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Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 94-102

Knowledge, attitude, and practice of community pharmacists toward tablet splitting and crushing at omdurman locality: A cross-sectional study

1 Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
2 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
3 Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan; Department of Pharmacology, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

Date of Submission14-Nov-2020
Date of Decision16-Dec-2020
Date of Acceptance28-Dec-2020
Date of Web Publication15-Apr-2021

Correspondence Address:
Dr. Zuheir Abdelrahman Osman
Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave., Khartoum 11111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_143_20

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Background: The splitting or crushing of tablets has many advantages, such as dose flexibility, cost reduction, and ease of swallowing. Despite these benefits, there are many drawbacks to this practice. Pharmacists should be able to make decisions and counsel patients concerning these techniques. Our study aimed to evaluate their knowledge, attitude, and practice about tablet splitting and crushing. Methods: A descriptive cross-sectional survey was carried out among 150 community pharmacists using a validated self-administered questionnaire. A stratified random sampling technique was used to select the participants. The knowledge, attitude, and practice were evaluated. Associations between the variables were tested using the Chi-square method. Results: Out of 147 participants, 67.1% were females. The majority of subjects were between 20 and 30 years of age. About 48% of respondents scored a fair knowledge level and 23% of them were knowledgeable of the subject matter. Furthermore, 51% of pharmacists showed good attitudes, as they do not usually recommend the splitting and crushing of tablet dosage. Moreover, more than half of the participants used alternative formulations for patients who were unable to swallow. Nearly 65% of participants did not encourage tablet splitting to help patients to save money. Almost 80% of them declared that they never advised a patient to split or crush enteric-coated or sustained-release tablets. Moreover, a significant association was found between participants' knowledge and their professional experience. On the other hand, the participants' attitude was significantly associated with their age and training levels. Conclusion: The study showed variable knowledge levels among participants. Nearly 51% of the participating pharmacists showed good attitudes regarding the study subject. Experience, age, and training have a positive effect on the knowledge and attitude of participants.

Keywords: Community pharmacists, knowledge, tablet crushing, tablet splitting

How to cite this article:
Gafar MA, Yousef BA, Ibrahim A, Osman ZA. Knowledge, attitude, and practice of community pharmacists toward tablet splitting and crushing at omdurman locality: A cross-sectional study. Curr Med Issues 2021;19:94-102

How to cite this URL:
Gafar MA, Yousef BA, Ibrahim A, Osman ZA. Knowledge, attitude, and practice of community pharmacists toward tablet splitting and crushing at omdurman locality: A cross-sectional study. Curr Med Issues [serial online] 2021 [cited 2022 Aug 15];19:94-102. Available from: https://www.cmijournal.org/text.asp?2021/19/2/94/313812

  Introduction Top

Tablets are solid dosage forms containing one or more active ingredients, which are generally designed for oral administration. A tablet can either be swallowed as a whole, chewed, dispersed in water, or retained in the mouth.[1] When manufactured, tablets may bear marks for breaking; they can either be coated or uncoated and may be of conventional or modified release profile.[2] Furthermore, tablets may need to be manipulated by splitting into small parts or crushing into powder to either get a required proportion of the drug amount for administration or make it easier for patients who cannot swallow.[3] Tablet manipulation also allows slow titration of the dose to help tolerate the drug and reduce adverse events. Moreover, tablet manipulation can be encouraged from an economic point of view because it may be cheaper to split the higher concentration formulation than buy the exact required dose.[3],[4],[5] It may be needed for children to use dosage forms manufactured for adults, and only a small part of an adult's dose may be required.[5]

Despite the many benefits, tablet splitting and crushing may have many disadvantages and complications. The process may be time consuming, inaccurate, and have unknown effects on the drug's stability and bioavailability, posing the risk of harmful or suboptimal doses being delivered. Moreover, there is an increased risk of errors in dose calculation.[3]

Many drugs are irritant to the esophagus and stomach or have a bitter taste. Thus, they are formulated or coated to reduce the risk toward patients. Crushing these types of tablets may increase the risk of gastric irritation or produce an unpleasant taste, which may lead to reduced patient compliance.[6] Furthermore, crushing a modified release tablet may alter the release characteristics, with the possibility for a large initial dose being delivered to the bloodstream, followed by suboptimal dosing at later times, leading to the loss of efficacy.[6],[7] The tablets' physical features, such as size, shape, the presence or absence of a tablet score, and different splitting methods, can result in more weight variability and drug content variation in the split tablets.[8]

Pharmacists are the health professionals in charge of managing the medicines' distribution to patients and ensuring their effective and safe use.[9],[10] Pharmacists should be able to identify inappropriate dosing of medication, potential interactions, or medicines that are unsuitable for the patient.[11] Concerning tablet splitting or crushing, as a result of their possible harmful consequences, a pharmacist should be able to judge the appropriateness of a tablet for splitting or crushing, evaluate the patient's ability and readiness to split or crush tablets, and correctly inform the patient about the best method of splitting and crushing.[6],[7] Thus, our study aimed to evaluate the knowledge, attitude, and practice of community pharmacists working in Omdurman locality regarding tablet splitting and crushing.

  Methods Top

Study setting

This study was a descriptive cross-sectional survey. The study population was the registered community pharmacists from Omdurman locality, Khartoum, Sudan. The study was carried out during November–December 2017.

Inclusion and exclusion criteria

Registered community pharmacists working at Omdurman's community pharmacies who agreed to participate in the study were included in the study; those who refused to enroll were excluded from the study.

Sample size and sampling technique

The total number of community pharmacies (N) in Omdurman locality was found to be 243 (data from the ministry of health). A stratified sampling method was used, and the sample size was calculated to be 150 according to Selvin's equation, n = N/1 + N(D)2, where N = total target population attending the center, n = sample size, and e = margin of error (0.05) at 95% confidence level. Omdurman locality was divided into three territories according to geographical location and types of health-care services and facilities. Each territory was considered a stratum; within each stratum, pharmacists were selected randomly using a simple random sampling technique according to the total weight of the territory. Three community pharmacists refused to participate in this study, reducing the sample size to 147. Thus, the response rate was 98%.

Data collection method

A self-administered questionnaire was developed based on a review of previous studies. The questionnaire included 35 questions (dichotomous, multiple-choice questions, and open-ended questions). The validity of items in the draft questionnaire was assessed by a panel of experts, including an assistant professor of pharmaceutics, an assistant professor of clinical pharmacy, a clinical pharmacist, and a statistician. The panel validated the questionnaire for readability, question design, length, and relevance. A pilot study for the questionnaire was conducted on several community pharmacists as a validity check, and some changes were made.

The questionnaire was divided into four parts: Part A investigated the demographic data of the participants, while parts B, C, and D investigated the knowledge, attitude, and practice, respectively. The collected data were checked for completion and manually scored before coding; each question in the knowledge and attitude section was marked for a correct answer, and a score of zero was given for the incorrect one.

Each participant in the study was given a level of knowledge about the study subject according to their responses to questions in the knowledge section, with 0 representing the lowest level and 14 representing the highest level. Participants were categorized according to their level of knowledge about tablet splitting and crushing using percentiles, with those scoring below the lower quartile[5] and above the upper quartile[8] categorized as having poor and good knowledge, respectively. Those who scored in between were considered to have a fair knowledge about the study subject. The same leveling method was used for attitude, with 0 and 7 representing the lowest and the maximum levels, respectively. The median attitude level (4.4) was used to categorize participants into bad and good overall attitude.

Data analysis

The collected data were analyzed using the Statistical Package for the Social Sciences for Windows, Version 22.0 software. The questionnaire was precoded, and all data entered and countered were checked. Descriptive analysis was carried out using frequencies and percentages to describe the participant characteristics. To examine the association between dependent and independent variables, Chi-square tests, and linear regression analysis were used. P < 0.05 was considered to be significant.

Ethical consideration

The study proposal was assessed and approved by the Faculty of Pharmacy's Ethical Committee, University of Khartoum (FPEC-05-2017). Verbal consent was obtained from all participants before administering the questionnaire. The questionnaire did not reveal the personal identities of participants to ensure confidentiality throughout the study.

  Results Top

Out of 147 community pharmacists who responded to the questionnaire, the majority were females (66.7%). Most of the participants aged between 20 and 30 years and had professional experience between 1 and 5 years. The vast majority (79.6%) were B. Pharm degree holders, 94.4% did their studies in Sudan, and 88.3% of them did not receive training or attended courses that dealt with the issue of tablet splitting and crushing or their effects [Table 1].
Table 1: Demographic characteristics and personal information of the study sample (n=147)

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After scoring of pharmacists according to their level of knowledge, almost half of them (48%) had fair knowledge, 29.3% were scored as having poor knowledge, while 23.1% had good knowledge. As shown in [Table 2], 74.1% and 64.6% of pharmacists knew that extended-release formulations must not be split or crushed because these tablets should cross the stomach or that it contains a layer of micrograins, respectively. Moreover, responses to different extended-release formulations such as Tegretol 400 mg CR®, Nifedipine XL, and enteric-coated omeprazole varied between the participants [Table 2]. There was a significant association (P = 0.004) between knowledge and experience of participants, while no significant association was found between knowledge and other demographic characteristics of participants (P > 0.05). There was no significant correlation between participants' knowledge and experience and qualifications (0.223* and 0.169*, respectively) [Table 3].
Table 2: Distribution of community pharmacists of Omdurman locality according to their knowledge toward tablet dosage form splitting and crushing (n=147)

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Table 3: Association and correlation of knowledge and attitude of community pharmacists of Omdurman locality with their sociodemographics characteristics (n=147)

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Regarding attitude, 51% of the study participants showed a good attitude toward splitting and crushing different dosage forms, while the rest were categorized as having a bad attitude [Table 4]. After running the Chi-square test, a significant association was found between participants' attitude, age, and training (P = 0.026 and 0.039, respectively). There was no significant correlation between the attitude of participants and their age (r = 0.212*), qualifications (r = 0.170*), or training (r = 0.173*) [Table 3].
Table 4: Distribution of community pharmacists of Omdurman locality according to their behavior toward tablet dosage form splitting and crushing (n=147)

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Concerning practice, as demonstrated in [Table 5], the majority of the participants (65%) do not encourage tablet splitting as a way to save money and the vast majority (80%) of them declared that they never advised a patient to split or crush enteric-coated or sustained-release tablet. About 44% of pharmacists said that they sometimes advise patients to split tablets to reach the desired dose, 31% never crushed a tablet, and more than half of them (57%) never asked an expert about the best method to split a tablet. For patients who could not swallow the prescribed tablets, 52.4% of respondents give alternative formulations (if available) in nonsustained-release and noncoated formulations, while for sustained-release tablets, the percentage was 55.8%. Cardiovascular, analgesic, and central nervous system (CNS) drugs were the most pharmacological classes that were dispensed by the study participants to be split before administration (19.8%, 19.3%, and 18%, respectively) [Table 6].
Table 5: Distribution of community pharmacists of Omdurman locality according to their practice toward tablet dosage form splitting and crushing (n=147)

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Table 6: Distribution of medications from different pharmacological classes that dispensed by community pharmacists of Omdurman locality to be split before administration (n=147)

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Furthermore, using the Chi-square test, there was neither a significant association nor correlation between participant's knowledge and attitude. Furthermore, no significant association was found between participants' knowledge and their advice to patients to split or crush enteric-coated or sustained-release tablets.

  Discussion Top

Prescribing and dispensing errors are among the most common causes of adverse drug events in pharmacy practice.[12],[13] One of the most common dispensing errors is dosage form modifications such as splitting and crushing. Such practice can be a source of health hazards for the person modifying and administering the medication and can increase the risk of clinically significant adverse effects for the patient.[12],[13] Pharmacists are often the first point of contact for people in the general community seeking advice regarding medications. As such, pharmacists need to have a good knowledge regarding dosage form modification.[14] Therefore, adequate knowledge of the health-care professional, including pharmacists, is essential to minimize medication dispensing errors. The current study has assessed the levels of knowledge, attitude, and practice among community pharmacists working in Omdurman locality about the splitting or crushing tablet dosage form and their awareness about their safety and therapeutic implications. One hundred and forty-seven community pharmacists were involved, 67.1% of whom were females. Almost 81.5% of the participants have 1–5 years of experience in pharmacy practice. This may be because that most newly graduated pharmacists start working in community pharmacies before seeking other jobs.[15],[16] Community pharmacists' experience is crucial in reducing dispensing errors and enhancing good dispensing performance and better services.[17],[18]

Regarding knowledge, only 23% of them revealed good knowledge and 29.3% were categorized to have inadequate knowledge about the study subject. These findings are in line with a previous study in Palestine, which found that one-third of pharmacists had poor knowledge.[4] Another study done in Australia showed that pharmacists are more aware than nurses and general practitioners about medication dosage form modifications and the associated problems with modifying dosage forms.[14] Cross-tabulation results revealed that highly experienced pharmacists are more knowledgeable about tablet splitting and crushing and their implications.

Furthermore, crushing an extended-release preparation may result in the potential of a larger amount of drugs enter the blood circulation than that intended to enter within a specific time.[19] These drug absorption changes may increase the risks of adverse effects and loss of clinical efficacy later.[7] Interestingly, most of the respondents knew that extended-release formulations consist of layers or micrograins with progressive dissolution time and should not be crushed or split; similar findings were also observed in a previous study.[4] Moreover, the controlled-release Nifedipine XL crushing may result in patient death due to hypotension and prevention compensatory increase in heart rate.[19] Here, we found that 57.2% of respondents said that it should not be crushed because it is an extended-release formulation. Likewise, splitting or crushing of controlled-release Tegretol CR® Divitabs will affect the absorption characteristics and result in severe clinical consequences such as therapeutic failure or toxicity due to carbamazepine's narrow therapeutic index. Interestingly, more than half of the participants do not agree with the splitting or crushing the Tegretol CR® Divitabs.[20],[21]

Enteric coatings on tablets are designed to allow the drug to bypass the stomach and dissolve in the small intestine's alkaline pH.[22] Therefore, enteric coatings help to prevent drug inactivation by the stomach contents, prevent stomach irritation, or delay the onset of action to a specific site within the gastrointestinal tract.[23] However, crushing enteric-coated tablets may result in loss of activity, irritation of the stomach, or early release of the drug.[6],[7] In the current study, 53.1% of respondents knew that Voltarin® 25 mg tablets should not be crushed or split because it is enteric coated. Furthermore, 61.2% of them know that crushing omeprazole enteric-coated granules will result in the drug's inactivation. These results are in line with a previous study.[4] Crushing of omeprazole has previously been reported to cause loss of efficacy due to the destruction of the protective enteric-coating layer.[24]

Furthermore, a sugar coat may sometimes be added to oral solid dosage forms to increase the active ingredient's stability or mask the drug's bitter taste and increase patient compliance.[7] Therefore, crushing of such a coated tablet may result in a bitter taste as in quinine, or expose light-sensitive drugs to light, such as nifedipine.[7] As a result of this, only 32.9% of participants knew that nifedipine is highly light sensitive and 71.1% of participants knew that quinine tablets have a bitter taste and therefore should not be crushed. Crushing or splitting of the coating may also lead to inhalation risk through increased powder aerosolization of many drugs, including antineoplastics, hormones, and corticosteroids.[7],[25] Since these drugs are mainly dispensed in hospitals, only 23.1% of community pharmacists correctly responded to this question, which was lower than those of the Palestinian study.[4] However, 69.4% of them knew that crushing or splitting might also cause altered pharmacokinetics and bioavailability, particularly for narrow therapeutic index medications such as phenytoin.[7]

On the other hand, the splitting of tablets can be practiced to obtain the prescribed dose when a specific dose is not available to facilitate administration for patients with swallowing difficulties and as a way of saving money by splitting tablets with higher concentrations.[26] In the current study, 64.6% of pharmacists do not encourage tablet splitting to help patients to save money and 43.5% of them said that they sometimes advise patients to split tablets to reach the desired dose. This may be because pharmacists give more importance to the consequences of tablet splitting over patients' economic constraints or seeking their own pharmacy's profit.

Furthermore, most of our study sample declared that they have never advised a patient to split or crush enteric-coated or sustained-release tablets, which is comparable to what was found in the previous study.[4] Moreover, 55.8% said that they would use alternative formulations for patients who could not swallow the prescribed one, whether sustained-release or nonsustained-release and noncoated tablets, while 27.2% would refer the patient to his/her doctor irrespective of the case type. These outcomes are contrary to that of Nguyen et al. in Australia, who found that most of the pharmacists would consult reference texts or refer patients to his/her doctor while less than 10% will use alternative formulations.[14] This difference may be attributed to the fact that in Sudan, communication between pharmacists and doctors may have more complexities than in Australia.

Cardiovascular, analgesic, and CNS drugs were the majority of medications dispensed by community pharmacists of Omdurman locality to be split before administration.[27],[28] This is due to the fact that cardiovascular and CNS dugs require precise dosing that is not easily available in the market. Paracetamol 500 mg tablet was the common tablet dispensed by respondents to be split before administration. This may be because there is a general perception that it is safe for the public. Hence, community pharmacists heavily dispense it as an over-the-counter treatment for headache, fever, and pain. It is also affordable and widely available in Sudan.[27]

This study's limitation is the cross-sectional design of the study, which does not allow the generalization of the findings to all community pharmacists in Sudan. Therefore, more studies are required to include a large number of community pharmacists in various areas in Sudan. Despite this limitation, this is the first such study in Sudan to evaluate community pharmacists' knowledge and practice toward dosage modifications such as splitting and crushing.

  Conclusion Top

The study showed variable knowledge levels among community pharmacists where approximately half of them have a good attitude about the study subject. Experience, age, and training have a positive effect on the knowledge and attitude of participants. The majority of respondents do not encourage tablet splitting to save money and do not advise patients to split or crush enteric-coated or sustained-release tablets. Cardiovascular, analgesic, and CNS drugs were the most commonly split medication.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Review Board / Ethics Committee review, and hence prior approval was obtained (FPEC-05-2017) We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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