86.8%, choice of AED during pregnancy = 71.1%). Fewer pharmacists knew about vitaminK supplementation (57.9%), and even fewer answered the question on breastfeeding correctly (33.6%).Pharmacists who interacted with the most patients per month had the highest scores.Conclusion: Pharmacists are in a key position to help women with epilepsy, and though there are someareas where pharmacists are generally knowledgeable about women’s issues in epilepsy, there are stillgaps in knowledge where educational interventions are clearly needed.

� 2008 Elsevier Inc. All rights reserved.

1. Introduction

Although epilepsy affects men and women equally [1], there aremany women’s health issues in epilepsy [2]. These women’s issuesinclude choice of antiepileptic drug (AED) in women of childbear-ing age, teratogenicity, breastfeeding, hormonal influences(pre- and postmenopause), contraceptive drug interactions, sexualdysfunction, AED impact on bone, and more. These issues can chal-lenge both the woman with epilepsy and the many health careprofessionals involved in her care.

Vazquez and colleagues recently reported results from a briefonline survey of 440 women with epilepsy [3]. They gathered thepatient’s perspective on the level of dialogue about women’s issuesand whether patients perceived a need for more information from

ll rights reserved.

).

their physician. Interestingly, though women reported that theirphysician was the primary source of information on women’s is-sues in epilepsy, more than half of them (55%) reported the infor-mation was insufficient. Crawford and Lee reported similarfindings from their survey of 1855 women [4].

Unfortunately, there are many examples in the literature dem-onstrating a lack of knowledge of women’s issues in epilepsy byhealth care professionals [5–7]. The Knowledge of Women’s Issuesand Epilepsy II (KOWIE-II) questionnaire was developed to assesswhat health care professionals know about issues pertaining towomen with epilepsy [8]. The validity and reliability of this tool,which can be used for clinical research and to assist with educa-tional interventions, have previously been established. Using theKOWIE-II, Long and Montouris evaluated the knowledge of wo-men’s issues in epilepsy of 202 health care professionals (mostlyphysicians) attending an American College of Physicians annualconference [9]. Collectively, these respondents were not

244 J.W. McAuley et al. / Epilepsy & Behavior 14 (2009) 243–246

adequately informed about many issues affecting women withepilepsy.

AEDs are the mainstay of therapy for patients with epilepsy [10].Because medication plays a major role in the treatment of epilepsy,pharmacists can serve an important function in the health care ofpatients with this chronic disease [11]. According to a recent sur-vey, patients with epilepsy report having a good relationship withtheir pharmacists, but patients desired more information from theirpharmacists to enhance their care [12]. Pharmacists should takeadvantage of the opportunity to expand their role in providing opti-mal care to their patients with epilepsy, including patient educationon women’s issues.

KOWIE-II has been used previously to assess the knowledge ofhealth care professionals, but was not targeted towardpharmacists. Although recent knowledge assessments have askedquestions of many different types of health care professionals,none have focused on pharmacists. The goal of this educationalproject was to assess pharmacists’ knowledge of women’s issuesin epilepsy using KOWIE-II.

2. Methods

Approval from The Ohio State University’s institutional reviewboard was obtained along with a waiver of consent. This was across-sectional study using the valid and reliable 10-item KO-WIE-II questionnaire. Pharmacists were asked to respond either‘‘true,” ‘‘false,” or ‘‘don’t know” to statements on general women’sissues in epilepsy (n = 4) and pregnancy-related issues (n = 6). Theresponses were scored as percentage correct and ranged from 0 to100%. Along with personal demographics (age and gender), respon-dents were asked to indicate years in practice, practice setting, andnumber of patients with epilepsy with whom they interact on amonthly basis. Respondents were grouped into one of three cate-gories: <10, 10–19, and P20 patients seen per month.

Pharmacists registered in the state of Ohio were the targetexperimental group. A random sample of 500 pharmacists wassent the KOWIE-II questionnaire along with a cover letter explain-ing the study. Additional pharmacists were recruited at a contin-uing education seminar, prior to the presentation. No incentivewas provided, but to encourage participation, pharmacists weretold the investigators would contribute $2 to the EpilepsyFoundation of Central Ohio for every completed survey received.

3. Results

3.1. Demographics

Our sample consisted of 109 completed surveys returned by mail.This represents a response rate of 21.8%. Additionally, 43 completedsurveys came from pharmacists attending a local seminar; no re-sponse rate could be calculated from the live seminar due to the nat-ure of the data collection. The completed surveys collected by both

Table 1Respondent demographics (n = 152).

Age (years) 50.5 ± 15.2a

Years in current practice setting 18.6 ± 15.3a

Patients with epilepsy seen per month 13.9 ± 21.1a

Women 45%

Practice settingCommunity pharmacy 79%Long-term care 4%Clinic/medical building 1%Other 16%

a Mean ± SD.

methods (n = 152) were pooled and analyzed. Table 1 summarizesthe demographics of the respondents. Nearly half were women(45%) and most (79%) identified themselves as communitypharmacists.

On the 10-item questionnaire, the overall average correct scorewas only 60.3%. Though this overall score is lower than optimal,93% of our sample expressed the desire to learn more about wo-men’s issues in epilepsy. Many pharmacists were aware of theirknowledge deficits as evidenced by many of them checking ‘‘don’tknow” rather than guessing incorrectly.

3.2. Epilepsy and women’s health

Table 2 details the responses to the four statements related toepilepsy and women’s health in general. Pharmacists had the high-est correct score (nearly 75%) on the statement inquiring about theinteraction between enzyme-inducing AEDs and contraceptives.The second most correctly answered item was on the issue ofAED-induced bone loss (nearly 70%). Nearly one-third of the phar-macists answered incorrectly when asked about the frequency ofsexual dysfunction in women with epilepsy (32.2%). Most of thepharmacists (69.1%) stated ‘‘don’t know” when asked about therelationship between hormones and seizure control.

3.3. Pregnancy-related issues

Table 3 summarizes the patterns of responses to the statementson pregnancy-related issues in epilepsy. Most pharmacists (morethan 70%) correctly answered four of the six statements (folicacid = 77.0%, healthy babies = 82.9%, continued AED adherenceduring pregnancy = 86.8%, choice of AED during preg-nancy = 71.1%). Fewer pharmacists knew about vitamin K supple-mentation (57.9%), and even fewer answered the question onbreastfeeding correctly (33.6%).

3.4. Clinical experience

Half of the respondents (50%) reported seeing fewer than 10 pa-tients with epilepsy per month. The remainder of the respondentswere nearly equally split between 10–19 patients per month (27%)and P20 patients per month (23%). Fig. 1 depicts the relationshipbetween frequency of contact with patients with epilepsy and aver-age correct score. There is a correlation between number of patientswith epilepsy seen per month and overall correct score on the KO-WIE-II. In contrast to number of patients seen, no correlation wasobserved between overall score and either years in practice or age.

4. Discussion

Pharmacists working in any practice setting serve as a valuableresource for patients and prescribers. As such, they should be awareof the many aspects of epilepsy, especially women’s issues. Thoughthe overall score on our assessment was only 60%, certain high-awareness areas were identified. Many of the areas were relatedto pregnancy-related issues. Pharmacists were generally aware ofthe need to adhere to AED regimens during pregnancy and knewthat most women with epilepsy have healthy babies, that folic acidsupplementation is important for women of childbearing potential,and that the best AED during pregnancy is one that is most appro-priate for the seizure type and/or epilepsy syndrome.

Our findings are consistent with a prior study that used the KO-WIE-II to assess the knowledge of physicians [9]. In the previouslypublished study, 75% of physicians surveyed knew that womenwith epilepsy should not discontinue AEDs during pregnancy andthat the best AED during pregnancy is one that is most appropriatefor the seizure type and/or epilepsy syndrome. Most physicians

Table 3Awareness of facts about pregnancy-related issues in women with epilepsy.

Statement True(%)

False(%)

Don’t know(%)

‘‘The majority of women with epilepsy have healthy children.” 82.9a 5.3 11.8‘‘Women with epilepsy should stop taking their antiepileptic drugs when they become pregnant.” 4.6 86.8 8.6‘‘Taking folic acid before and during pregnancy may reduce teratogenesis in children born to women with epilepsy taking antiepileptic

drugs.”77.0 4.6 18.4

‘‘The best antiepileptic drug during pregnancy is the one that is most appropriate for the patient’s seizure type and or syndrome.” 71.1 17.8 11.1‘‘Vitamin K may reduce the risk of the newborn hemorrhagic disorder associated with certain antiepileptic drugs.” 57.9 5.9 36.2‘‘Most women taking antiepileptic drugs can safely breastfeed.” 33.6 35.5 30.9

a Correct answers are in boldface.

Table 2Awareness of facts about epilepsy and women’s health.

Statement True(%)

False(%)

Don’t know(%)

‘‘During the menstrual cycle, endogenous estrogen has been found to be proconvulsant, while progesterone has anticonvulsantqualities.”

17.8a 9.9 72.3

‘‘Enzyme-inducing antiepileptic drugs may reduce the effectiveness of contraceptives.” 74.3 8.6 17.1‘‘Some antiepileptic drugs are associated with osteomalacia (reduced bone mass).” 69.1 4.6 26.3‘‘Women with epilepsy have a higher incidence of sexual dysfunction compared to women without epilepsy.” 30.9 32.2 36.9

a Correct answers are in boldface.

58.3 60.667.1

0

20

40

60

80

<10 ≥2010 to 19Number of Epilepsy Patients Seen per Month

Mea

n C

orre

ct S

core

(Max

=100

)

50% 27% 23%

Fig. 1. Relationship between number of patients seen per month and averagecorrect score.

J.W. McAuley et al. / Epilepsy & Behavior 14 (2009) 243–246 245

(86%) were also aware that the majority of women with epilepsycan have healthy babies, and 92% understood the importance of fo-late supplementation.

On non-pregnancy-related issues, the pharmacists in this studyand physicians in the prior study [9] were fairly knowledgeable.Knowledge concerning AED drug interactions (awareness of theinteraction between certain AEDs and contraceptives) and AEDtoxicity (negative impact of AEDs on bone) were areas of relativestrength for both groups. Although it is important for physiciansto be aware of all items specific to women with epilepsy, it isexceptionally important for pharmacists to identify AED–contra-ceptive interactions, as failure to do so could result in an un-planned pregnancy. Though long-term adverse effects of AEDs onbone often go unaddressed, the morbidity and mortality associatedwith fractures, especially in older individuals, are significant. Theseaspects of care (drug interaction screening and adverse effect iden-tification) were highlighted by patients as areas for enhanced dis-cussions with their pharmacists [12].

Interestingly, in both cases where the KOWIE-II has been usedto assess knowledge of health care professionals, there is a positive

relationship between larger number of patients seen per monthand score. Pharmacists who see many patients with epilepsy eachmonth are more aware of women’s issues in epilepsy as comparedwith those who see fewer patients, but there is still room forimprovement. Frequency of contact with patients with epilepsyappears to be the only demographic predictor associated withoverall score, as neither age nor years in practice was correlatedwith score.

In two areas, the percentage of pharmacists answering incor-rectly was higher than the percentage answering correctly. Therespondents to our survey need be much more aware of the issuesof breastfeeding and sexual dysfunction in women with epilepsy.This is consistent with the information gathered for physicians,as only 42% were aware that women taking AEDs may breastfeedsafely, and fewer were aware (37%) of the increased incidence ofsexual dysfunction in this population [9]. It is important for phar-macists to be knowledgeable on these specific issues as pharma-cists are a readily available resource for patients.

Most of the respondents (93%) welcomed further education.This positive desire for more education and identification of gapsin knowledge will be helpful in shaping future epilepsy educa-tional interventions for pharmacists. Though we did not inquireas to their preferred method of epilepsy education, recent workby Stuart and Muir suggests that short courses on epilepsy man-agement are preferred by general practitioners in the UnitedKingdom [13]. Perhaps this method would work well for phar-macists also. An option would be to partner with local and na-tional groups like the Epilepsy Foundation, the AmericanEpilepsy Society, and/or the American Pharmacists Associationto enhance their educational training for pharmacists. Thesetraining sessions, led by experts in the field, could be held atthe annual meeting of the American Pharmacists Association orat the state and local pharmacy association levels. Optimally,the sessions would provide continuing education credits thatare required for all licensed pharmacists.

Our findings are consistent with similar studies documentingthe lack of knowledge of women’s issues in epilepsy of healthcare professionals [5–7,9]. Health care professionals involved in

246 J.W. McAuley et al. / Epilepsy & Behavior 14 (2009) 243–246

caring for women with epilepsy have a responsibility to educatethemselves on issues specific to women. Counseling women withepilepsy on issues specific to them is a very important compo-nent of facilitating patient care and improving outcomes.Although the current study did not evaluate the impact of edu-cational interventions and related knowledge outcomes, it doessupport the need to further educate pharmacists on these verycritical issues.

Our study is not without limitations. The response rate was only21.8% for the mailed surveys. Another limitation is that the KOWIE-II questions are not ‘‘case based.” If the questions had been casebased, it may have made responding to the questions more dis-cernable. This project is also limited in scope as only data from152 pharmacists registered in Ohio are reported.

In conclusion, pharmacists are in a key position to help womenwith epilepsy, and though there are some areas where pharmacistsare generally knowledgeable about women’s issues in epilepsy,there are still gaps in knowledge where educational interventionsare clearly needed.

References

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[2] McAuley JW, Anderson GD. Treatment of epilepsy in women of reproductiveage: pharmacokinetic considerations. Clin Pharmacokinet 2002;41:559–79.

[3] Vazquez B, Gibson P, Kustra R. Epilepsy and women’s health issues: unmetneeds—survey results from women with epilepsy. Epilepsy Behav2007;10:163–9.

[4] Crawford P, Lee P. Gender difference in management of epilepsy—what womenare hearing. Seizure 1999;8:135–9.

[5] Krauss GL, Brandt J, Campbell M, et al. Antiepileptic medication and oralcontraceptive interactions: a national survey of neurologists and obstetricians.Neurology 1996;46:1534–9.

[6] Morrell MJ, Sarto GE, Shafer PO, et al. Health issues for women with epilepsy: adescriptive survey to assess knowledge and awareness among healthcareproviders. J Womens Health Gend Based Med 2000;9:959–65.

[7] Spanaki MV, Shafer PO, Schachter SC. Knowledge among neurology residentsabout epilepsy-related issues in women: results of a survey [abstract].Epilepsia 2003;44(Suppl. 9):292.

[8] Long L, McAuley JW, Shneker B, Moore JL. The validity and reliability of theKnowledge of Women’s Issues and Epilepsy (KOWIE) questionnaires I & II. JNeurosci Nurs 2005;37:88–91.

[9] Long L, Montouris G. Knowledge of women’s issues and epilepsy (KOWIE-II): asurvey of health care professionals. Epilepsy Behav 2005;6:90–3.

[10] Azar NJ, Abou-Khalil BW. Considerations in the choice of an antiepileptic drugin the treatment of epilepsy. Semin Neurol 2008;28:305–16.

[11] McAuley JW, Mott DA, Schommer JC, Moore JL, Reeves AL. Assessing the needsof pharmacists and physicians in caring for patients with epilepsy. J Am PharmAssoc 1999;39:499–504.

[12] McAuley JW, Miller MA, Klatte E, Shneker BF. Patients with epilepsy’sperception on community pharmacist’s current and potential role in theircare, in press.

[13] Stuart JC, Muir WJ. Designing and delivering an epilepsy course for GPs to helpmeet their educational needs. Seizure 2008;17:218–23.