ABSTRACT
Antimicrobial resistance (AMR) is a global threat to human health. Education on antibiotics is essential for AMR prevention, and training should be provided for undergraduate pharmacy students. This study evaluated the knowledge regarding antibiotic use and AMR among fourth-year Japanese pharmacy students and the effect of a lecture on treating infectious diseases with antibiotics had on their knowledge. A questionnaire survey was conducted, and the responses were recorded before and after participants attended the lecture. A small subset of the prelecture survey questions was used for the postlecture survey. From a total of 540 participants, 330 and 234 responses were collected before and after the lecture, respectively. In the prelecture survey, 39.4% of the participants incorrectly answered that antibiotics can effectively treat the common cold, 13.3% had taken leftover antibiotics, and 17.3% had taken antibiotics prescribed for their family members or others. Furthermore, the prelecture survey data showed that the mean number (± standard deviation) of correct answers across the eight questions on treatment and diagnosis of infectious diseases and antibiotics was 2.21 ± 1.64. However, in the postsurvey, this figure increased to 5.00 ± 1.82. Although the lecture improved their knowledge to some extent, the results suggested that fourth-year pharmacy students have inaccurate knowledge regarding the appropriate use of antibiotics and AMR. Therefore, it is necessary to improve early-year undergraduate pharmacy education on antibiotics in Japan.
KEYWORDS: antibiotics, Japanese pharmacy student, antimicrobial resistance, pharmacy education
INTRODUCTION
Antimicrobial resistance (AMR) has become a serious threat to human health globally. The reduction of unnecessary and inappropriate use of antibiotics is the most important preventative measure for AMR (1). The government of Japan established the National Action Plan on AMR in 2015 to reduce antibiotic use by two-thirds of the 2013 usage rate by the year 2020 (2). Although the usage of antibiotics in Japan decreased by 29.9% in 2020 compared to 2013, the targeted reduction could not be achieved, making it necessary to continue implementing preventative measures for AMR (3). Therefore, comprehensive measures are needed to reduce the inappropriate use of antibiotics, including promoting public awareness by providing education for both the general public and medical professionals.
Pharmacists educated on the treatment of infectious diseases are core members of the antimicrobial stewardship (AS) program (4). Promoting the appropriate use of antibiotics can reduce AMR (5–7), and pharmacists can play an important role in AS education for other medical professionals (8). Education on the proper use of antibiotics is an essential part of the AS program. Some studies have reported that AS education for pharmacy students effectively reduces AMR (9, 10). Although some elements necessary for AS are included in undergraduate education for pharmacy and other medical students, they are not exhaustive (6, 7). Additionally, because increasing personal knowledge influences attitudes and perceptions toward practices, the World Health Organization Global Action Plan on AMR has proposed population-based knowledge, attitude, and practice surveys as part of the monitoring and evaluation framework (1). To date, some studies have conducted surveys of the knowledge, attitudes, perceptions, and practices of pharmacy students related to AMR and AS (10–12). However, there are no such reports among undergraduate pharmacy students in Japan.
To the best of our knowledge, this study is the first to examine the AMR knowledge of Japanese pharmacy students. The purpose of this study was to compare fourth-year Japanese pharmacy students’ knowledge of the appropriate use of antibiotics and AMR with that of the general public and to examine the effect of a single lecture on basic knowledge related to proper antibiotic use and infectious disease treatment.
METHODS
Curriculum
In Japan, 6 years of undergraduate education is necessary to obtain a pharmacist’s license from the Faculty of Pharmaceutical Sciences; a postgraduate education is not a requirement. According to the model core curriculum of pharmaceutical education in Japan, first- to fourth-year pharmacy students acquire knowledge of the fundamental pharmaceutical sciences, including biology, chemistry, microbiology, pathophysiology, and pharmacokinetics/pharmacodynamics (PK/PD) (13). For example, at the Hoshi University School of Pharmacy and Pharmaceutical Sciences, chemistry and biology are taught in the first year, pharmacology of antibiotics and antimicrobial resistance are taught in the microbiology module in the second year, and PK/PD and diagnosis and treatment of infectious diseases are taught in the third year. Additionally, students learn about the ethics and culture expected of pharmacists as health care professionals. Fourth-year pharmacy students acquire skills and knowledge pertaining to pharmaceutical care during their preclinical training; this also forms their attitudes toward pharmaceutical care. After passing both objective structured clinical examinations and a computer-based test of their knowledge, attitudes, and practices, fifth-year pharmacy students participate in a 22-week-long clinical practice at a hospital and compounding pharmacy.
Study design and participants
This study was a cross-sectional, web-based anonymous questionnaire survey designed to evaluate the knowledge, attitudes, and perceptions of undergraduate pharmacy students regarding the use of antibiotics. This survey was conducted with fourth-year pharmacy students at Hoshi University School of Pharmacy and Pharmaceutical Sciences from 23 September 2020 to 2 October 2020 and from 24 September 2021 to 8 October 2021. To prevent the spread of coronavirus disease 2019 (COVID-19), fourth-year pharmacy students at the university attended on-demand lectures on the diagnosis and treatment of infectious diseases in their own time during the survey period in preclinical training. Table 1 shows the details of the lecture. Before the students attended the lecture, they participated in the prelecture survey after they received explanations of the purpose of the survey and how to access the prelecture survey questionnaire. The participants further responded to the postsurvey questionnaire immediately after the on-demand lecture.
TABLE 1.
Outline of the on-demand lecturea
| Course outline |
|---|
| Learning objectives |
| Can evaluate the need for antibiotics in clinical cases. |
| Can recommend appropriate antibiotics prescription in clinical cases. |
| Introduction |
| AMR and AS programs |
| Case study 1: Catheter-related blood stream infection with Staphylococcus aureus |
| Necessity of antibiotics |
| Detection of pathogens and antibiotic susceptibility |
| Empiric therapy and definitive therapy |
| Appropriate dose and interval of administration of antibiotics |
| Duration of treatment of antibiotics |
| Case study 2: Common cold in children |
| Manual of Antimicrobial Stewardship in Japan |
| Appropriate use of oral antibiotics |
| Adverse events of oral antibiotics |
| National Action Plan on AMR in Japan |
| Conclusion |
Instructor was a pharmacist. Lecture length was 60 min. In the lecture, the instructor addressed the topics related to all questions of the questionnaire. Students could attend this lecture on their own time during the term of preclinical training.
Ethics statement
When participants accessed the website to respond to the questionnaires, the policy for using the collected data and the protection of personal information were presented. Only those who agreed to provide informed consent were allowed to respond to the questionnaire. The study protocol was approved by the Institutional Review Board of Hoshi University (2020-02).
Questionnaire
A web-based anonymous questionnaire was administered to the students before (prelecture survey) and/or after (postlecture survey) an on-demand lecture. The prelecture survey questions were composed with the reference of the Antibiotics Awareness Survey 2018, which was conducted on the general public (14). A small subset of the prelecture survey questionnaire was used as the postlecture survey questions. Table 2 shows the details of the survey items.
TABLE 2.
Survey items
| Question | Answer options | Timinga |
|
|---|---|---|---|
| Pre | Post | ||
| Q1: Do you know what kind of diseases antibiotics are effective against? Please select all applicable answers. | Common cold | • | |
| Influenza virus | |||
| Norovirus | |||
| Cystitis | |||
| Pneumonia | |||
| Otitis media | |||
| Diarrhea | |||
| Do not know | |||
| Others | |||
| Q2: What kind of medicine would you like to receive when seeing a doctor for the common cold? Please select all applicable answers. | Antitussive | • | |
| Antipyretic | |||
| The medicine that suppresses runny nose | |||
| Antibiotics | |||
| Expectorant | |||
| Analgesic | |||
| Troche | |||
| Gargle | |||
| Stomach medicine | |||
| Others | |||
| Nothing applies | |||
| Q3: Do you take the full dose of antibiotics prescribed? | Take up all they prescribed | • | |
| Stop taking them when the condition is healed | |||
| Forget to take them and have not taken up all | |||
| Do not take them as much as possible from the beginning | |||
| Q4: How do you manage leftover antibiotics? Please select all applicable answers. | Keeping them for use when needed | • | |
| Take them when falling ill | |||
| Giving them to others | |||
| Throwing them away | |||
| Consult the pharmacy and throw them away | |||
| Others | |||
| Q5: Have you ever taken antibiotics obtained from your family or others? | Yes | • | |
| No | |||
| Q6: What do you think about taking antibiotics obtained from your family or others? | Try not to take them | • | |
| Worried because I have not seen a doctor, but take them | |||
| Convenient because I do not have to go to the clinic | |||
| No problem if the symptoms are the same as before | |||
| Others | |||
| Q7: Do you know about antimicrobial resistance? | I know | • | |
| I have only heard (but do not know) | |||
| I do not know | |||
| Q8: Answer the following statements regarding treatment and diagnosis of infectious disease | • | • | |
| C-reactive protein is a specific marker for bacterial infection. | True / False / Do not know | ||
| Fever is a specific marker for bacterial infection. | True / False / Do not know | ||
| Blood culture after antibiotic administration is useful for identifying the pathogen of infectious disease. | True / False / Do not know | ||
| Clinical breakpoint is the minimum concentration of antibiotics that can inhibit the growth of bacteria. | True / False / Do not know | ||
| Gram-positive cocci are stained by Gram stain. | True / False / Do not know | ||
| Broth microdilution method is one of the quantitative susceptibility methods. | True / False / Do not know | ||
| Q9: Which pathological conditions do you think the treatment using antibiotics is recommended for? Please select all applicable answers. | Common cold in adults | • | • |
| Viral pharyngitis in children | |||
| Mild acute nasal sinusitis in children | |||
| Acute bronchitis in adults without underlying health conditions, such as chronic respiratory diseases | |||
| Nothing applies | |||
| Q10: Which antibiotics are recommended for administration in a single dose but not for a divided dose when the daily dose is the same? | Levofloxacin (new quinolone) | • | • |
| Ampicillin (penicillin) | |||
| Meropenem (carbapenem) | |||
| Cefazolin (first-generation cephalosporin) | |||
| Gentamicin (aminoglycoside) | |||
| Nothing applies | |||
Some questions were asked prelecture and also postlecture.
Statistics
Data were collected using the Questant software, an online questionnaire program (Macromill, Tokyo, Japan). Simple tabulation was performed using SPSS version 26.0 (IBM, Armonk, NY, USA). In the prelecture and postlecture comparisons, an unpaired t test was performed to compare the average number of correct answers across the eight questions. Statistical significance was set at a P level of <0.05.
RESULTS
The response rates for the questionnaire were 61.1% (330/540 pharmacy students) and 43.3% (234/540 pharmacy students) before and after attending an on-demand lecture, respectively. Furthermore, it was confirmed that all pharmacy students, including the respondents, viewed the entire lecture.
Table 3 shows the prelecture survey responses to the questions regarding antibiotics and medicines administered for selected infectious diseases, including the common cold. The prelecture survey showed that some respondents incorrectly considered the effectiveness of antibiotics against the common cold (39.4%) and influenza (30.9%). Moreover, 15.8% of the respondents in the prelecture survey wanted to take antibiotics against the common cold. Table 4 shows the prelecture survey responses to questions regarding antibiotic medication adherence and AMR. The prelecture survey showed that the majority of the respondents (69.7%) had used antibiotics according to the instructions of the prescriber. However, the ratio of the respondents who did not finish the prescribed antibiotic courses because of recovery from symptoms was 20.9% in the prelecture survey. In addition, 30.3% of the respondents kept antibiotics for later use, and 13.3% reported taking leftover antibiotics when they experienced other ailments. The current results showed that 17.3% of the respondents reported taking antibiotics prescribed to members of their families or others. Moreover, 17.8% of the respondents considered it unproblematic to take antibiotics prescribed to others. Although 85.5% of the respondents were knowledgeable about AMR, 13.3% had only heard of the term. Tables 3 and 4 summarize the results of our comparison of fourth-year Japanese pharmacy students with the general public in terms of responses to the Antibiotics Awareness Survey 2018 (14).
TABLE 3.
Perceptions of pharmacy students regarding antibiotics and various infectious diseases before taking the on-demand lecture
| Question and perception | Response rate (%) |
|
|---|---|---|
| Prelecture | AAS 2018 | |
| Question 1: Effectiveness of antibioticsa | ||
| Common cold | 130 (39.4) | 339 (49.9) |
| Influenza virus | 102 (30.9) | 334 (49.2) |
| Norovirus | 104 (31.5) | 158 (23.3) |
| Cystitis | 139 (42.1) | 181 (26.7) |
| Pneumonia | 197 (59.7) | 175 (25.8) |
| Otitis media | 137 (41.5) | 136 (20.0) |
| Diarrhea | 77 (23.3) | 64 (9.4) |
| Do not know | 5 (1.5) | |
| Others | 16 (4.8) | 25 (3.7) |
| Question 2: Expectation on prescribing for the common cold | ||
| Antitussive | 257 (77.9) | 446 (61.9) |
| Antipyretic | 236 (71.5) | 431 (59.8) |
| The medicine that suppresses runny nose | 227 (68.8) | 382 (53.0) |
| Antibiotics | 52 (15.8) | 217 (30.1) |
| Expectorant | 197 (59.7) | 210 (29.1) |
| Analgesic | 72 (21.8) | 130 (18.0) |
| Troche | 101 (30.6) | 99 (13.7) |
| Gargle | 56 (17.0) | 98 (13.6) |
| Stomach medicine | 20 (6.1) | 69 (9.6) |
| Others | 4 (1.2) | 18 (2.5) |
| Nothing applies | 5 (1.5) | |
For Question 1, prelecture n = 330, AAS 2018 n = 679; for Question 2, lecture n = 330; for AAS 2018 (the Antibiotics Awareness Survey 2018 [14]), n = 721.
TABLE 4.
Knowledge of pharmacy students regarding prescribed and nonprescribed antibiotics before taking the on-demand lecture
| Knowledge area | Response rate (%) |
|
|---|---|---|
| Prelecture (n = 330) | AAS 2018a (n = 679) | |
| Taking the full dose of antibiotics (Question 3) | ||
| Take the full dose as prescribed | 230 (69.7) | 356 (52.4) |
| Stop taking when condition is healed | 69 (20.9) | 231 (34.0) |
| Forget to take full course | 13 (3.9) | 39 (5.7) |
| Do not take them as much as possible from the beginning | 13 (3.9) | 53 (7.8) |
| Unanswered | 5 (1.5) | |
| Making do with leftover antibiotics (Question 4) | ||
| Keep for later use | 100 (30.3) | 201 (29.6) |
| Take when falling ill | 44 (13.3) | 147 (21.6) |
| Give to others | 3 (0.9) | 18 (2.7) |
| Throw away | 134 (40.6) | 303 (44.6) |
| Consult pharmacy and throw away | 15 (4.5) | 36 (5.7) |
| Other | 29 (8.8) | |
| Taking antibiotics prescribed for your family or others (Question 5) | ||
| Yes | 57 (17.3) | 144 (21.1) |
| No | 269 (81.5) | 535 (78.8) |
| Unanswered | 4 (1.2) | 4 (1.2) |
| Think about taking antibiotics prescribed for your family or others (Question 6) | ||
| Try not to take them | 259 (78.5) | 403 (59.4) |
| Worried because I have not seen doctor, but take them | 34 (10.3) | 115 (16.9) |
| Convenient because I do not have to go to clinic | 9 (2.7) | 67 (9.9) |
| No problem if symptoms are same as before | 16 (4.8) | 121 (17.8) |
| Others | 7 (2.1) | 9 (1.3) |
| Unanswered | 5 (1.5) | |
| Knowledge of AMR (Question 7) | ||
| I know | 282 (85.5) | |
| I have heard of it but do not have good knowledge | 44 (13.3) | |
| I do not know | 1 (0.3) | |
| Unanswered | 3 (0.9) | |
AAS 2018 is the Antibiotics Awareness Survey 2018 (14).
Table 5 shows a comparison of results of the prelecture and postlecture surveys. The mean number of correct responses across the eight questions in the postlecture survey (i.e., Question 8, statements 1 to 6, and Questions 9 and 10) was 2.21 ± 1.64 for the prelecture survey. However, the postlecture survey data showed that the mean number of correct answers significantly increased to 5.00, with a standard deviation of 1.82 (P < 0.001). In the postlecture survey, although the correct answer rates for each statement of Question 8 increased, the correct answer rate for the timing of blood culture was the lowest, at 44%. Regarding pathological conditions that generally do not require treatment with antibiotics (Question 9), the percentage of respondents who correctly answered “nothing applies” was 14.2% in the prelecture survey, which increased to 56.8% in the postlecture survey. In answering the question on the dosage administration of various antibiotics (Question 10), only 4.2% of respondents answered correctly in the prelecture survey. However, correct responses increased to 23.1% in the postlecture survey.
TABLE 5.
Knowledge of pharmacy students regarding treatment and diagnosis of infectious diseases and antibiotics both before and after taking the on-demand lecture (Questions 8 to 10)a
| Question and answer | Rate (%) of correct responses |
|
|---|---|---|
| Prelecture (n = 330) | Postlecture (n = 234) | |
| Question 8: Statements regarding treatment and diagnosis of infectious disease | ||
| C-reactive protein is a specific marker for bacterial infection. (False) | 91 (27.6) | 172 (73.5) |
| Fever is a specific marker for bacterial infection. (False) | 149 (45.2) | 150 (64.1) |
| Blood culture after antibiotic administration is useful for identifying the pathogen of infection disease. (False) | 86 (26.1) | 103 (44.0) |
| Clinical breakpoint is the minimum concentration of antibiotic that is able to inhibit the growth of bacteria. (False) | 70 (21.2) | 172 (73.5) |
| Gram positive cocci are stained red by Gram stain. (False) | 164 (49.7) | 189 (80.8) |
| Broth microdilution method is one of the quantitative susceptibility methods. (True) | 93 (28.2) | 198 (84.6) |
| Question 9: Pathological conditions where treatment using antibiotics is recommended | ||
| Common cold in adults (False) | 93 (28.2) | 17 (7.3) |
| Viral pharyngitis in children (False) | 146 (44.2) | 23 (9.8) |
| Mild acute nasal sinusitis in children (False) | 110 (33.3) | 37 (15.8) |
| Acute bronchitis in adults without underlying health conditions such as chronic respiratory diseases (False) | 137 (41.5) | 69 (29.5) |
| Nothing applies (True) | 47 (14.2) | 133 (56.8) |
| Question 10: Antibiotics where administration in a single dose is recommended | ||
| Levofloxacin (True) | 121 (36.7) | 139 (59.4) |
| Ampicillin (False) | 98 (29.7) | 24 (10.3) |
| Meropenem (False) | 47 (14.2) | 13 (5.6) |
| Cefazolin (False) | 65 (19.7) | 46 (19.7) |
| Gentamicin (True) | 78 (23.6) | 90 (38.5) |
| Nothing applies (False) | 26 (7.9) | 11 (4.7) |
| Completely correct answers (all 6) | 14 (4.2) | 54 (23.1) |
Overall, the mean (± SD) number of correct answers, per person, for Questions 8 to 10 was 2.21 ± 1.642 before the lecture and 5.00 ± 1.821 after the lecture. This increase was significant (P < 0.001, unpaired t test).
DISCUSSION
In the present study, we examined the knowledge of antibiotic use and AMR among fourth-year Japanese undergraduate students and the effect of a lecture on their knowledge, using a questionnaire. In the prelecture survey, 39.4% of the respondents considered that antibiotics were effective against the common cold. Moreover, 13.3% of the respondents had taken leftover antibiotics, and 17.3% of the respondents had taken antibiotics prescribed for their family members or others. Furthermore, the mean number of correct answers across the eight questions on infectious treatment and antibiotics increased in the postlecture survey compared to the prelecture survey. Although the lecture improved their knowledge to some extent, the results suggested that fourth-year pharmacy students have inaccurate knowledge related to the appropriate use of antibiotics and AMR.
Overprescription of antibiotics can lead to the development and progression of AMR (15). Several surveys of the general public’s knowledge and attitudes regarding antibiotics have been conducted in Japan and abroad; in the Antibiotics Awareness Survey 2018 and 2020, 49.9% and 34.3% of the respondents, respectively, stated that antibiotics were effective against the common cold, indicating that the general public’s knowledge regarding antibiotics and the common cold had improved since 2018 (14, 16). Furthermore, in other surveys of the general public, approximately 40% of the respondents also considered antibiotics to be effective against the common cold (17–20). Moreover, although fourth-year Japanese pharmacy students have been learning the basics of antibiotics and microbiology, their awareness in the present study was almost the same as that of the general public (16–20). Moreover, 39.7% and 34.6% of the respondents answered that they stopped taking antibiotics contrary to their physician’s instructions in the Antibiotics Awareness Surveys of 2018 and 2020, respectively (14, 16). On the contrary, the Nippon AMR One Health Report (NAOR) 2019 revealed that the percentage of the general public who had stopped taking antibiotics or adjusted a dose based on their own judgment was 23.6% (2017) and 24.0% (2018) (18). Although the results of these surveys are varied, medication adherence for antibiotics among pharmacy students is considered to be better or similar to that of the general public. In addition, the NAOR 2019 reported that the percentage of respondents who kept leftover antibiotics was 11.7% (2017) and 11.9% (2018) (18). Meanwhile, the percentage of respondents who kept leftover antibiotics was 29.6% and 31.6% in the Antibiotics Awareness Surveys of 2018 and 2020, respectively (14, 16). Therefore, the proportion of pharmacy student respondents who kept leftover antibiotics in the present study was the same or higher than that of the general public. Furthermore, approximately 20% of the respondents reported taking leftover antibiotics prescribed to them or others in both the present study and the Antibiotics Awareness Survey 2018 (14). Although more than 80% of the respondents knew about AMR, these results indicated the possibility that there are as many students as the general public who cannot appropriately manage antibiotics for the suppression of AMR. The poor results in the prelecture survey may reflect the common knowledge and basic attitudes of early-year pharmacy students. Considering that acquiring sufficient knowledge and forming appropriate attitudes lead to desirable behaviors (21), modifying the basic education on AMR for early-year pharmacy students may be necessary.
From the results of the prelecture survey in this study, although fourth-year pharmacy students have been learning fundamental pharmaceutical sciences such as microbiology and pathophysiology, it is possible that their knowledge related to AS is underestablished. In addition, the principles of AS educational content may not be fully covered in the educational program. Therefore, it is necessary to review the curriculum so that the principles needed for the proper use of antibiotics are covered. Moreover, although a single on-demand lecture improved the correct answer rate of each question related to infectious disease treatment and the use of antibiotics, only 25% of the respondents understood the dose used for various antibiotics after taking the lecture. Furthermore, less than half of the respondents correctly answered the question on the timing of blood culture, even after attending the lecture. These results suggest that the present lecture alone may not have improved their knowledge, including PK/PD and identifying the pathogen. Therefore, it is also necessary to improve the educational program, including our present lecture, in preclinical training. In addition, the present study only evaluated the short-term effects of a single lecture and could not examine the long-term effects. Considering the inadequate knowledge of AS from the results of the prelecture survey, a long-term effect of the lecture may not be expected. In addition, passive educational programs, including lectures, are important for acquiring knowledge of AS. However, these may not be enough (7). Various educational programs based on an active learning approach have been used to teach the topics of AS (22). For example, the AS elective course, which mainly consists of preclass assignments and in-class group work, has been shown to improve students’ awareness and familiarity with the principles of AS and increase their confidence in participating in the AS program (23). Although the active learning theory was not considered in the present study, active learning programs are expected to be useful for pharmacy AS education. It is necessary to introduce an active educational program based on the clinical utilization of AS principles using training methods not only during the preclinical training but also during the first 3 years of pharmacy education.
There are some limitations to the present study. First, since the survey was conducted at one institution, the results could be influenced by the educational curriculum of that university. Second, it is possible that the respondents had access to external resources, such as a web browser, when answering the questions; this may have influenced the results. Third, after undergoing the lecture, the respondents could answer the postlecture survey at any time during the survey period. Therefore, it is possible that some time elapsed between the lecture and the completion of the postlecture survey. Fourth, the survey was conducted for 1 year and before participants acquired pharmacy practice experience; therefore, we could not examine the differences in knowledge between the students in different years. In future studies, a comprehensive survey with larger sample sizes will be required to evaluate pharmacy students’ knowledge of antibiotic use. Finally, because the questionnaires were anonymous, we could not confirm whether the respondents completed both the prelecture and postlecture surveys. In the future, a registered survey is needed to examine individual changes caused by AS education.
In conclusion, the present survey suggests that undergraduate Japanese pharmacy students, as well as the general public, have inaccurate knowledge related to the use of antibiotics. Although the lecture improved their knowledge in the present study, their poor knowledge of the fundamental pharmaceutical sciences related to AS and AMR remains a critical problem. Therefore, there is a need to revise undergraduate education to improve early-year pharmacy students’ knowledge of AMR and AS.
ACKNOWLEDGMENTS
We thank all participants who completed the questionnaire survey. We also acknowledge Kazuhiro Torigoe and Makoto Hiraide at Hoshi University School of Pharmacy and Pharmaceutical Sciences for their assistance in conducting the questionnaire survey. We thank Editage for English language editing. This research received no specific grant from any funding agency in the public, commercial, or nonprofit sectors.
We certify that we have no conflicts of interest.
Contributor Information
Takuya Azechi, Email: t-azechi@juntendo.ac.jp.
Samantha T. Parks, Georgia State University
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