A survey on the attitudes of pediatric residents toward rational use of medicines and associated factors in Izmir, Turkey

Abstract

Background

Considering children’s sensitive and developmental needs, pediatricians play a pivotal role in ensuring rational use of medicines (RUM), alongside healthcare systems, pharmacists and patients.

Aim

To assess pediatric residents’ attitudes toward RUM in three Izmir hospitals.

Study design

A cross-sectional study.

Methods

The attitude of pediatric residents at three tertiary hospitals in Izmir toward RUM was assessed using the Scale for Determining Family Physicians’ Attitudes on RUM. Independent variables included sociodemographic characteristics, prescribing practices, and RUM-related education. Data were analyzed using Student’s t-test, One-Way ANOVA, and Linear Regression.

Results

The study included 187 participants with a 98.9% coverage rate. Pediatric residents prescribed an average of 2.4 ± 0.7 medicines, with only 12.8% prescribing injectables. The most common source of prescribing information for residents is application programs (84.5%). Pediatric residents excelled in explaining diseases (91.5%) and treatments (93.1%), though only 52.9% believed patients understood the information, and 49.7% sometimes prescribed medications upon request. Most (89.8%) considered treatment feasibility, but only 46.6% frequently accounted for costs. While 93.6% avoided prescribing without examination, only 23.6% knew medication prices, and 41.2% reported occasional influence from pharmaceutical promotions. Participants scored an average of 3.6 ± 0.3 on the total RUM attitudes scale. Multivariate analysis showed that the scale mean was 0.018 points higher for those using peer-reviewed publications and 0.012 points higher for those reporting adverse effects, while it was 0.024 points lower for those relying on pharmaceutical promotional resources (p < 0.05), explaining 17.3% of the variance.

Conclusion

Pediatric residents in Izmir show a positive attitude toward RUM, excelling in communication and prescribing, though gaps persist in cost-awareness, evidence use, and managing external influences. Targeted education focusing on cost-conscious prescribing and the critical appraisal of information sources is necessary. Implementing active monitoring and feedback systems can further promote adherence to RUM principles, ensuring safer and more effective pediatric care.

Introduction

Irrational use of medicines is one of the most serious public health problems [1, 2]. It is associated with increased morbidity and mortality, medicine-medicine interactions, frequent adverse events, reduced compliance, development of medicine resistance, disease recurrence and increased economic and social burden [1,2,3,4,5,6]. According to estimates from the World Health Organization (WHO), over half of all medications are sold, administered, delivered, and used improperly [7]. WHO defines rational use of medicines (RUM) as the ability to easily access the appropriate medication based on clinical findings and individual characteristics, at the appropriate time and dose, and at the lowest possible cost. It recommends compliance with the principles of efficacy, safety, appropriateness, and cost [3].

Healthcare systems, pharmacists, physicians, patients and the public are all responsible for the rational use of medicines, with physicians playing the most crucial role [1, 8]. The intrinsic factors influencing physicians’ prescribing behaviors include insufficient and inconsistent RUM training, both prior to graduation and during service. Role models who fail to emphasize the importance of RUM, along with a lack of firsthand knowledge about medication effectiveness or adverse effects, and financial incentives, also contribute to these behaviors [9]. External factors such as high patient load and pressure from peers, patients, and pharmaceutical representatives further complicate prescribing decisions [9]. Pediatric pharmacology and prescribing practices fundamentally differ from those in adults. Developmental pharmacokinetics, which include changes in medicine absorption, distribution, metabolism, and excretion, significantly impact medication efficacy and safety across different pediatric age groups [10]. Furthermore, children are particularly vulnerable to medication errors and adverse effects due to their limited ability to communicate symptoms, variable medicine responses, and frequent off-label medicine use in pediatrics [11].

In pediatric practice, issues such as polypharmacy, unnecessary use of antibiotics and sedatives, and discontinuation of medications without medical consultation after adverse effects or vomiting contribute to irrational medicine use [9, 12]. Challenges in rational pediatric prescribing have been observed globally, with the first pediatric-specific RUM tool developed in France in 2014, followed by studies in the United Kingdom and Ireland [12, 13]. Increasing pediatricians’ attitudes of RUM is essential for improving health outcomes by reducing morbidity and mortality, minimizing adverse medicinereactions and medicine resistance, and optimizing healthcare resource allocation [2, 4, 6, 14]. Understanding the attitudes of pediatric residents on rational medicine use can help identify the interventions needed to enhance their prescribing practices and ensure adherence to RUM principles. The purpose of this study was to ascertain the attitudes of pediatric residents at three public hospitals in Izmir on RUM and related issues.

Material and method

This cross-sectional study was initially designed to include four tertiary care hospitals in Izmir, comprising two university hospitals and two state hospitals. Among the 264 pediatric residents employed across these institutions, the minimum required sample size was calculated to be 189, assuming a prevalence of 50%, a margin of error of 5%, and a confidence level of 99%. However, due to the inability to obtain permission from one of the state hospitals with 62 residents, the study was conducted in the remaining three hospitals.

Definition of variables

The dependent variable of the study was physicians’ attitudes toward the rational use of medicines (RUM), measured using Salğın’s Scale for Determining Family Physicians’ Attitudes Toward Rational Use of Medicine (SPARUM), developed in 2018 [15]. The scale employs a five-point Likert scale (1: never, 2: seldom, 3: sometimes, 4: frequently, 5: always), with no cut-off point, and the evaluation is based on the mean score. Exploratory factor analysis of the original scale identified a three-factor structure explaining 43.12% of the total variance, with a Cronbach’s alpha coefficient of 0.87, indicating high reliability [15]. In the current study, the Cronbach’s alpha coefficient was calculated as 0.74, demonstrating acceptable internal consistency for this sample. The SPARUM is a 23-item scale designed to assess physicians’ attitudes toward Rational Use of Medicines (RUM) across three dimensions. The first dimension, Physician-Patient Relationship, consists of eight items focusing on communication about diagnoses, treatments, and medicines. The second dimension, Physician-Treatment Regulation Relationship, includes eight items evaluating prescribing behaviors, treatment feasibility, and cost considerations. The third dimension, Physician-Medication Knowledge Relationship, comprises seven items assessing physicians’ knowledge of medicine-related policies, pricing, and the influence of pharmaceutical promotions. Together, these dimensions provide a comprehensive assessment of attitudes and practices related to RUM.

Independent variables were categorized into three main sections: sociodemographic characteristics, prescribing practices, and RUM-related education and information sources. Sociodemographic characteristics included gender, age, hospital of employment, total years of work, and duration of residency training. Prescribing practices covered the average number of medicines per prescription, percentage of injectable preparations in the last 100 prescriptions, the most frequently prescribed medicine group, and reporting of adverse medicine effects. RUM-related education and information sources focused on whether residents had received RUM training before or after graduation, their awareness of the Ministry of Health’s RUM-related website, self-perceived knowledge levels regarding RUM, and their information sources for prescribing, such as mobile applications, peer-reviewed literature, or pharmaceutical promotional resources.

Data collection tool

The data collection tool consisted of a 41-item questionnaire, including the 23-item SPARUM scale and 18 additional questions developed by the researchers based on a literature review. The additional questions explored sociodemographic characteristics, prescribing practices, and RUM-related education and information sources.

The draft questionnaire was evaluated during a panel session consisting of the researchers, two pediatric specialists, and two pediatric residents to ensure its relevance, clarity, and comprehensiveness. As a result of the review, an explanatory note was added to the SPARUM scale to specify that items addressing communication referred to interactions with parents. Additionally, minor adjustments were made to two scale items to improve their clarity and understanding. The finalized questionnaire was then piloted with 15 pediatric residents outside the study sample to evaluate its clarity and ease of use. Feedback from the pilot testing led to revisions in the wording of three items, ensuring the validity and reliability of the tool for data collection.

Ethical approval and permissions

Ethical approval for the study was obtained from the Medical Research Ethics Committee of the Faculty of Medicine at Ege University (approval number: E99166796-050.06.04-2817667). Written consent was also obtained from the hospitals where the study was conducted. Additionally, all participants provided both written and verbal informed consent prior to their inclusion in the study.

Statistical analysis

Data were analyzed using SPSS version 24.0. The normality of the variables was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. To examine the associations between the mean total scale scores and categorical variables, Mann-Whitney U test, Student’s t-test, Kruskal-Wallis test, and One-Way ANOVA were employed. The dependent variable and standard errors were determined to follow a normal distribution. Independent variables that were significantly associated with physicians’ attitudes toward RUM in bivariate analyses, and were not strongly correlated with each other, were included in a backward stepwise multiple linear regression analysis model. Sociodemographic variables such as age and gender were also incorporated into the model. Statistical significance was set at p < 0.05.

Result

The study included 187 participants, achieving a coverage rate of 98.9%. Of these, 72.2% were female, and approximately half were aged 29 years or older (range: 24–36). The average years of experience as a physician were 3.05 ± 1,85, and the average duration of residency was 2.19 ± 1.39. On average, physicians prescribed 2.4 ± 0.7 medicines per prescription (min-max: 1–5), with only 12.8% including injectable preparations, as per WHO [16] recommendations (13.4–24.1%). Antibiotics were identified as the most frequently prescribed medicine group by 13.4% of participants. Participants reported using a variety of information sources for RUM. Mobile phone and internet applications were the most commonly used source (84.5%), followed by peer-reviewed literature (33.2%), medication information software (22.5%), pharmacology books (8.0%), and pharmaceutical promotional resources (7.5%). Only 22.4% of participants followed the Ministry of Health’s activities and website on RUM. Among the participants, 82.9% had received RUM training before graduation, 44.9% after graduation, and 77.5% expressed a desire for further RUM training (Table 1).

Table 1 Distribution of pediatric residents according to independent variables

The mean total score on the SPARUM scale was 3.6 ± 0.3 (min-max: 2.8–4.7), with sub-scores of 3.6 ± 0.4 for the physician-patient relationship dimension, 3.8 ± 0.4 for the physician-treatment regulation dimension, and 3.4 ± 0.4 for the physician-medication knowledge dimension.

Within the Physician-Patient Relationship Dimension, residents exhibited strong practices in explaining diseases (91.5%) and treatment rationales (93.1%) to patients. However, only 52.9% believed that patients understood the information provided, indicating a communication gap. Additionally, while 93.1% provided information about prescribed medicines, only 39.0% informed patients and the public about RUM principles, and just 34.2% addressed storage conditions. Furthermore, 49.7% of residents sometimes prescribed medications upon patient request, reflecting external pressures that could affect rational prescribing (Table 2).

Table 2 Distribution of pediatric residents by responses to the SPARUM* questions (n:187)

In the Physician-Treatment Regulation Relationship Dimension, 89.8% of residents considered treatment feasibility, and 85.6% recommended non-medicine treatments when appropriate, reflecting alignment with RUM standards. However, only 46.6% frequently considered treatment costs, and just 40.7% evaluated treatment outcomes, with 35.3% consistently monitoring patient conditions. Positively, 82.3% avoided prescribing more than the required number of medicines, while only 1.6% re-prescribed a medication without patient evaluation (Table 2).

The Physician-Medication Knowledge Relationship Dimension revealed both strengths and gaps. Nearly all residents (93.6%) avoided prescribing without a patient examination. However, only 23.6% frequently knew the prices of prescribed medicines, highlighting limited cost-awareness. While 51.3% reported seldom being influenced by pharmaceutical promotional resources, 41.2% acknowledged occasional influence. Encouragingly, 72.2% frequently consulted colleagues when uncertain, but only 16.0% consistently adhered to pharmaceutical policies and legislation (Table 2).

Sociodemographic characteristics such as age and gender were not significantly related to RUM attitudes (p > 0.05). No significant association was found between the rate of prescribing injectable preparations or the most frequently prescribed medicine group and SPARUM scores (p > 0.05). However, residents who prescribed three or fewer medicines per prescription and those who reported adverse effects achieved significantly higher scores (p < 0.05). Residents who used peer-reviewed literature as an information source, followed the Ministry of Health website, and avoided pharmaceutical promotional resources and software applications also had significantly higher mean RUM scores (p < 0.05) (Table 3). The multivariate linear regression analysis demonstrated that the mean SPARUM score was 0.018 points higher for those using peer-reviewed literature as an information source and 0.012 points higher for those reporting adverse effects. Conversely, reliance on pharmaceutical promotional resources as an information source was associated with a 0.024-point decrease in the SPARUM score (p < 0.05). This model explained 17.3% of the variance in SPARUM scores (Table 4).

Table 3 Distribution of pediatric residents’ SPARUM* scores by independent variables

Table 4 Multiple regression analysis of factors associated with SPARUM* scores

Discussion

This study explored the attitudes of pediatric residents in Izmir toward Rational Use of Medicines (RUM) and examined the intrinsic factors influencing these attitudes. The findings revealed that most residents exhibit a positive attitude toward RUM; however, their commitment and implementation vary across different dimensions, highlighting areas for improvement. Residents who reported adverse effects, relied on peer-reviewed literature, and avoided pharmaceutical promotional resources demonstrated stronger alignment with RUM principles, emphasizing the importance of evidence-based practices and responsible prescribing behaviors.

When compared to family physicians in the study where the SPARUM scale was developed, pediatric residents in this study scored higher across the three dimensions, indicating a more favorable attitude toward RUM [15]. Despite this, the physician-patient relationship dimension revealed a significant communication gap. Although most participants reported effectively explaining diagnoses and treatment rationales to patients in accordance with the literature [17], a significant portion believed that patients or their caregivers did not fully understand the information provided. This highlights a critical communication gap that could impact treatment adherence and overall care quality. This gap could be attributed to the indirect nature of communication in pediatrics, where parents mediate interactions. Improving communication strategies through targeted training programs and the use of visual aids or simplified language could enhance understanding, reduce treatment non-adherence, and improve care outcomes.

Patient pressure also emerged as a potential factor influencing irrational prescribing, as more than half of the residents occasionally or frequently prescribed medications requested by patients or caregivers. Literature indicates that between 65% and 75% of prescriptions are written for patient-desired medicines [18, 19]. A separate Turkish study found that physicians often feel pressured to avoid conflict when patients demand specific medicines [19]. Addressing these extrinsic factors requires patient education initiatives and policies to support physicians in making rational prescribing decisions. Among the three dimensions, the physician-treatment regulation relationship dimension received the highest scores, reflecting a strong focus on non-medicine therapies (85.6%) and treatment feasibility (89.8%). However, less than half of the participants consistently monitored patient outcomes or considered treatment costs, which aligns with the literature [15, 17, 20]. Controlling prescription costs is critical for improving patient compliance and reducing the economic burden on healthcare systems. Although 82% of participants rarely prescribed more medication than necessary, the average number of medicines per prescription (2.4 ± 0.7) exceeded the WHO-recommended range of 1.6–1.8 [21]. This finding aligns with studies from countries like Afghanistan (2.9) and Sri Lanka (2.8) but contrasts with lower averages reported in Jordan (1.8) and India (2.0) [2, 5, 22,23,24,25,26]. Differences in institutional levels, disease burden, and prescribing habits may account for this variation. Reducing unnecessary polypharmacy through training and clinical guidelines could help align prescribing practices with international benchmarks.

The physician-medication knowledge relationship dimension had a mean score of 3.4 ± 0.4, suggesting that residents generally possess knowledge about pharmaceuticals. Nonetheless, this area requires particular attention in pediatrics, as medication pharmacokinetics can vary significantly depending on a child’s age and developmental stage. Similar to a Saudi Arabian study, over 70% of participants consulted colleagues when uncertain about medication selection [27]. Only 23.6% of participants were familiar with medication pricing, reflecting limited cost-awareness, which is consistent with studies from the Netherlands and Jordan showing that physicians often lack this knowledge [28, 29]. Similar to other studies in Turkey, no significant correlation was found between SPARUM scores and sociodemographic characteristics or previous RUM training [15, 17, 18, 20]. However, a systematic review of 50 studies highlighted the effectiveness of RUM training in improving prescribing practices [30]. In this study, many pediatric residents expressed a strong interest in receiving additional RUM training, highlighting its perceived importance. Pediatric residents who prescribe fewer medications tend to have a more favorable attitude toward RUM; however, studies in the literature suggest that the number of medicines per prescription may not always be directly related to this issue [18]. Similar to our findings, pediatricians in India who reported adverse effects demonstrated greater awareness of RUM [6]. This finding suggests that active engagement in monitoring and evaluating treatment outcomes is associated with more thoughtful and rational prescribing practices. It highlights the importance of fostering a culture of systematic reporting and analysis of adverse events to improve patient safety and medication use practices. Digital tools and mobile applications were the most frequently used information source (84.5%), yet their use was associated with less favorable attitudes toward RUM. This contrasts with studies from Germany and Poland, where application programs positively influenced RUM adherence [31, 32]. The discrepancy may reflect differences in the quality or reliability of the applications used by residents in this study. Integrating validated, evidence-based digital tools into training programs could enhance their utility and foster adherence to RUM principles. Peer-reviewed literature was positively associated with RUM scores, underscoring the value of traditional and reliable information sources. Conversely, reliance on pharmaceutical promotional resources was linked to lower scores, echoing findings from studies in Pakistan, Ethiopia, and Lebanon that highlight the detrimental impact of promotional activities on rational prescribing [8, 33,34,35,36,37].

Limitations and strengths

The inclusion of pediatric residents from both university hospitals and state teaching-research institutions enhances the representativeness and inclusivity of this study, providing valuable insights into RUM attitudes across diverse training environments. Additionally, the study achieved a high participation rate and utilized a validated scale (SPARUM), which was reviewed by an expert panel and pilot-tested to ensure its suitability for pediatric residents, further strengthening the reliability of the findings.

However, the inability to obtain permission from one hospital slightly limits the study’s generalizability to all pediatric residents in Izmir. Although the SPARUM scale was adapted for use with pediatric residents, it was originally developed for family physicians, which could influence its applicability to this population. These limitations should be considered when interpreting the results.

Conclusion

While pediatric residents demonstrate a generally positive attitude toward RUM, this study identifies key areas for improvement, particularly in communication, cost-awareness, and evidence-based prescribing practices. To address these gaps, integrating periodic RUM training modules into pre-service and in-service programs, as well as incorporating RUM principles into residency evaluations, could strengthen adherence. Health systems should establish mechanisms to mitigate external pressures, such as patient demands and pharmaceutical promotions, while fostering a culture of adverse event reporting and discussion within medical facilities. Legislators should prioritize stricter oversight of pharmaceutical marketing and ensure transparency in medical education. Future studies should assess the impact of these strategies and explore innovative teaching methods to enhance RUM practices in pediatric care.