Introduction 

Information retrieval, evaluation, and application skills represent a significant component of the core skill set all pharmacists must possess [1]. Drug information on pharmaceutical products has become increasingly easy to obtain through the Internet. However, the accuracy of the information is questionable. Taking this into consideration, pharmacists must be able to provide accurate drug information to patients and medical staff. That is, pharmacists must possess drug information literacy (DIL)—defined as appropriate understanding, interpretation, analysis, and restatement/expression of drug information. As pharmaceutical products and standard pharmacotherapies are continuously updated, it is increasingly important that pharmacists be able to correctly examine and interpret drug information to accurately administer appropriate pharmacotherapies to patients and other medical staff.

We previously elucidated that Japanese pharmacists are less likely than American pharmacists to make a habit of critically reading clinical trial literature [2]. One of the reasons is that Japanese pharmacists did not learn how to critically examine clinical trial literature when they were students. The Drug Information committee of the Japan Pharmaceutical Association also reported that Japanese pharmacists need to improve their DIL for the evaluation of pharmacotherapies [3].

Recently, e-learning programs have been globally utilized online [4-6]. Here, e-learning is defined as learning conducted through an Internet process [7]. A review article reported that e-learning in pharmacy education effectively increases knowledge and is a highly acceptable instructional format for pharmacists and pharmacy students. However, there is limited evidence that e-learning effectively improves skills or professional practice. Moreover, there is no evidence of long-term learning outcomes [8]. In this study, therefore, we seek to examine behavioral changes—specifically, the transfer of learning to the workplace—brought about through a DIL-focused e-learning program. Attitudinal change as a result of e-learning is one of the best strategies to create this transfer to the workplace [9, 10]. Therefore, we created an e-learning program to train pharmacy students in DIL. The program targeted P5 students (fifth year) before they began their practical pharmacy experience training (PPE). The e-learning program we created allowed students to learn at home in their free time. We then evaluated the program’s educational outcomes in terms of attitudinal changes among the students.

Materials and Methods

This study targeted P5 students (fifth year) who had prepared for their PPE. In Japan, pharmacists receive six years of training, and students received five months of practical clinical training in their fifth year. The e-learning program in this study was conducted from January 23 to February 25, 2019. It took place before the students began their PPE. The program was not required for P5 students.        

E-learning content

The e-learning platform used in this study was a cloud-based e-learning system called “ManaBeat” (SSTT Co. Ltd., https://satt.jp). Table 1 shows the content of the program. Topic videos and report assignments were uploaded on the platform. Students were required to finish a content component before the next became available on the platform. Content units 1 and 2 included videos on understanding evidence hierarchy and using the web and Google Scholar to search for therapeutic guidelines. Students were then asked to apply these skills in content unit 3. Faculty members added comments and corrections to students’ report files and gave feedback to them online. After that, students watched a final video regarding using the web for medical terminology and Google Translation in unit 4. Finally, in unit 5, they were asked to apply skills based on content units 1, 2, and 4.

Topic videos and report assignments were uploaded on the platform “ManaBeat.” Students were required to finish a content unit before the next became available.

Outcomes

The primary outcome of the study was whether the e-learning program actively enhanced the P5 students’ DIL. The outcome was evaluated using questionnaires regarding DIL before and after the e-learning program. Figure 1 shows the questionnaire schedule. The questions were as follows: “Q1. Do you understand the meaning of DIL?,” “Q2. How important do you think drug information is in your practical training?,” “Q3. Do you find the primary source of drug information useful if you come across something you don't know about medications or pharmacotherapies in your practical training?,” “Q4. Would you like to find and respond to primary literature if you come across something you don't know about medications or pharmacotherapies in your practical training?,” and “Q5. Can you reasonably answer questions about medications from physicians and nurses in your practical training?” Each question was answered on a Likert scale from 1 to 4.

A secondary outcome was how P5 students who took the program utilized their DIL skills during their PPE. A second survey was performed after they finished their PPE. The survey included the following questions: “Q1. Did you utilize your skills during the practical training period?” and “Q2. Which practice training did you utilize your skills, community pharmacies or hospital?”

Statistics

The sample size for the study was calculated with G*Power software, version 3.1. The calculation was carried out by assuming the use of matched-pairs Wilcoxon signed-rank test (2-tails, effect size = 0.5, alpha = 0.05, 80% power). G*Power suggested we would need 35 participants.

Categorical data were analyzed with the Chi-square test and Fisher’s exact test. The Wilcoxon signed-rank test was carried out to compare data between students who responded to the pre-and post-questionnaires for the primary outcome. P values of less than 0.05 were statistically significant. All statistical analyses were performed with EZR (“Easy R”) (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for the programming language, R (The R Foundation for Statistical Computing). More precisely, it is a modified version of R commander, designed to add statistical functions that are frequently used in biostatistics [11].

Ethical considerations

This study was approved by the ethics committee of Ohu University (No. 283). Written informed consent was obtained from those students who were willing to participate in this study. All methods were performed following the relevant guidelines and regulations.

Results and Discussion

Table 2 shows the demographic backgrounds of the participants. The total number of participating students was 21, of which 10 were female and 11 were male. Because 66 students were in P5, 31.8% of P5 students participated in the study. There were no significant differences in terms of GPAs and average score ratio on the Drug Information section on external exams, adjusted by a national average between female and male students (GPA; p = 0.662, external exam score ratios; p = 0.868).

GPA: Grade point average

Figure 2 shows the results of the questionnaires for the primary outcome. There were significant differences between the pre-and post-learning questionnaires regarding Q1 (p = 0.008) and Q5. (p = 0.031). In contrast, there were no significant differences regarding Q2 (p = 0.371), Q3 (p = 0.572), and Q4 (p = 0.129).

Figure 3 shows the results of the questionnaires for the secondary outcome. Seven of the 13 students (54%) who responded used the DIL skills they had acquired, and they applied the skills more often in hospital training than in community pharmacy training. Table 3 summarizes the free descriptions given by students who took part in the program.

This study aimed to elucidate whether the e-learning program actively enhances DIL among P5 students. The program significantly enhanced pharmacy students’ understanding of DIL, and they became more confident in terms of answering questions from physicians or nurses. Seven of the 13 students (54%) who responded to the post-PPE questionnaire (secondary outcome) said that they utilized DIL in their PPE sites. Therefore, the e-learning program to foster DIL was successful. Nonetheless, Table 3 shows the reasons why some students did not use DIL. For the most part, the students stated that they did not encounter an opportunity to use DIL at their PPE sites. We would evaluate these reasons as doubtful because pharmacy students do not have enough knowledge regarding a variety of pharmacotherapies most of the time. Otherwise, as the Drug Information committee in the Japan Pharmaceutical Association reported previously [3], Japanese pharmacists need to improve their DIL to be able to evaluate pharmacotherapies, which suggests some preceptors might not ask students to search for evidence using DIL.