Exploring communication challenges with children and parents among pharmacists in Saudi Arabia ============================================================================================== * Mustafa A. Malki * Rahaf A. Alnemary * Sarah K. Alabbasi * Dania M. Almanea ## A cross-sectional study ## ABSTRACT **Objectives:** To identify trends and challenges in pharmacists’ communication with pediatric patients in Saudi Arabia. It also studies the potential factors affecting their overall performance. **Methods:** A cross-sectional survey of 170 pharmacists working in different healthcare settings in Saudi Arabia was carried out. A novel comprehensive 38-item survey questionnaire was utilized. The questionnaire comprised 2 main sections: demographic data and potential influencing factors and communication skills with children. The communication domain assessed the degree to which the pharmacist could communicate with a child in 7 main areas. Comparisons of communication performance were carried out by Chi-square tests, and associations with 24 factors were determined by logistic regression analyses. **Results:** Approximately 76% of pharmacists demonstrated unsatisfactory communication with children (*p*=8.47×10−10). Approximately 91% of pharmacists depended on speaking to parents rather than directly talking to children, even when present (*p*=7.791×10−26). In addition, although 88.23% of pharmacists expressed high confidence in their communication skills (*p*=9.899×10−24), their actual performance with children in different age groups showed that 63.52% performed poorly, while only 36.46% demonstrated good performance (*p*=4.2×10−4). Factors which might be associated with pharmacists’ performance were identified. **Conclusion:** Pharmacists in Saudi Arabia face significant challenges in communicating with pediatric patients. Targeted training is needed to improve communication skills, medication adherence, and children’s health outcomes. Keywords: * pharmacists * communication * pediatric patients * Saudi Arabia **E**ffective communication is a key to quality health care, ensuring proper understanding between the patient and the health care provider. It ensures making informed decisions related to treatments and outcomes. Communication helps build a patient’s trust, adherence to medical instructions, and overall satisfaction, which is important in enhancing health outcomes. Poor communication leads to misunderstandings, medication errors, and poor adherence, compromising safety and the effectiveness of care.1 Pharmacists are an important link in this communication network, providing a connection between the patient and health professionals. The role of pharmacists has continued to evolve from only medication dispensing to include medication counselling, ensuring appropriate drug use, and facilitating adherence. They can identify issues, educate a patient on their medication, and actively engage in discussions that spur patient-centred care. Studies show that effective communication between pharmacists and patients leads to improved adherence and better treatment outcomes, reinforcing their relationship.2 Communication becomes increasingly crucial in pediatric care, as a child’s cognitive development affects their understanding of health and medication information. Beardsley et al3 emphasize that pharmacists must tailor communication to a child’s cognitive level for better comprehension. However, studies show that pharmacists rarely communicate directly with children, often addressing parents instead.3 Additionally, many children do not visit pharmacies, limiting pharmacist-child interaction.4,5 This gap is concerning, as greater involvement could benefit children, particularly those with chronic conditions like asthma. Research on pediatric asthma management found that community pharmacists lack confidence in providing personalized care and communicating with children due to time constraints and inadequate training.6-8 Research on pharmacist-child communication is limited, with most studies carried out in community pharmacies in Western countries. There are particularly even fewer studies focusing on hospital visits and on Saudi Arabia, where cultural differences and health challenges can significantly impact interactions. Sin et al9 examined some factors that influence the provision of clinical paediatric services but did not outline how the attitude and communication practices of pharmacists relating to children influence these services. The lack of relevant literature therefore makes it imperative that the way pharmacists communicate with children be explored further, along with the barriers they encounter in communication. This study aims to address a significant gap in knowledge regarding pharmacists’ communication with children and their parents in Saudi Arabia. ## Methods The survey was carried out from November 2023 to June 2024, using both face-to-face and online methods to engage a broad population of pharmacists in Saudi Arabia. In-person distribution allowed pharmacists to complete the survey on-site in community pharmacies and hospitals, while the online method utilized social media platforms like WhatsApp, X, Telegram, and LinkedIn, allowing pharmacists to respond at their convenience. To boost response rates, regular follow-up communications were sent, and measures like IP tracking were implemented to prevent multiple submissions. The survey was also shared in pharmacist-focused social media groups to enhance data validity. The research team, being pharmacists by profession, had already undergone an intensive theoretical and practical course on communication skills, of which communication with children was also a part. This gave the research team a solid background to properly explain the survey and maintain a focus on the objectives of the study. The research was carried out according to ethical standards of, and was approved by, the biomedical research ethics committee, Umm Al-Qura University, Makkah, Saudi Arabia (approval no.: HAPO-02-K-012-2023-11-1862). Prior to survey participation, information on the study, including its objectives, voluntary nature, and confidentiality assurances, was recorded in the introduction of the electronic survey. Participants were required to read this information before proceeding with the survey, ensuring informed consent was obtained implicitly through their voluntary participation. All data were collected and handled anonymously and solely for research purposes. No personally identifiable information was gathered apart from basic demographic data, which was necessary for the analysis. Confidentiality was ensured through secure online platforms, encrypted data transmission, and access restricted to authorized research personnel. For an ideal presentation of the study, a consensus-based checklist for reporting of survey studies was followed for the entire manuscript.10 This is a cross-sectional survey-based study constructed based on the chapter on communication with children from the well-regarded reference “communication skills in pharmacy practice”.3 This foundational text provides a comprehensive framework for communication skills with children in pharmacy practice, ensuring the survey is grounded in expert knowledge and industry standards, enhancing the validity of its content. The survey consists of 2 main sections with a total of 38 questions. Section 1 focuses on demographics and potential influencing factors on communication, containing 22 questions in 5 main categories as shown in Table 1. The variables in this section are descriptive and were not re-classified, but height and weight variables were used to generate 2 other variables, namely, body mass index (BMI, using the formula BMI (kg/m2) = weight (kg) ÷ height2 (m)) and obesity class based on BMI (underweight of <18.5, normal of 18.5-24.9, overweight of 25-29.9, obesity class I of 30-34.9, obesity class II of 35-39.9, or obesity class III of 40 or more).11,12 This provides a total of 24 variables (Table 1). View this table: [Table 1](http://smj.org.sa/content/46/5/529/T1) Table 1 - Demographics and potential influencing factors gathered in the survey in 5 main categories. Section 2 assesses communication skills when interacting with children through 16 questions in 7 main categories, as shown in Table 2. The multiple answers per question (Appendix 1) were re-classified as “good” or “poor” based on pre-defined ideal answers presented in Table 2. In addition, another variable was produced which measures participant overall performance based on the overall percentage of good answers they provided. Good performers are those who correctly responded to more than half of the questions. View this table: [Table 2](http://smj.org.sa/content/46/5/529/T2) Table 2 - The measured communication skills in the survey in 7 categories along with the overall pharmacists’ performance. As a clarifying note for the study discussion, reference to a child’s parent can be understood to also include an adult guardian. The target population for this study consisted of pharmacists working in Saudi Arabia. This included those employed in community pharmacies, hospital pharmacies, and medical wards as clinical pharmacists. Exclusion criteria were pharmacists outside SA, those in pharmaceutical companies without direct patient interaction, and non-pharmacist participants. A convenience sampling method was used for this study. The main outcome of this study was the proportion of pharmacists in Saudi Arabia who had poor communication skills when communicating with children. The sample size was calculated using Cochran’s formula for sample size estimation for proportions: n0=Z2.p. (1-p)/e2 where n0 is the required sample size, Z is the Z-value corresponding to a 95% confidence level (1.96), p is the estimated proportion of pharmacists with poor communication skills (0.5), and e is the accepted margin of error (0.05). Using these parameters, the sample size was calculated with the online Cochran’s sample size calculator. The required minimum sample size was determined to be 384 pharmacists. Although this study has adopted the convenience sampling strategy, the dispersion of the questionnaire through different regions in Saudi Arabia and the use of different recruitment strategies (in-person and through social media) were carried out with the intention of diversifying these samples. Participants are therefore representative of a wide cross-section of pharmacists in Saudi Arabia, from all types of pharmacy, and with diverse experience levels. However, this sample may not be generalized across all pharmacists in the country. Generalization beyond this sample should therefore be carried out with caution. ### Statistical analysis Data analysis was carried out using the R programming language (v4.4.1, 2024-06-14), a recognised tool for statistical analysis. Descriptive statistics were computed to summarise participant demographic data, including frequencies and percentages of categorical data, and means and standard deviations for continuous variables. Regarding the primary outcome, which was to determine the proportion of pharmacists who possess poor communication skills when relating to children, 2 statistical analyses were used. First, descriptive analysis calculated frequencies and percentages to show the distribution of pharmacists with good and poor communication skills based on survey responses. Second, an exploratory Chi-squared test was applied to determine whether there was a statistically significant difference between the observed proportions of responses for each communication scenario among pharmacists, compared to expected equal proportions (50-50%). While a binomial test confirmed the Chi-squared findings, we chose to report the Chi-squared results for their efficiency and widespread acceptance in categorical data analysis. Results were categorized into the following 3 main groups: I) poor communication skills, reflecting a statistically significant difference (*p*<0.05) between good and poor answers, most answers being poor. These are the pharmacists that require more effort to improve; II) medium level skills, needing further improvement, but for which no statistically significant difference between good and poor answers is observed (*p*>0.05, in other words, those for whom the number of positive and negative responses is roughly equal). Some effort to improve such skills is recommended with the aim of achieving a minimum accepted percentage of 80% good performers; and III) skills which can be regarded as good, showing a statistically significant difference (*p*<0.05) between good and poor responses, most responses being good. Pharmacists in this category do not need to make further efforts to improve. For the secondary outcome, which was to identify possible associations between any of the 24 explanatory variables and overall pharmacist performance in interacting with children, a binary logistic regression model was used to assess factors associated with poor communication skills, presenting results as odds ratios (ORs) with *p*-values. To account for multiple comparisons, the Bonferroni adjustment set significance at *p*<0.002. This conservative method helps control type I errors and ensures rigorous control of false-positive results when testing multiple explanatory variables. ## Results A total of 190 survey responses were received. Nine participants were excluded for not being pharmacists. Of the remaining 181 pharmacists, 12 were also excluded: 8 worked in pharmaceutical companies with no child interaction, and 3 were not practicing in Saudi Arabia. Ultimately, a final sample of 170 responses was analysed (Figure 1). Key findings are described below (Appendix 2). ![Figure 1](http://smj.org.sa/https://smj.org.sa/content/smj/46/5/529/F1.medium.gif) [Figure 1](http://smj.org.sa/content/46/5/529/F1) Figure 1 - Flowchart of study participant selection. Among the 170 pharmacists, 56.47% were male, and 55.29% were aged 20-29 years. Most were Saudi nationals (88.24%), residing mainly in Makkah (33.53%), Riyadh (20.59%), and Jeddah (13.53%). In terms of marital status, 55.88% were single, and 42.35% were married. Most pharmacists worked in hospital pharmacies (55.88%), followed by community pharmacies (26.47%), and clinical pharmacy roles in medical wards (17.65%). Common workplaces included Al-Nahdi Pharmacy (12.94%) and major hospitals like King Abdulaziz Medical City. Most participants held a bachelor’s degree (75.88%), with 28.82% having 2-4 years of experience, while 18.24% had over 10 years. In terms of BMI, 46.71% of pharmacists had a normal BMI, while 34.73% were overweight. Most rated their appearance as excellent (58.82%) or good (31.76%). Approximately 67.65% felt encouraged to be independent during upbringing, while 24.12% experienced overprotective parenting. Additionally, 51.18% reported being generally happy and satisfied. Only 12.35% studied child-specific communication skills, while 39.41% took general pharmacy communication courses. Despite this, 36.47% felt confident communicating with children. Notably, 62.94% received no rewards for good communication, and 56.47% felt overloaded at work. Additionally, 51.18% believed they performed better in the morning shifts. Most pharmacists (59.41%) did not have children, and nearly half (48.24%) reported a moderate monthly income of 7,000-14,000 SAR, while 33.53% reported higher incomes between 15,000-19,000 SAR. Pharmacists’ communication performance across different scenarios was assessed using Chi-square and Binomial tests, yielding similar results (Appendix 2). Table 3 presents a summary, with key findings outlined below. For further clarification, there are 2 types of ‘overall performance’ measures used: one summarizing the overall performance in a specific skill (applied to 3 skills - ability to communicate effectively with different age groups, effective conversation initiation, and respecting privacy) and another summarizing the overall performance of pharmacists across all communication scenarios tested in the survey. View this table: [Table 3](http://smj.org.sa/content/46/5/529/T3) Table 3 - Poor, moderate, and good communication skills with children among pharmacists in Saudi Arabia along with the Chi-squared test *p*-values. If a child was present with a parent, only 8.82% of pharmacists reported communicating primarily with the child and 91.17% with the parent (*p*=7.79×10-26). If the child was absent, only 30.58% of pharmacists reported asking the parent to involve the child. Approximately 69.41% of pharmacists reported communicating with the parent alone (*p*=9.36×10-7). Pharmacists expressed high confidence in their communication abilities, with 88.23% rating themselves as good (*p*=9.90×10-24). However, performance in age-specific scenarios revealed significant gaps. For children aged 3-6, only 45.29% could explain the cause-effect relationship of medications appropriately (*p*=0.242), and 49.41% communicated dosage frequency effectively (*p=*0.815). In contrast, 64.11% of pharmacists were able to explain these concepts to 7-12-year-olds, while 35.88% gave suboptimal responses (*p*=2.5×10-4). For toddlers and preschool children (3-5 years), only 5.88% provided suitable drug information, while 94.11% failed to meet age-appropriate communication criteria (*p*=1.25×10-30). For school-age children (6-12 years), only 6.47% of pharmacists gave appropriate responses (*p*=7.33×10-30). With adolescents (13-19 years), only 28.23% effectively explained brand versus generic medications (*p*<1.32×10-8), and 55.88% guided device use like inhalers (*p*=0.139). Overall, 63.52% of pharmacists performed poorly across all communication skills related to these age groups (*p*=4.2×10-4). Pharmacists’ ability to initiate conversations with children was evaluated, revealing that only 47.64% used effective techniques (*p*=0.585). For shy children, 45.88% utilized appropriate conversation strategies (*p*=0.311). Overall, 46.76% of pharmacists initiated conversations effectively, while 53.23% did not (*p*=0.4002). In discussing drug-drug and drug-food interactions with adolescents, 88.23% of pharmacists reported explaining these interactions regularly, while 11.76% did not (*p*=2.02×10-24). Pharmacists asked for time alone with children in 52.35% of cases (*p*=0.483). Regarding adherence to adolescents’ requests not to disclose sensitive information to parents, only 47.05% of pharmacists respected these requests (*p*=0.585). The combined results in this category indicated that approximately 50% of pharmacists respected children’s privacy, while 50% did not (*p*=0.939). Strategies such as visual aids were used by 62.35% of pharmacists, while 37.64% did not incorporate engagement techniques (*p*=8.1×10-4). Only 24.11% of pharmacists were classified as good performers, whereas 75.88% performed poorly across all evaluated scenarios (*p*=8.48×10-10). A binary logistic regression model assessed 24 potential factors influencing pharmacist performance. After Bonferroni correction (*p*<0.002), no variable showed a statistically significant association. However, 8 factors were nominally significant (*p*<0.05): city, age, obesity, physical appearance, parenting style, studying communication skills with children, confidence, and working hours. Pharmacists in Jeddah, Saudi Arabia, were 2.6 times less likely to perform poorly than those in Makkah (*p*=4.4×10-2). Pharmacists aged 40-49 (*p*=3.53×10-2) and those with obesity class III (*p*=4.67×10-2) were 5 times less likely to perform poorly than younger pharmacists and those with ideal body weight. Those rating their appearance as excellent were twice as likely to perform well as those rating themselves as good (*p*=4.34×10-2). Parenting style also played a role; those who received discouraging statements were 3 times more likely to perform poorly (*p*=2.87×10-2). Those who took only general communication courses or none were 3-3.6 times more likely to perform poorly compared to those who studied child-specific communication (*p*=3.77×10-2 and *p*=4.72×10-2). Lastly, lower confidence and a preference for morning shifts, rather than being unaffected by working times, were also linked to poorer performance. Table 4 summarizes all the potentially important findings. View this table: [Table 4](http://smj.org.sa/content/46/5/529/T4) Table 4 - Explanatory variables with nominal significant associations with overall pharmacist performance when communicating with children. ## Discussion This study highlights some of the major communication challenges encountered by pharmacists in Saudi Arabia when communicating with children. A majority of participants (~76%) exhibited low overall communication performance in various scenarios with paediatric patients. Most importantly, only 9% of participant pharmacists in Saudi Arabia primarily addressed children during communication, less than that reported by Nilaward et al13 who found 20.2% of pharmacists to directly engage children. Not engaging children in communication limits the opportunity of a child to understand their medication, which is important for health literacy and ownership of personal health. The results also showed that, in the absence of the child, 69.41% of the pharmacists communicated exclusively with the parents while only 30.58% attempted to engage the child over the phone or another medium. This further restricts the child from being engaged in discussions regarding their medicines, reducing their interest and understanding of crucial information on treatment. This is a critical gap in communication by pharmacists, highlighting the need for approaches which, even in the absence of the child, engage them in discussions regarding their health. A critical result of the current study is the difference between self-reported confidence and actual communication performance. While 88.23% of the responding pharmacists reported confidence to communicate effectively with children in different age groups, the actual assessment showed significant gaps in their capability to explain essential medication-related concepts, most significantly to a younger child. These findings agree with those of Nilaward et al,13 which suggest that perceived and actual communication capabilities among pharmacists do not always agree. Furthermore, this study finds that it is difficult for pharmacists to provide information on drugs which is appropriate for the child’s age. Only 5.88% of the pharmacists provided appropriate information for toddlers and preschool children aged 3-5 years, while 94.11% provided unsatisfactory information. Also, for the school children aged 6-12 years, only 6.47% of the pharmacists gave appropriate responses. Indeed, these findings raise concern at every stage of a child’s development since children require information on medication adjusted to their cognitive ability, even if a parent is present during the consultation.14 A lack of adjustment to age may lead to a child failing to comprehend their ailment or treatment, especially in chronic diseases where early education is investment for long-run adherence and independence. Another communication shortfall identified in the survey was that only 28.23% of the responding pharmacists explained the differences between brand and generic medicines to adolescents. This knowledge is important to enable a patient to make sound decisions regarding their care, and an adolescent can be expected to start to take responsibility for their own health. Secondly, although 55.88% of the responding pharmacists demonstrated proper use of devices like inhalers, 44.11% failed to do so, revealing another gap for adolescents who suffer from chronic conditions such as asthma. Another important gap pertained to respect for the privacy of adolescents during consultations. Only 50% of the responding pharmacists always asked for time with adolescent patients alone or respected the request of the patient not to disclose sensitive information with others. The other half did not exercise these techniques, which might prevent effective communication between the pharmacist and the adolescent patient. Respecting patients’ privacy is a significant ingredient for trust and will be very important to an adolescent, particularly since it can affect compliance with treatment. Encouragingly, pharmacists were more positive in using methods to hold a child’s attention during consultation. The cumulative percentage of pharmacists who used methods like visual aids or interactive feedback for maintaining focus, an important component of effective communication, was 62.35%. However, such methods were not used by 37.64% of the pharmacists, leaving scope for improvement in the domain of making communication engaging and child-friendly. Pharmacists can build a trusting relationship by beginning a conversation with questions on their favourite movie or game. This can help both parties feel more comfortable and encourage the child’s interaction with someone they are not familiar with.15 The study also identified 8 variables nominally associated with communication performance, including city, age, obesity class, physical appearance, parenting style, prior education in communication skills, confidence, and working hours. Pharmacists in Jeddah, Saudi Arabia, performed better than those in Makkah, Saudi Arabia. This may be due to better training or infrastructure. Pharmacists aged 40-49 years performed better than younger ones, likely due to more experience in using different communication strategies. Surprisingly, pharmacists with obesity class III were less likely to perform poorly than those with an ideal BMI, a result that warrants further exploration. Confidence, both in communication skills and physical appearance, was positively associated with performance, reinforcing previous findings regarding the important role that confidence plays in effective communication.16 Pharmacists who reported hearing discouraging words from their parents performed worse, supporting other research that links overprotective parental behaviours to maladaptive outcomes in adolescents.17 Lastly, pharmacists who had studied communication skills specifically aimed at interactions with children performed better, indicating the importance of targeted training in developing effective communication skills. ### Study limitations The questionnaire, while developed based on established communication frameworks and reviewed by experts for content validity, was not piloted in a smaller sample before full implementation. Future studies may consider carrying out additional validation procedures to confirm its reliability. In addition, the use of the convenience sampling method limits the generalizability of the results. While the sample included pharmacists from different regions of Saudi Arabia, it may not fully capture the diversity of the broader pharmacist population with potential regional differences in healthcare infrastructure and training. Moreover, due to limited study period, only 170 pharmacists were recruited, despite extensive efforts to maximize participation, which is smaller than the calculated target sample size. However, this was sufficient for our primary outcome, which was exploratory in nature and aimed to identify trends in pharmacists’ communication behaviours with children. Although the smaller sample size may limit statistical power for secondary outcomes, the findings offer valuable exploratory insights. Future research with larger sample sizes is recommended to validate these associations and enhance statistical robustness. Special attention should be given to the development of tailored training programs that equip pharmacists with the skills needed to engage children effectively, provide age-appropriate information, and respect adolescents’ privacy. Assessing the impact of such interventions on health outcomes in paediatric populations will be critical in determining their efficacy. Additionally, understanding the cultural and contextual factors influencing pharmacist-child interactions in SA is essential for designing culturally appropriate communication strategies that align with local healthcare practices. In conclusion, this study reveals significant deficiencies in pharmacists’ communication with child patients in Saudi Arabia, with most interactions focused on parents rather than the paediatric patients themselves. Despite high self-reported confidence, actual communication performance, particularly in providing age-appropriate information, was lacking. Addressing these gaps through targeted training is essential for enhancing pharmacists’ ability to engage children effectively and to improve paediatric health outcomes. By fostering more inclusive, child-centred communication, pharmacists can play a crucial role in empowering young patients to take responsibility for their own health. ## Acknowledgment *The authors gratefully acknowledge all pharmacists who participated in this study and appreciate the support provided by their respective institutions. The authors also would like to thank Cambridge Proofreading & Editing LLC for the English language editing.* ## Appendix 1 - Survey questionnaire. **Section 1: Demographic data and potential influencing factors** **1. Where are you working?** ○ In a community pharmacy. ○ In a hospital pharmacy. ○ In medical wards as a clinical pharmacist. **2. What is the name of your workplace?** \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_ **3. Where do you live?** \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_ **4. Nationality:** ○ Saudi ○ Egyptian ○ Sudanese ○ Syrian ○ Other: \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_ **5. Gender:** ○ Male ○ Female **6. Age group:** ○ 20-29 ○ 30-39 ○ 40-49 ○ 50-59 ○ 60 or more **7. Weight: (kg)** \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_ **8. Height: (cm)** \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_ **9. How do you rate your general appearance?** ○ Excellent ○ Good ○ Fair ○ Poor ○ Bad **10. Marital status:** ○ Married ○ Single ○ Divorced ○ Widowed **11. How do you think you were raised by your parents?** ○ They frequently say: don’t do that, this could be harmful for you. We will do it for you. ○ They frequently say: you can do this, try and we will support you if you need. ○ They just don’t take care most of the time. They let you do whatever you want. **12. Economic status:** ○ Very high monthly income (20,000 SAR or more). ○ High monthly income (15,000-19,000 SAR). ○ Moderate monthly income (7000-14,000 SAR). ○ Poor monthly income (6000 SAR or less). **13. How do you evaluate your quality of life?** ○ Very happy and satisfied most of the time. ○ Happy and satisfied in general. ○ Moderate happiness and satisfaction. ○ Poor happiness and satisfaction. ○ I have been through chronic stress, and I have been treated or I think I need to be treated for some potential psychological illnesses. **14. Educational level:** ○ Bachelor’s degree ○ Master’s degree or PGY1 ○ PhD degree or PGY2 **15. Years of work experience:** ○ 0-1 years ○ 2-4 years ○ 5-10 years ○ More than 10 years **16. Did you study communication skills in pharmacy practice course?** ○ No ○ I studied general communication skills course which is not specifically directed to pharmacists. ○ Yes, but I did not study a topic on communications’ skills with children. ○ Yes, and I studied communication skills with children. **17.** In a pharmacy setting, how confident are you regarding your communication with children and or parents? ○ Not confident at all ○ Slightly confident ○ Somewhat confident ○ Fairly confident ○ Completely confident **18. Do you get a reward from your pharmacy manager regarding your good communication and patient satisfaction?** ○ Yes ○ No **19. Do you think that you are generally overloaded, so you do not have enough time to communicate with patients?** ○ Yes, most of the time ○ Sometimes ○ Not at all **20. Does the time of your shift (morning, afternoon, or night) affect your ability to communicate?** ○ Yes, I feel better in the morning. ○ Yes, I feel better in the afternoon. ○ Yes, I feel better at night. ○ Not at all **21. Do you feel you are losing the attention you give to patients as work hours pass?** ○ Yes ○ No **22. Do you have children of your own?** ○ Yes ○ No **Section 2: Communication skills’ questions** **1. If children (who are patients) accompany their parents to pharmacy to pick up drugs, to whom you communicate most of the time?** ○ Parents ○ Their children **2. Do you know that children in different ages and different cognitive developmental levels understand different aspects of medications and illness?** ○ No. I communicate the same with all children. ○ Yes, I know how to communicate with each different age or each different developmental level. **3. How would you communicate with a 3-6 years-old child about his medications?** ○ This drug will make you better because it will fight bacteria in your body. ○ This drug will make you better. Take it regularly. ○ I cannot see any difference; I would use any of the above statements. **4. If you want to explain to a 3-6 years-old child on the dosage frequency, what will you say?** ○ Take the drug three times daily. Your mom will help you to know when to stop the drug. ○ Take the drug every 8 hours daily. Your mom will help you to know when to stop the drug. ○ Take the drug every 8 hours daily. Work with your mom so you both know when to stop the drug. ○ Take the drug three times daily until the 2nd of November. ○ I cannot see any difference; I would use any of the above statements. **5. How would you communicate with a 7-12 years-old child on his medications?** ○ This drug will make you better because it will fight bacteria in your body. ○ This drug will make you better as it will improve your immune system via killing E.coli bacteria causing your illness. ○ I cannot see any difference; I would use any of the above statements. **6. When talking to a child in the pharmacy, how would you approach the conversation?** ○ Ask about his/her favorite game before talking about drugs. ○ Ask simple “yes” or “no” questions about his/her drugs before talking about drugs. ○ I would not approach the conversation; I will ask him/her to call his/her parent. **7. With toddlers and pre-school children (3-5 years), what information do you believe they will understand and need to know about their medicine?** ◻ Why they should take it. ◻ How to take it. ◻ Its therapeutic purpose. ◻ Side effects. ◻ Importance of complying with its regimen. ◻ The difference between medicines for children and medicines for adults. ◻ The child is too young for such information. **8. With school-age children (6-12 years), what information do you believe they will understand and need to know about their medicine?** ◻ Its ingredient. ◻ Its mechanism (how it works). ◻ Is it working? ◻ How they are made. ◻ Potential for interactions. ◻ Is it used for different illnesses? ◻ Are there other medicines for the same illness? ◻ Are there different medicines for different illnesses? ◻ Device demonstrations (namely, how to use inhalers). **9. How often did you tell an adolescent (13-19 years) about the potential of their drug interactions with other drugs or food?** ○ Always ○ Often ○ Sometimes ○ Rarely ○ Never **10. If adolescents, ask you not to tell their parents/guardians what they say or buy, usually you…** ○ Ignore their request. ○ Obey their request. ○ Ask them for a reason, then decide whether to ignore or obey. ○ Try to help them communicate with their parents/guardians. **11. Do you explain the difference between brand and generic medicine for children or adolescents?** ○ No, I do not think they should know. ○ I did not have the chance, but I will. ○ Yes, I believe they should know. ○ Only for adolescents. **12. You use device demonstrations (namely, show how to use inhalers) method with:** ○ Children (< 3 years). ○ Children (3-5 years). ○ Children (6-12 years). ○ Adolescent (13-19 years). ○ I do not use it. **13. If children did not accompany their parents/guardians to the pharmacy, what do you normally do? (please select what you do but not what you think to be true)** ○ Discuss medication with their parents/guardians only. ○ Ask the parent/guardians to have the child call the pharmacy. **14. If the child and or parent appear uninterested or distracted, what do you normally do? (please select what you do but not what you think to be true)** ○ Assume they know their medication. ○ Hurry in counseling even if they appear uninterested. ○ Ask them for feedback. ○ Use visual aids (e.g., iPads with medical educational games, colorfully written materials, or demonstrative devices). ○ Other: \_\_\_|\\_\_\_|\\_\_\_|\\_\_\_|\\__\_|\_ **15. How often do you ask parents to give you a few minutes alone with their child to ensure privacy and a quiet area to counsel?** ○ Always ○ Often ○ Sometimes ○ Rarely ○ Never **16. If the child were shy or embarrassed, what do you normally do? (please select what you do but not what you think to be true)** ○ Assume they prefer me to talk to their parents. ○ Just tell them the information they need to hear. ○ Initiate the conversation with icebreakers (e.g., ask them to talk to you about their favorite game or cartoon movie). **\---| Extra open questions (not for the purpose of evaluating performance)\---|--** **1. In general, what is the age group you find the hardest to communicate with?** a. Children (< 3 years). b. Children (3-5 years). c. Children (6-12 years). d. Adolescent (13-19 years). e. I do not have any difficulty. **2. From your work experience, what do you think is the most common barrier/s for communication with children?** ◻ Pharmacists are not aware about the importance of communication with children. ◻ Children are not usually accompanying their parents to pharmacies. ◻ The child being shy. **3. Please feel free if you want to share more about your experience (optional)** ## Appendix 2A - Detailed statistical results. View this table: [Table5](http://smj.org.sa/content/46/5/529/T5) View this table: [Appendix 2A](http://smj.org.sa/content/46/5/529/T6) Appendix 2A - Detailed statistical results (continuation). View this table: [Appendix 2A](http://smj.org.sa/content/46/5/529/T7) Appendix 2A - Detailed statistical results (continuation). View this table: [Appendix 2A](http://smj.org.sa/content/46/5/529/T8) Appendix 2A - Detailed statistical results (continuation). View this table: [Appendix 2B](http://smj.org.sa/content/46/5/529/T9) Appendix 2B - Characteristics of study participants and potential influencing factors (continuous variables). View this table: [Appendix 2C](http://smj.org.sa/content/46/5/529/T10) Appendix 2C - Percentages of “good” and “poor” answers to various communication skills questions along with the percentages of “good” and “poor” performers of pharmacists (categorical variables). View this table: [Appendix 2C](http://smj.org.sa/content/46/5/529/T11) Appendix 2C - Percentages of “good” and “poor” answers to various communication skills questions along with the percentages of “good” and “poor” performers of pharmacists (categorical variables, continuation). ![Figure 1](http://smj.org.sa/https://smj.org.sa/content/smj/46/5/529/F2.medium.gif) [Figure 1](http://smj.org.sa/content/46/5/529/F2) Figure 1 - Results from both Chi-squared and Binomial tests showing difference from a pre-defined expected proportion of 50% for each primary outcome variable. 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