Assessment of community pharmacists' knowledge, attitudes, awareness, and practice-related responses regarding oral anticoagulants in the Northern West Bank, Palestine: a cross-sectional study.

Abstract

Background: Oral anticoagulants, including warfarin and direct oral anticoagulants (DOACs), are widely used for the prevention and treatment of thromboembolic disorders. Community pharmacists are accessible healthcare professionals who may support safe use through counselling on adherence, interactions, adverse effects, and monitoring requirements. This study assessed community pharmacists' knowledge, attitudes, awareness, and practice-related responses regarding warfarin and DOACs and examined factors associated with knowledge scores.

Methods: This cross-sectional study was conducted among community pharmacists working in the northern West Bank, Palestine, between October 2022 and March 2023. A total of 340 pharmacists were approached, and 329 completed the questionnaire (response rate: 96.8%). Data were collected using a structured 70-item questionnaire covering sociodemographic and professional characteristics, knowledge, awareness and attitudes, and practice-related items. Descriptive statistics were used to summarize participant characteristics and questionnaire responses. Knowledge scores were compared across subgroups using Mann-Whitney U and Kruskal-Wallis tests, and multivariable linear regression was used to examine independent associations with knowledge scores. A p value < 0.05 was considered statistically significant.

Results: The study included 329 pharmacists with a mean age of 33.64 years; 70.5% were women and 80.9% held a bachelor's degree in pharmacy. Warfarin (Coumadin 5 mg) was available in 87.8% of participating pharmacies. Across knowledge items, 49.1% of responses were correct. Only 48.6% correctly recognized that missing a single DOAC dose could worsen a patient's condition, and 49.2% selected "do not know" regarding the interaction of apixaban or rivaroxaban with St. John's wort. For warfarin, 84.8% recognized potential dietary interactions and 84.2% recognized the importance of international normalized ratio (INR) monitoring, whereas only 35.3% identified vitamin K as a reversal option for excessive warfarin anticoagulation or bleeding. In univariable analyses, no statistically significant differences in knowledge scores were observed according to sociodemographic or professional characteristics (all p > 0.05). Consistent with these findings, the multivariable model was not statistically significant, and no independent predictors of knowledge score were identified.

Conclusions: Community pharmacists in the northern West Bank showed suboptimal knowledge regarding oral anticoagulants, with important gaps related to DOAC reversal agents, drug and herbal interactions, and missed-dose counselling. No independent predictors of knowledge score were identified, suggesting that educational needs are broadly distributed among pharmacists. Targeted continuing education focused on practical anticoagulant counselling and medication-safety issues may strengthen pharmacists' contribution to safer oral anticoagulant use.