Knowledge, attitude and practice towards oral anticoagulants: a cross-sectional study among healthcare professionals in Nigeria

Abstract

Background

Oral anticoagulants (OACs) are essential for managing thromboembolic disorders. Good knowledge, attitude, and practice of healthcare professionals (HCPs) can ensure the safe and effective use of these medicines in patients. This study assessed the knowledge, attitude, and practice of OACs use by HCPs in Nigeria and identified the predictors associated with these factors.

Methods

The study was a nationwide cross-sectional study conducted via a structured questionnaire disseminated via online and physical methods. Knowledge (18 items) was assessed through multiple-choice questions, while attitude (7 items) and practice (8 items) were measured using Likert scale items. Knowledge and practice scores were categorised as good (≥ 70%), fair (> 40 – <70%), or poor (< 40%), while attitude was grouped as positive (≥ 70%), neutral (> 40 – <70%), or negative (< 40%). Multiple linear regression was carried out to determine the predictors of knowledge, attitude, and practice of the HCPs.

Results

A total of 687 HCPs [nurses (280, 40.8%), pharmacists (273, 39.7%), and physicians (134, 19.5%)] participated. Most of the HCPs showed fair knowledge (physicians 67 (50.0%), pharmacists 143 (52.4%), nurses 172 (61.4%)), positive attitude (physicians 113 (84.3%), pharmacists 254 (93.1%), nurses 216 (77.1%)) and good practice (physicians 97 (72.4%), pharmacists 191 (70.0%), nurses 190 (67.9%)) regarding OAC usage. Nurses had significantly lower knowledge (B = − 0.783, p = 0.035) and attitude scores (B = − 1.059, p = 0.004) than pharmacists, whereas physicians had comparable knowledge (B = 0.267, p = 0.475) and attitude scores (B = 0.354, p = 0.304). Prior training was associated with higher knowledge (B = 1.228, p < 0.001) and practice (B = 1.339, p = 0.002) scores of OAC use among HCPs.

Conclusion

Most healthcare professionals reported fair knowledge, positive attitude, and good practice toward oral anticoagulant use. Prior training and profession type were significant predictors. Targeted training programs are essential to improve competency and ensure optimal patient care in the use of OACs.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12875-026-03474-4.

Background

Oral anticoagulants (OACs) play crucial roles in preventing and treating thromboembolic disorders such as atrial fibrillation, deep vein thrombosis, and pulmonary embolism. Their proper use reduces complications such as stroke and mortality [1]. Oral anticoagulants are classified as high-alert medications because of their association with medication errors and adverse drug events [2, 3]. They contribute to more than 6% of total medication errors, which include inaccurate dosing, insufficient monitoring, and poor patient adherence in healthcare settings [2, 4]. These errors increase the likelihood of in-hospital mortality by up to 25% [2, 5]. As a result, physicians are increasingly turning their attention to newer agents, specifically direct oral anticoagulants (DOACs), which, compared with traditional vitamin K antagonists (VKAs), offer predictable pharmacokinetics, fewer food and drug interactions, rapid onset of action, no need for routine monitoring, and a reduced risk of serious bleeding [6].

Effective anticoagulation therapy necessitates a multidisciplinary approach that includes the collaboration of various healthcare professionals. Physicians are responsible for prescribing and monitoring treatment, whereas nurses provide essential patient education and administer medications. Pharmacists have contributed by optimising therapy through comprehensive medication reviews and counselling [7, 8]. This multidisciplinary strategy, which involves the robust knowledge and practice of healthcare professionals (HCPs), is critical for enhancing patient care outcomes [9].

Despite the acknowledged importance of OACs, the literature reveals significant gaps in the knowledge of HCPs and practical applications concerning OAC usage across different countries and geographical contexts. In developed nations, challenges include inadequate understanding of atrial fibrillation pathophysiology [10] and uncertainties regarding anticoagulation monitoring practices [11]. In contrast, research from developing regions highlights challenges such as insufficient dietary counselling for warfarin management [12], limited awareness regarding anticoagulant switching [13], and a lack of familiarity with laboratory monitoring tools [14].

The attitudes of HCPs towards OACs significantly influence their prescribing habits and strategies for patient management [15]. For example, physicians who express concern about bleeding risks may be more hesitant to prescribe OACs than their counterparts who do not share these concerns [16]. This hesitancy may also vary depending on the specific type of OAC involved. Similarly, pharmacists who hold negative attitudes towards OACs may be less motivated or confident in providing thorough patient counselling, potentially limiting the quality of education patients receive [17]. The adequacy of practice and knowledge concerning OACs can also hinge on access to updated guidelines, variances in professional training, practical experience, and availability of resources [18–20].

Therefore, the challenge of ensuring both safety and therapeutic effectiveness for patients on OACs persists, especially in resource-limited settings such as Nigeria [21, 22]. In Nigeria, common challenges include high patient-to-physician ratios [23], restricted access to medications [24], and disparities in professional expertise [25, 26]. These issues, if not addressed, could lead to suboptimal management of OAC therapy, consequently increasing the risk of adverse outcomes.

As the global burden of thromboembolic conditions continues to escalate, the imperative for effective anticoagulation therapy, including the use of OACs, becomes increasingly significant. The complexity of managing patients on OAC therapy, particularly in balancing the therapeutic benefits to ensure the safety and efficacy of these agents, necessitates a comprehensive understanding and proficient management by HCPs. Thus, this study aims to assess the knowledge, attitude, and practice (KAP) of HCPs concerning the use of OACs in Nigeria. Furthermore, this study seeks to identify key predictors that influence KAP, which can inform targeted interventions aimed at enhancing anticoagulation management.

Methods

Study design, setting, and population

This study was a nationwide cross-sectional study conducted among nurses, pharmacists and physicians working in hospitals, community pharmacies, and nongovernmental organisations across Nigeria from November 2023 to September 2024.

Sample size determination

The required sample size was estimated via G*Power version 3.1.6.7 [27] on the basis of a moderate effect size (0.3), a 5% significance level, 80% power, and the use of chi-square test. An estimated minimum sample size of 270 was obtained. An additional 10% was added to the sample size to account for attrition, resulting in a minimum sample size of 297 respondents. A proportionate allocation was used to determine the minimum number of each HCP using the distribution of HCPs in Nigeria [28]. The proportionate allocation for each profession can be found in Supplementary File 1 (Table S1). The minimum sample sizes for nurses, pharmacists and physicians were 200, 34, and 63, respectively.

Inclusion and exclusion criteria

Practicing healthcare professionals who were nurses, pharmacists, or physicians with a minimum of one year of professional experience were included in the study. Pharmacy, nursing, and medicine interns and those undergoing mandatory one-year National Youth Service were excluded from the study.

Data collection instrument

A structured questionnaire, developed after a thorough search of the literature [11, 19, 29–36], was used to collect data from the participants. The questionnaire had two versions: an electronic version, designed via Google Forms^® (Google LLC, United States) and disseminated through professional healthcare groups on social media platforms (Facebook^®, WhatsApp^®, X^®, LinkedIn^®), and a paper-based version, which was administered in person. The questionnaire comprises four sections. The demographics section contained 10 items, including gender, age, years of experience, additional qualifications, and type of profession. The knowledge section assessed HCPs’ understanding of key areas of OAC knowledge, including monitoring parameters and drug interactions. The knowledge section had 18 items in multiple-choice and yes/no formats. Section C evaluated the attitude of the HCPs towards OAC use and included seven items rated on a 5-point Likert scale (strongly agree = 5 and strongly disagree = 1). Section D had eight items that evaluated key practice areas by HCPs, such as the monitoring of therapeutic outcomes and the role of patient education in anticoagulant management. The items in the practice section were rated on a 5-point Likert scale ranging from “Strongly Agree = 5” to “Strongly Disagree = 1”. The data collection instrument used is attached in Supplementary File 2.

Content validity was evaluated by five experts (three lecturers in the Department of Clinical Pharmacy and Public Health, Afe Babalola University, Ado-Ekiti, and one lecturer in social and administrative pharmacy, Afe Babalola University, Ado-Ekiti, and one consulting clinical pharmacist at Afe Babalola University Multisystem Hospital, Ado-Ekiti), who were experienced in questionnaire design and use. The experts reviewed the questionnaire items for clarity, relevance, and comprehensiveness. Suggestions were made to include years of experience in the demographics section, along with revising the area of practice to encompass nongovernmental organisations. In the knowledge section, response formats were standardised, utilising multiple-choice options instead of open-ended responses for crucial items, such as identifying the most significant side effects of oral anticoagulants. The experts also suggested that the number of DOAC examples needed be specified. The attitude section was updated to highlight the importance of shared decision-making and specialised training. Finally, the practice section included changes reflecting real-world clinical involvement and active monitoring of therapeutic outcomes and adverse drug reactions. A pretest was conducted among 20 healthcare professionals, which included 12 pharmacists, 5 nurses, and 3 physicians, at Afe Babalola University Multisystem Hospital in Ado-Ekiti, Ekiti State. The data collected during the pretest were not included in the final analysis. The reliability of the KAP scales was assessed using the Cronbach’s alpha test, which produced scores ranging from 0.712 to 0.753.

Scoring rubrics

Each correct answer in the knowledge assessment scale was allotted a score of “1,” whereas incorrect answers were allotted a score of “0.” For the attitude and practice statements, the Likert scale-graded responses were converted to scores of 1 to 5, with higher scores indicating positive attitude or good practice. The total score for each respondent was calculated by summing the scores for all the items. This total was converted to a percentage by dividing the total score of each respondent by the maximum possible score for each scale and multiplying by 100. The total score obtained was then categorised into good (> 70%), fair (≥ 40 – <70%), or poor (< 40%) for knowledge and practice, while attitude was grouped as positive (> 70%), neutral (≥ 40 – <70%), or negative (< 40%). The categorisation of knowledge, attitude and practice employed in this study was based on similar studies [32, 37].

Data collection

Data were collected via both online and in-person distribution methods to increase participation among HCPs across diverse regions and healthcare settings. A combination of convenience sampling and snowball sampling techniques was used to gather responses. The online questionnaire link was disseminated across various social media platforms, including Facebook, WhatsApp, X, and LinkedIn, through strategically crafted social media posts. To optimise response rates, the links were posted and shared on a weekly basis throughout the ten-month data collection period. Only those who consented to participate in the study by checking the consent box in the online questionnaire were programmed to complete the questionnaire. Those who refused consent were not able to complete the questionnaire further.

To complement the online survey, self-administered questionnaires were physically distributed conveniently in hospitals and community pharmacies across different states. The states included Ekiti, Lagos, Oyo, and Akwa Ibom State. All HCPs in these facilities who consented to participate were given the questionnaire, which took approximately 15 min to complete, and the completed forms were retrieved the same day.

Data analysis

Data analysis was conducted via IBM Statistical Product and Service Solutions (SPSS) version 27 and Microsoft Excel version 365. Descriptive statistics were employed to summarise the sociodemographic characteristics of the participants. The dependent variables (knowledge, attitude, and practice related to OACs) were presented as percentages, frequencies, and visual charts.

To determine the appropriate inferential statistical tests, the normality of the data was assessed via the Kolmogorov–Smirnov test. The findings indicated that the dependent variable data were not normally distributed, with knowledge scores (p < 0.001), attitude scores (p < 0.001), and practice scores (p < 0.001). This outcome informed the decision to implement nonparametric tests for subsequent inferential analyses.

In the analysis, three negatively worded items were reverse scored: “I do not consider balancing the risk of thromboembolic events and bleeding complications a key consideration in my practice of oral anticoagulant management”; “I am less involved in monitoring adverse drug reactions to oral anticoagulant therapy”; and “I am not confident in my ability to manage patients on anticoagulant therapy.”

To identify predictors of knowledge, attitude, and practice regarding anticoagulant therapy among the HCPs, multiple linear regression analysis was conducted. Univariate analysis was performed to evaluate the associations between sociodemographic variables and knowledge, attitude, and practice concerning OAC usage among HCPs. Variables that demonstrated statistical significance at p < 0.20 in the univariate analysis were subsequently included in the regression model to identify predictors for the outcomes, aligning with methodologies documented in the literature [38, 39]. All inferential statistical analyses were conducted with a significance threshold set at p ≤ 0.05.

Ethical considerations

Ethics approval for the study was obtained from the Ekiti State University Teaching Hospital Ethics and Research Committee, with approval number EKSUTH/A67/2023/09/012, on 28 September 2023. Participation was voluntary, informed consent was obtained, and the respondents were informed that they could withdraw at any point during the study.

Results

Of the 350 questionnaires distributed physically, 340 were returned, and 337 were considered valid for analysis, resulting in a response rate of 96.3%. Additionally, a total of 350 questionnaires were completed online, resulting in a total of 687 questionnaires.

Sociodemographics of healthcare professionals

Six hundred eighty-seven HCPs participated in this study, comprising 134 physicians (19.5%), 273 pharmacists (39.7%), and 280 nurses (40.8%), with an overall mean age of 34.91 ± 10.74 years (range: 20–69 years). There were more female HCPs, 470 (68.4%), while 341 (49.6%) were single. The age of the HCPs (p = 0.005), sex (p < 0.001) and additional qualification (p < 0.001) varied significantly across the three HCP groups (Table 1).

Table 1.

Comparison of the sociodemographic characteristics of healthcare professionals

Characteristic	Total HCPs (n = 687)	Physicians (n = 134)	Nurses (n = 280)	Pharmacists (n = 273)	Test Statistic	p value
Age, Mean ± SD, (Range)	34.91 ± 10.74 (20–69)	32.92 ± 7.33 (23–61)	34.60 ± 11.88 (21–67)	36.22 ± 10.76 (20–69)
Age, Mean rank		328.86	321.77	374.23	U = 10.650	0.005*a
Gender, n (%)					χ² = 134.529	< 0.001*b
Male	217 (31.6)	65 (48.5)	19 (6.8)	133 (48.7)
Female	470 (68.4)	69 (51.5)	261 (93.2)	140 (51.3)
Marital Status, n (%)					χ² = 4.319	0.115b
Single	341 (49.6)	76 (56.7)	140 (50.0)	125 (45.8)
Married	346 (50.4)	58 (43.3)	140 (50.0)	148 (54.2)
Years of Practice, Mean ± SD, (Range)	7.55 ± 7.99 (1–42)	5.78 ± 5.01 (1–36)	8.26 ± 9.58 (1–42)	7.68 ± 7.27 (1–37)
Years of Practice, Mean Rank		319.39	340.08	360.10	U = 4.005	0.135a
Additional Qualification n (%)					χ² = 73.138	< 0.001*b
None	480 (69.9)	91 (67.9)	243 (86.8)	146 (53.5)
Postgraduate	207 (30.1)	43 (32.1)	37 (13.2)	127 (46.5)
Specialised Training n (%)					χ² = 2.308	0.315b
Yes	129 (18.8)	20 (14.9)	59 (21.1)	50 (18.3)
No	558 (81.2)	114 (85.1)	221 (78.9)	223 (81.7)

^a Kruskal-Wallis test; ^b Chi-square test; *value of significance at p ≤ 0.05

In terms of the distribution of the study participants, the Southwest Region of Nigeria had the highest representation, with 382 participants (55.6%), whereas the Northeast Zone had the lowest representation, with only 9 participants (1.3%). The distribution is summarised in Fig. 1. The distribution of participants by state of practice is summarised in Fig. 2.

Fig. 1.

Study participants in geopolitical zones in Nigeria

Fig. 2.

Number of study participants based on state of practice

Healthcare professionals’ knowledge of oral anticoagulants

Table 2 shows that 489 participants (71.2%) identified the international normalised ratio (INR) as the main monitoring parameter for warfarin therapy. Additionally, 590 participants (85.9%) recognised bleeding as the most significant adverse effect of oral anticoagulants. Furthermore, 272 professionals (39.6%) correctly stated that direct oral anticoagulants (DOACs) are contraindicated in patients with renal insufficiency. Additionally, 512 (74.5%) acknowledged the need to avoid vitamin supplements and herbal medicines with oral anticoagulants.

Table 2.

Differences in healthcare professionals’ knowledge of oral anticoagulant use

Statement	Correct answers				Test statistic	p valuea
	Totaln (%)	Physician n (%), Mean Rank	Pharmacist n (%), Mean Rank	Nurse n (%), Mean Rank
		N = 134	N = 273	N = 280
Mention the most important monitoring parameter for warfarin Answer: International Normalised Ratio (INR)	489 (71.2)	126 (94.0), 422.49	204 (74.7), 356.18	159 (56.8), 294.56	63.964	< 0.001*
Most important side effect when oral anticoagulants are taken Answer: Bleeding	590 (85.9)	116 (86.6), 346.36	253 (92.7), 367.34	221 (78.9), 320.12	21.571	<  0.001*
DOACs can be used safely in patients with renal insufficiency Answer: No	272 (39.6)	34 (25.4), 295.16	118 (43.2), 356.47	120 (42.9), 355.21	14.060	< 0.001*
DOACs cannot be used safely in pregnancy Answer: Yes	371 (54.0)	57 (42.5), 304.62	153 (56.0), 351.01	161 (57.5), 356.01	8.915	0.012*
It is safe to take vitamin supplements and herbal medicines with these medications Answer: No	512 (74.5)	90 (67.2), 318.71	216 (79.1), 359.78	206 (73.6), 340.72	6.986	0.030*
Drinking alcohol can increase the risk of side effects with oral anticoagulants Answer: Yes	576 (83.8)	103 (76.9), 320.03	230 (84.2), 345.40	243 (86.8), 354.11	6.629	0.036*
DOACs are associated with fewer major bleeding events compared to warfarin Answer: Yes	444 (64.6)	93 (69.4), 360.40	180 (65.9), 348.48	171 (61.1), 331.78	3.085	0.214
DOACs have a lower risk of intracranial haemorrhage than warfarin Answer: Yes	412 (60.0)	84 (62.7), 353.33	172 (63.0), 354.42	156 (55.7), 329.38	3.566	0.168
It is acceptable to double the next dose of DOACs when a dose is missed Answer: No	535 (77.9)	100 (74.6), 332.84	220 (80.6), 353.31	215 (76.8), 340.26	2.175	0.337
Skipping one dose of DOACs could worsen a patient’s condition Answer: Yes	212 (30.9)	36 (26.9), 330.28	74 (27.1), 331.11	102 (36.4), 363.13	6.864	0.032*
It is not safe to take anti-inflammatory medicines like ibuprofen while patients are taking oral anticoagulants Answer: Yes	479 (69.7)	79 (59.0), 307.01	212 (77.7), 371.25	188 (67.1), 335.14	16.357	< 0.001*
Age is an important factor to consider when prescribing DOACs Answer: Yes	479 (69.7)	78 (58.2), 304.45	197 (72.2), 352.37	204 (72.9), 354.76	10.472	0.005*
INR values in the supratherapeutic range can eventually cause bleeding Answer: Yes	381 (55.5)	85 (63.4), 371.39	153 (56.0), 346.01	143 (51.1), 328.93	5.661	0.059
The most common INR target range for patients on warfarin is 2–3 Answer: Yes	399 (58.1)	90 (67.2), 375.21	136 (49.8), 315.62	173 (61.8), 356.73	13.757	0.001*
INR is used to monitor the effects of DOACs Answer: No	135 (19.7)	51 (38.1), 407.24	50 (18.3), 339.41	34 (12.1), 318.21	39.009	< 0.001*
It is important that all healthcare practitioners involved in a patient’s care know they are taking oral anticoagulants Answer: Yes	617 (89.8)	119 (88.8), 340.55	258 (94.5), 360.13	240 (85.7), 329.93	11.840	0.003*
Mean knowledge score (range), mean rank: Min. = 0, Max = 20	11.63 ± 3.56 (0–19)	11.84 ± 3.65, (1–18), 363.75	12.11 ± 3.35, (3–19), 366.22	11.06 ± 3.64, (0–19), 312.88	11.725	0.003*
Knowledge Category	Frequency (%)
< 40% (Poor)	77 (11.2)	15 (11.2)	27 (9.9)	35 (12.5)
≥ 40% - <70% (Fair)	382 (55.6)	67 (50.0)	143 (52.4)	172 (61.4)
≥ 70% (Good)	228 (33.2)	52 (38.8)	103 (37.7)	73 (26.1)

DOACs direct oral anticoagulants, INR international normalised ratio, SD standard deviation, Min minimum score obtainable, Max. maximum score obtainable; ^a Kruskal-Wallis test; *significant value at p < 0.05

Significant disparities in knowledge scores among HCPs were noted regarding OACs. For example, physicians (mean rank: 320.03) demonstrated less understanding than did pharmacists (345.40) and nurses (354.11) about the increased risk of side effects when OACs are consumed alcohol (p = 0.036). Additionally, familiarity with the anticoagulant rivaroxaban was greater [pharmacists (67; 9.8%), nurses (77; 11.2%), and physicians (33; 4.8%)] than familiarity with the anticoagulants apixaban [pharmacists (38; 5.5%), nurses (36; 5.2%), and physicians (15; 2.2%)] and edoxaban [pharmacists (8; 1.2%), nurses (16; 2.3%), and physicians (2; 0.3%)] (see Fig. 3). Vegetables (n = 318; 46.3%) and citrus fruits (n = 201; 29.3%) were the two major food categories identified by HCPs to interact with warfarin (Fig. 4). As shown in Table 2, all the health professionals had fair knowledge of OAC use.

Fig. 3.

Familiarity of healthcare professionals with direct oral anticoagulants

Fig. 4.

Food categories identified by health professionals to interact with warfarin

Healthcare professionals’ attitude towards oral anticoagulants

Healthcare professionals expressed confidence in the long-term safety and efficacy of DOACs for managing atrial fibrillation (median = 4, interquartile range (IQR) = 3–5). Shared decision-making with patients was seen as a crucial aspect of selecting oral anticoagulant therapy (median = 5, IQR = 4–5). The preference for DOACs over warfarin for most indications requiring anticoagulation received a median score of 4 (IQR = 4–5). Patient adherence to anticoagulant therapy was widely considered critical for preventing adverse events, as reflected by a median score of 5 (IQR = 4–5). All healthcare professionals supported specialised training in anticoagulation therapy, particularly those working in anticoagulation centers (median = 5, IQR = 4–5). Compared with newer anticoagulants, physicians were more likely to believe that warfarin remains the mainstay for stroke prevention in patients with atrial fibrillation, with significant differences among groups (mean rank: pharmacists 379.78, physicians 313.09, nurses 323.91, p < 0.001). There was a significant difference in the attitude scores among healthcare professionals (mean rank: pharmacists 379.78, physicians 313.09, nurses 323.91, p < 0.001). Overall, the majority of healthcare professionals (583 or 84.9%) demonstrated a positive attitude toward oral anticoagulants. This is summarised in Table 3.

Table 3.

Differences in attitude of health professionals towards oral anticoagulant use

Statements	Total Median, IQR	Physician Median, IQR (Mean rank)	Pharmacist Median, IQR (Mean rank)	Nurse Median, IQR (Mean rank)		Test statistics	p valuea
I have confidence in the long-term safety and efficacy of DOACs for patients with atrial fibrillation	4, 3–5	4, 3–5 (356.79)	4, 3–5 (344.97)	4, 3–5 (336.94)		1.008	0.604
Shared decision-making with patients is an important aspect of choosing the type of oral anticoagulant therapy	5, 4–5	5, 4–5 (329.10)	5, 4–5(373.15)	5, 4–5 (322.71)		12.805	0.002*
I believe that DOACs are more appropriate than warfarin for most indications requiring oral anticoagulants	4, 4–5	4, 3–5 (342.25)	4, 4–5(385.23)	4, 3–5 (304.64)		25.856	< 0.001*
I believe that patient adherence to oral anticoagulant therapy is a critical factor in preventing adverse events	5, 4–5	4, 4–5 (312.41)	5, 4–5(383.83)	5, 4–5 (320.28)		23.319	< 0.001*
I am of the opinion that health professionals in anticoagulation centres should receive specialised training on oral anticoagulant therapy.	5, 4–5	5, 5–5 (313.09)	5, 4–5 (379.78)	5, 4–5 (323.91)		24.840	< 0.001*
I believe that the use of warfarin should be minimised in favour of newer anticoagulant options like DOACs	4, 4–5	4, 4–5 (323.31)	5, 4–5 (379.10)	4, 3–5 (319.68)		16.185	< 0.001*
I believe that despite the comparative advantage of DOACs over warfarin, warfarin still remains the main stay in the prevention of stroke in patients with atrial fibrillation	4, 3–4	3, 3–4 (454.97)	4, 3–4 (337.36)	4, 2–4 (297.37)		62.791	< 0.001*
Mean Attitude score (range), mean rank: Min. = 7, Max = 35	27.86 ± 3.34, (15–35)	28.20 ± 3.59, (19–35), 362.99	28.65 ± 3.03, (15–35), 389.69	26.93 ± 3.28, (17–32), 290.37		36.529	< 0.001*
Attitude category
< 40% (Negative)	-
≥ 40% - <70% (Neutral)	104 (15.1)	21 (15.7)	19 (6.9)		64 (22.9)
≥ 70% (Positive)	583 (84.9)	113 (84.3)	254 (93.1)		216 (77.1)

DOACs direct oral anticoagulants, IQR interquartile range; ^a Kruskal-Wallis test; *Statistically significant value, p ≤ 0.05

The practice of healthcare professionals towards oral anticoagulants

Balancing the risk of thromboembolic events and bleeding complications was identified as a key consideration in the practice of HCPs regarding OACs, with a median score of 4 (IQR = 3–5). The physicians exhibited the highest level of agreement, with a mean rank of 405.34, followed by the pharmacists at 356.83 and the nurses at 302.13, with significant differences across the groups (p < 0.001). Reliance on current guidelines for OAC therapy yielded a median response of 4 (IQR = 3–5), with no statistically significant difference among the professional groups (mean rank: pharmacists, 345.44; physicians, 318.99; nurses, 354.57; p = 0.198). Patient demographics, such as age and comorbidities, were recognised as significant factors influencing the selection and management of anticoagulant therapy, with a median score of 4 (IQR = 4–5), and pharmacists displayed the highest agreement (mean rank: pharmacists 375.23, physicians 345.03, nurses 313.06; p < 0.001). There was a notable difference in practices concerning the monitoring of adverse drug reactions to anticoagulants, with nurses (mean rank 388.84) being the least involved compared with pharmacists (mean rank 294.94) and physicians (mean rank 350.26) (p < 0.001). However, there were no significant differences in practice scores among the HCPs (mean rank: pharmacists 337.34, physicians 351.85, nurses 346.73; p = 0.751). Overall, 69.6% of the respondents demonstrated good practices in relation to OACs (Table 4).

Table 4.

Practice of healthcare professionals towards oral anticoagulants

Statements	Total Median, IQR	Physician Median, IQR (Mean rank)	Pharmacist Median, IQR (Mean rank)	Nurse Median, IQR (Mean rank)	Test statistic	p valuea
I do not consider balancing the risk of thromboembolic events and bleeding complications a key consideration in my practice of oral anticoagulant management	4, 3–5	4, 3–5 (405.34)	4, 3–5 (356.83)	4, 2–4 (302.13)	28.096	< 0.001*
In the facility where I work, we rely frequently on current guidelines and recommendations for oral anticoagulant therapy	4, 3–5	4, 3–5 (318.99)	4, 3–5(345.44)	4, 3–5 (354.57)	3.240	0.198
Patient demographics such as age and comorbidities, influence my selection and management of oral anticoagulant therapy	4, 4–5	4, 4–5 (345.03)	5, 4–5(375.23)	4, 4–5 (313.06)	15.746	< 0.001*
I am less involved in monitoring adverse drug reactions to oral anticoagulant therapy.	3, 2–4	3, 2–4 (350.26)	3, 2–4(294.94)	4, 2–4 (388.84)	32.709	< 0.001*
I am actively involved in the monitoring of therapeutics outcomes in patients on oral anticoagulants.	4, 3–5	4, 2–4 (307.93)	4, 3–5 (319.43)	4, 3–5 (385.21)	22.180	< 0.001*
Patient education and counselling play a central role in anticoagulant management practice	5, 4–5	5, 4–5 (312.57)	5, 5–5 (384.95)	5, 4–5 (319.11)	27.409	< 0.001*
I am not confident in my ability to manage patients on anticoagulant therapy	3, 2–4	3 2–4 (379.15)	2, 2–4 (308.48)	3, 2–4 (361.81)	16.024	< 0.001*
I would rather allow those who have specialised training in anticoagulation therapy to be involved in the management of patient requiring oral anticoagulants.	4, 3–5	4, 3–5 (346.13)	4, 3–5 (374.86)	4, 3–5 (312.89)	14.810	< 0.001*
Mean Practice score (range), mean rank: Min. = 8 , Max = 40	29.89 ± 4.33 (16–40)	30.16 ± 4.33, (23–40),351.85	29.74 ± 3.94,(20–40),337.34	29.90 ± 4.68, (16–40),346.73	0.573	0.751
Practice Category
< 40% (Poor)	-		-
≥ 40% - <70% (Fair)	209 (30.4)	37 (27.6)	82 (30.0)	90 (32.1)
≥ 70% (Good)	478 (69.6)	97 (72.4)	191 (70.0)	190 (67.9)

Items 1, 4 and 7 are negative questions and were reverse scored;

Interquartile range; ^a Kruskal-Wallis test; *Statistically significant value, p < 0.05

Relationships among sociodemographics, knowledge, attitude and practice of healthcare professionals towards oral anticoagulants

This study revealed no significant associations between gender and knowledge (p = 0.613) or practice scores (p = 0.594), although a statistically significant association was found with attitude scores (p = 0.008). Additionally, a significant correlation was observed between years of experience and knowledge scores (p = 0.041) but not between years of experience and attitude (p = 0.407) or practice (p = 0.423). Moreover, additional qualifications significantly influenced the knowledge (p = 0.003) and practice scores (p < 0.001) of healthcare professionals (HCPs), whereas attitude remained unaffected (p = 0.487). Training on oral anticoagulants also significantly influenced knowledge (p = 0.009) and practice scores (p = 0.033) but not attitude (p = 0.101).

Predictors of knowledge, attitude, and practice of oral anticoagulants

Healthcare professionals with 6–10 years of experience demonstrated greater knowledge of OAC use (B = 0.657, 95% CI: −0.020–1.334), as did those with over 10 years of experience (B = 0.517, 95% CI: −0.152–1.186), although these findings were not statistically significant. A comparison of knowledge of OAC use scores revealed that nurses had significantly lower scores than did pharmacists (B = − 0.783, 95% CI: −1.511 to − 0.054), whereas no significant difference was noted between physicians and pharmacists (B = 0.267, 95% CI: −0.465 to 0.998). Nurses exhibited a significantly more negative attitude towards OAC use than did pharmacists (B = − 1.059, 95% CI: −1.784 to − 0.335). OAC training was significantly correlated with greater knowledge (B = 1.228, p < 0.001) and OAC use scores (B = 1.339, p = 0.002) but not with attitude towards OAC use scores (B = − 0.146, p = 0.654) (see Table 5 for details).

Table 5.

Predictors of healthcare professionals’ knowledge, attitude and practice of oral anticoagulant use

Independent Variable	Category	Knowledge scores		Attitude score		Practice score
		B (95% CI)	p value	B (95% CI)	p valuea	B (95% CI)	p valuea
Gender (Confounder)	-	-	-	-	-	-	-
Age (Confounder)	-	-	-	-	-	-	-
Additional Qualification (Confounder)	-	-	-	-	-	-	-
Years of experience	6–10 years (ref: 1–5 years)	0.657 (-0.020 -1.334)	0.057	-	-	-	-
	≥ 10 years (ref: 1–5 years)	0.517 (− 0.152–1.186)	0.129	-	-	-	-
Profession	Physician (ref: Pharmacist)	0.267 (-0.465-0.998)	0.475	0.354 (− 0.322–1.031)	0.304	-	-
	Nurses (ref: Pharmacist)	-0.783 (-1.511–0.054)	0.035*	-1.059 (-1.784–0.335)	0.004*	-	-
Previous training on oral anticoagulants	Yes (ref: No)	1.228 (0.551–1.906)	< 0.001*	− 0.146 (− 0.784–0.492)	0.654	1.339 (0.510–2.168)	0.002*

A cut-off p value of < 0.2 was used to include variables in the regression model after univariate analysis (see Supplementary File 3). Empty cells indicate variables that did not have significant values during bivariate analysis. Age, sex, and additional qualifications were controlled for during the regression analysis

Dependent variables= Knowledge scores, Attitude scores, Practice scores; B = Unstandardised beta coefficient; CI = Confidence interval; ^aMultiple linear regression; *Statistically significant at p ≤ 0.05; Ref: Reference value

Discussion

The appropriate use of OACs is critical in preventing and managing thromboembolic disorders. This study assessed the knowledge, attitudes, and practices of HCPs regarding OACs, providing insight into their ability to monitor parameters, adverse effects, contraindications, and clinical decision-making processes. Our findings reveal variations in knowledge across professional groups, with pharmacists demonstrating better knowledge of drug interactions and monitoring requirements. Most HCPs exhibited a positive attitude toward OAC therapy and acknowledged the importance of shared decision-making. With respect to practice, adherence to guidelines was generally high, but disparities existed in monitoring adverse drug reactions, particularly among nurses. These findings highlight key areas for targeted educational interventions and policy improvements to optimise anticoagulant use in clinical practice.

Most HCPs reported average knowledge of OAC therapy, with approximately 33% demonstrating good knowledge. This mirrors findings by Swed et al. (2024) [37], where only 23% of HCPs in Syria showed good knowledge of OAC therapy in atrial fibrillation. Conversely, a Chinese study [32] reported that 75% of HCPs demonstrated good knowledge of OAC therapy. This disparity may stem from various factors, such as differences in educational resources, training opportunities, and clinical guidelines available to HCPs in these countries. Inadequate knowledge among HCPs can lead to critical issues, such as dosing errors and inappropriate prescriptions, ultimately resulting in increased hospitalisations and adverse events [40–42]. These findings highlight the essential necessity for ongoing training and education about OAC management tailored to the specific knowledge deficits identified in each region.

Most HCPs identified the INR as an important parameter for monitoring patients on warfarin. Compared with nurses, pharmacists and physicians showed better knowledge regarding INR monitoring. Most HCPs accurately recognised the potential for bleeding as a significant adverse effect associated with warfarin use, with pharmacists scoring the highest in this domain. This aligns with findings from Almuqbil et al. (2023) [43], who reported that pharmacists possessed superior knowledge of anticoagulation monitoring, particularly in areas such as bleeding risk assessment (88% for pharmacists vs. 65% for physicians), thrombosis risk assessment (67% vs. 24%), and drug‒drug interactions (42% vs. 11%). Our findings are in tandem with findings from other studies where pharmacists have been reported to be uniquely positioned and have been shown to have a positive effect on monitoring patients on warfarin therapy, including improved patient understanding [44], reduced emergency room visits [45] and a percentage of the INR within the therapeutic range [46]. The relatively poor understanding of INR monitoring among nurses raises concerns about the potential for inadequate patient oversight, which could lead to preventable complications such as excessive anticoagulation and bleeding. Therefore, integrating OAC management into training curricula for nurses and general practitioners has emerged as a vital strategy to enhance safe prescribing and monitoring practices.

Conversely, HCPs demonstrated a significant gap in knowledge concerning DOACs, with only a minority recognising their contraindications in cases of renal insufficiency. Interestingly, while 54% were aware of the contraindication of DOACs during pregnancy, physicians presented the lowest knowledge in this area. These findings differ from those observed among HCPs in Sudan, where 43% and 30% recognised the contraindications of DOACs with renal disease and pregnancy, respectively [13]. In contrast, a study conducted in Canada reported higher knowledge among HCPs regarding DOACs [29]. An insufficient understanding of DOAC contraindications related to renal insufficiency and pregnancy poses a risk of drug toxicity and treatment failure [47]. There is a need to promote guideline-based education on DOACs and renal function for HCPs as their clinical use continues to escalate.

In terms of attitude, most of the HCPs reported positive attitudes towards OACs, similar to the findings of studies carried out among physicians in China [32] and Malaysia [12], where the majority reported positive attitude towards patients receiving oral anticoagulants. This increase in positive attitude shown across these studies may be due to increased global awareness and recommendations promoting the use of OACs in the management of thromboembolic disorders. Most HCPs expressed confidence in the long-term safety and efficacy of DOACs for managing atrial fibrillation, which is consistent with the findings of Osasu et al. (2021) [48], who reported that HCPs exhibit greater confidence and preference for DOACs. This preference may be attributed to their predictable pharmacokinetics, lower risk of major bleeding, and ease of use compared with traditional VKAs [49, 50]. The growing preference for DOACs over VKAs may stem from their simplified dosing regimens and reduced need for frequent monitoring. The positive attitude toward and confidence in DOACs suggest that HCPs are well positioned to optimise anticoagulation therapy.

The HCPs also reported that shared decision-making with patients is an important factor in determining the choice of OAC, with pharmacists showing greater agreement with this statement. This finding is consistent with Rajiah et al. (2021) [51], who emphasised pharmacists’ roles in patient-centred care, particularly in terms of medication adherence and education. Kunneman et al. (2020) [52] and Wu et al. (2024) [53] also support this perspective, showing that involving patients in treatment decisions improves outcomes and adherence to OAC therapy. The reason for this could be the role of pharmacists in patient education, medication adherence, and safety. However, despite the importance of shared decision-making, differences may exist in access to OACs and the level of pharmacist integration in anticoagulation management across countries. While pharmacists in high-income countries are more actively involved in patient education and anticoagulation management, resource limitations in Nigeria may restrict their role, necessitating further policy reforms to leverage their expertise. The strong agreement on shared decision-making underscores the need for patient-centred anticoagulation care models through incorporating pharmacists into anticoagulation clinics to optimise the therapy outcomes of patients.

All the HCPs agreed on the need for specialised training in OAC therapy. This is similar to other studies where training programs increased competencies among HCPs [54] and improved patient outcomes [55]. Continuous training programmes should be organised among HCPs to optimise OAC management.

Concerning practice, most HCPs reported that they regularly consult established guidelines when managing patients in OACs. This aligns with a study by Capiau et al. (2022) [33], in which most physicians indicated that they followed appropriate guidelines before prescribing OACs. This could be due to the commitment of the HCPs to evidence-based practice to ensure optimal patient outcomes. Similarly, in a study by Piccini and colleagues [56], improvement in adherence to guidelines was associated with appropriate prescriptions for patients on OACs, highlighting the effectiveness of quality improvement in guideline adherence. However, a prospective cohort study in a tertiary hospital revealed that 44% of prescribed anticoagulant doses were associated with medication errors, with physician nonadherence to evidence-based guidelines being a major contributing factor [57]. This suggests that despite the widespread availability of guidelines, barriers to full compliance could influence patient safety. These findings underscore the need for ongoing education on the use of guidelines in the management of patients in OACs. Strengthening adherence through enhanced training, decision-support tools, and system-wide quality improvement measures could further optimise anticoagulant therapy and improve patient outcomes.

Nurses reported being the most involved in overseeing adverse drug reactions, whereas pharmacists were the least involved. This mirrors the findings of Schjøtt and colleagues [58], who reported that nurses engage in pharmacovigilance activities more than other HCPs do because of their close involvement in direct patient care. The limited involvement of other healthcare professionals in monitoring adverse reactions could indicate an urgent need for targeted training focused on recognising, documenting, and managing adverse drug events, as well as integrating these practices into their roles to increase patient safety.

Despite their role in patient education and counselling regarding OACs, pharmacists exhibited the lowest confidence in managing patients on these medications. This contrasts with the findings of a multinational study performed in 18 countries [59] and a study in Malaysia [60], where pharmacists showed greater confidence in managing patients on warfarin than DOACs did. Pharmacists’ lower confidence in managing OACs may stem from their familiarity with warfarin and monitoring it requires, whereas DOACs involve individualised dosing with fewer standardised protocols. Enhancing pharmacist training and clinical exposure to DOACs could help bridge this confidence gap and improve patient management.

Healthcare professionals with prior training in OAC management were more likely to achieve high practice scores on OACs than were those without training. This finding aligns with a study conducted in Syria, where healthcare professionals who received prior training on anticoagulation demonstrated average or good practices [37]. This underscores the importance of structured training programs in improving the competency of healthcare professionals in OAC management.

Previous training strongly predicted higher knowledge scores among the HCPs in this study. This aligns with a study conducted in Syria, which reported that training improved knowledge among participants [37]. These findings emphasise the vital role of continuous professional training and education in enhancing the understanding of managing complex diseases, which should be implemented within healthcare systems in Nigeria.

The type of profession also predicted participants’ knowledge of OACs. Pharmacists outperformed nurses in this study, likely due to the influence of pharmacy-specific education on medication management topics [61, 62]. Additional training could benefit nurses, as they may not have received thorough instruction on these drugs during standard nursing education.

This study also revealed that the type of profession significantly influenced the attitude of HCPs toward OACs. Compared with physicians and nurses, pharmacists exhibited a more positive attitude toward OACs, which contrasts with findings in Syria, where professional title did not significantly affect positive attitude toward OACs [37]. The positive attitude demonstrated by the pharmacists may be attributed to their greater familiarity with drug interactions and associated drug effects. To enhance attitudes toward OACs, attitudinal barriers among physicians and nurses should be addressed through collaborative and multidisciplinary education sessions.

Limitations of the study

The distribution of professionals in this study may have influenced the results. Pharmacists (n = 273) and nurses (n = 280) were more highly represented than physicians (n = 134), and this imbalance could have contributed to the observed differences in knowledge and practice scores. The smaller physician sample may also have limited the generalizability of findings for this group. To address this, regression analyses were adjusted for professional category to reduce the effect of unequal group sizes. Nonetheless, future studies should aim to recruit larger and more proportionate physician samples and examine the influence of professional specialization on OAC knowledge and practices.

Additionally, participants’ responses regarding attitude and practice may have been influenced by social desirability bias, which could have led to exaggeration of knowledge, attitude and practice of OAC use. Our study was a nationwide cross-sectional study conducted among nurses, pharmacists and physicians working in hospitals, community pharmacies, and nongovernmental organisations across Nigeria from November 2023 to September 2024. However, the types of hospitals and community pharmacies were not documented in the questionnaire. This can be an important addition in future studies to contribute to the robustness and more detailed demography of the healthcare professionals.

Geographic distribution also posed a limitation. Although online recruitment was open nationally, the Southwest region contributed the largest proportion of participants, partly because physical questionnaires were distributed in states where access was feasible (Ekiti, Lagos, Oyo, and Akwa Ibom). The paper-based questionnaires were conveniently distributed among pharmacists in tertiary hospitals and private owned community pharmacies while for the online it was not possible to determine the type of hospital or community pharmacies since these were not part of the questions in the questionnaire. This may have influenced the overall findings, as regional differences in healthcare infrastructure, training opportunities, and access to resources could explain variations in knowledge and practice. Despite efforts made by the authors to include respondents from multiple states, the regional imbalance remains. Therefore, caution is advised when generalising these results to the entire country. Future studies should ensure a more balanced recruitment across all geopolitical zones to enhance representativeness.

Implications for policy and practice

The findings highlight the need for targeted educational interventions to address knowledge gaps among HCPs, particularly regarding DOAC contraindications and INR monitoring. Policies should focus on integrating structured anticoagulation training into medical, pharmacy, and nursing curricula to ensure competency across professions. Additionally, healthcare institutions should incorporate pharmacists into anticoagulation clinics and promote multidisciplinary approaches to OAC management. Regulatory bodies should also ensure continuous professional development of OACs through mandatory training sessions.

Conclusion

Healthcare professionals in Nigeria exhibit fair knowledge, positive attitude, and good practice concerning the management of oral anticoagulants. Prior training and the specific healthcare profession notably influence their understanding. However, significant gaps persist, particularly in areas related to direct oral anticoagulants and the monitoring of adverse drug reactions associated with oral anticoagulant therapy. To bridge these gaps, a focus on targeted professional education is essential. Enhancing education and training in these critical areas can significantly improve the safe and effective use of anticoagulant therapy, thereby minimising adverse events and promoting better patient outcomes throughout various healthcare settings in Nigeria.

Abbreviations

OACs

Oral anticoagulants

DOACs

Direct oral anticoagulants

HCPs

Healthcare professionals

INR

International normalisation ratio

Authors’ contributions

SS conceived the study, led the study design and methodology, contributed to data analysis and interpretation, and critically revised the manuscript for important intellectual content. EO developed the data collection tools, coordinated and performed data collection, carried out the primary data analysis, and drafted the first manuscript. Both authors reviewed and revised subsequent drafts, approved the final manuscript, and are accountable for all aspects of the work.

Funding

The authors did not receive any support from any organisation for the submitted work.

Data availability

The data used in this study will be made available by the corresponding authors upon request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ekiti State University Teaching Hospital Ethics and Research Committee (approval number: EKSUTH/A67/2023/09/012) on 28 September 2023. All participants provided informed consent prior to participation. Participant confidentiality was preserved throughout, and all procedures followed relevant ethical guidelines and regulations.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.