Effect of Coaching Program on Mothers’ Awareness regarding Administration of Over the Counter Drugs to their Children

: Over -The- counter (OTC) medicines can be described as “drugs that used without medical advice”, it was reported that 25% of parents in the world tend to use medication without medical consultation. So, the aim of this study was to determine the effect of a coaching program on mothers’ knowledge, attitudes, and reported practice about administration of over-the-counter drugs to their children. Subject and method: Study design : A quasi-experimental design was utilized in this study. Setting: The study was conducted at Alshamla pediatric outpatient clinic of Tanta Main University Hospital. Subjects : Convenience sample of 116 Mothers were included in the current study. Tool of the study: Tool (1): Assessment of Over the counter drugs questionnaire: it include; Part 1 : Socio-demographic characteristics; and Part 2 : Assessment of the mothers’ knowledge, Tool (2): Mothers' reported practice of over the counter medication administration and Tool (3): Mothers' attitudes regarding over the counter medication administration. Results:- it was Points out that there were highly statistically significance improvements in mothers' knowledge, attitude and reported practices immediately post and at follow-up phases of a coaching program implementation Conclusion : Coaching program application improved mothers’ awareness about over-the-counter drugs medications administration for young children with a statistically significant between pre & post implementation of coaching program Recommendations : Continuous in-service educational programs should be conducted for the mothers in pediatric outpatient clinics about safe medication administration.


Introduction
In developing countries, children constitute a large percent of the population.Globally, drug utilization for children has received a lot of attention.In the developed and developing countries different studies have been conducted in this issue , and have all shown various problems ranging from misuse, abuse of prescribed medications (Adraa H. 2020, Ahmed S. 2013).Most drugs in children are used outside the health settings or hospital with or without medical prescription.Self-medication is the initial response of the parent to many illnesses in their children(Al sayed M S 2012).Over the counter (OTC) medicines can be defined as "taking of herbs, medicine, or home remedies on one's initiative, or advice of another one, without consultation".It was evident that twenty five percent of children in the world tend to use medication without medical prescription (Alazab R. 2012& Andritsou F. 2017).Inappropriate use of medications or over-used globally become phenomenon consider as important health issue (Basheir A 2016).Over the counter medication behaviors' used for children mainly by their parents following minor symptoms ( Basheir A.2014).
Over-the -counter medicines may be used by parent for many complaints.Fever is among the chief complaints of all pediatric consultations in general practice (Changa J, 2018).A study by (Crocitti, et al. 2001) indicated that parents still have a problem to resolve the fever in children.Some parents believe that fever is one of the diseases which may occur among their children, rather than to be a sign or symptom of ailment (Gohar U., 2017).In many countries, the antipyretic drugs and other OTC drugs are commonly used among parents to treat their children (Hassan A , 2018).Using OTC drugs among parents may be affected by their attitudes towards illnesses.
The chief complaints of children including; fever, flu, diarrhea, headache and sore throat can be treated at home.Some minor complaints can be relieved with OTC medications such as paracetamol or with some other traditional or herbal medicines, without seeking for physician consultation.When a child complains, the parents' concerns are often influenced by their knowledge of the diseases and treatment.Parents may get knowledge through social media, family belief friends and via other sources, which affect their responses toward the complaints.
Various literatures mentioned medication was over used globally and this phenomenon was considered important health issue (Hockenberg M. 2016).Overthe -counter medicines behaviors' used for adults and children mainly by their parents, especially antibiotics (Huang W. 2015).Many research confirmed the significant contribution of mothers in particular into the education about medicines and the use of medicine in children, compared to fathers and that mothers are the family members responsible for looking after other family members, mainly children.(Huang W. 2015).
Society knowledge and attitudes toward OTC is needed to be focus and broad to increase the awareness about OTC drugs, antibiotic reaction, adverse outcomes, and be judicious consumers Part 2: Assessment of mothers' knowledge, and the pattern of over counter drugs practice.It was adapted from Adraa H. 2020, Hassan A. 2018 featured 20 questions used to examine the type of medications given to treat the children, most frequent medicines used and the most favorite sources of health information, indication for using OTC, causes, the harming of using OTC to children, how to give OTC dose, mothers' knowledge about drugs tolerance and antibiotics resistance, and mothers responses in failure of over the counter drugs with their children.

Scoring system
According to the answers provided by the mothers' a scoring system was used, with ) 1) Awarded for each correct answer and (0) for each incorrect answer.A 20 grades make up the questionnaire's total score.The overall of mothers' knowledge will be categorized into the following categories based on the sum of their scores, divided by the total, and converted to percentages:  High level 75% ≤ 100%  Moderate level 50% < 75%  Low level <50% Tool (2): Mothers' reported practice of over the counter medication administration: It was developed by Adraa H. 2020, Hassan A. 2018 to evaluate Mothers' reported practice regarding using of OTC.It is formed from 35 questions used to examine the right medication, right time, right dose, and care before and after oral medications administration, antibiotic administration, and practice concerning antipyretics, cough and cold medications administration.Scoring system: A scoring system was developed based on the feedback provided by the mothers, with each question that was right and completed receiving a score of (1) and each question that was not right and incomplete receiving a score of (0), for a total practices score of 35 grades.The total reported practices by the parents was then added together and converted to a percentage, and was afterwards divided into: -Satisfactory practice ≥ 60% -Unsatisfactory practice < 60% Tool (3): Mothers' attitudes regarding over the counter medication administration using of OTC scale: It was developed by Adraa H. 2020, Hassan A. 2018 to evaluate attitudes towards using of OTC.Five-point Likert scales ranging from strongly agree to strongly disagree used to determine the attitude and the reasons of using over counter drugs.mother`s attitude concerning OTC usage which included 13 items including positive and negative attitudes regarding antibiotic use.The item scores were added up, and the amount was divided by the total number of things.These ratings were turned into percentages.Consequently the total parents' attitude was categorized into: -Positive attitude 50 % ≤ 100% -Negative attitude < 50% Operational Design Three phases made up the operational design for this study, namely preparatory phase, pilot study, and fieldwork.Preparatory Phase During this stage, literature on mothers' awareness regarding using OTC was reviewed.As a result, the data gathering tools for the study were developed The interview with the illiterate mothers takes longer because they require more explanation of tool items.According to the research tools, the mothers were asked to provide their comments.It took roughly 45 minutes to collect information from each mother.The interviewing questionnaire took an average of 15 minutes to complete, the attitude scale evaluation took 10 minutes, and the mothers'reported checklists took 20 minutes.The researchers visited the aforementioned locations three days a week (Saturdays, Mondays, and Wednesdays) from 9.00 a.m. to 2.00 p.m.

Coaching program phases
This program was carried out on five consecutive phases, assessing, developing, implementing, follow-up and evaluation Phase I: An assessment of the pre-coaching program was performed.In order to determine the needs of mothers, this phase assessing their knowledge, attitude and reported practices of mothers about overcontour medication.Phase II: Based on existent Mothers' need assessment about knowledge, attitude and practices regarding uses of OTC, a coaching program was created.The theoretical content covered the following items: type of medications given to treat the children, most frequent medicines used and the most favorite sources of health information, indication for using OTC, causes, the harming of using OTC to children, how to give OTC dose, mothers' knowledge about drugs tolerance and antibiotics resistance, and mothers' responses in failure of over the counter drugs with their children.

Phase III: Implementation of the program :
Implementation of the coaching program was carried out at the previously mentioned settings.At the beginning of the first session, an orientation of the coaching program and its purpose was presented.Mothers were divided into groups, and each group consisted of 8-10 mothers approximately.Each session started with a summary about what had been given through the previous sessions and the objectives of the new topic, taking into consideration the use of simple language to suit the level of mothers' education.As well, the session ended by a summary of its content and a feedback gained from mothers.The coaching program was delivered over the course of five sessions, with each session lasting between 30 and 45 minutes depending on the requirements of the mothers and the dynamics of the group.The theoretical component of the coaching program was provided over the course of three lectures and conversations / discussions, and was then followed by the practical component, which was shown over the course of two sessions using role playing, a simulator actual objects, discussions, and brainstorming.Power point presentations and posters were two efficient information-delivery tools employed by the researchers.After the coaching program was implemented, mothers were given a handout as a reference.Phase IV and V: Evaluation phases: The evaluation phases was done immediately post implementation of the coaching program and at follow up one month later by comparing changes in parents' knowledge, attitudes and practices regarding coaching program for using OTC.

Administrative Design
The directors of the Pediatric Outpatient Clinics in the Alshamla Clinics of Tanta Main University Hospital received approval through a letter issued by the dean of the nursing faculty at Tanta University.The researchers then met with the directors to discuss the goals and procedures for gathering the data.

Ethical Consideration
Before beginning the investigation, the Faculty of Nursing scientific Research Ethical Committee approval was taken Code No.-----Before include the mothers in the study, their consent was obtained; a concise explanation was given based on their knowledge level and level of physical and mental preparation.They made sure that all collected data was private and solely used for research.The mothers were advised that they could opt to participate in the study or not, and that they have the right to leave the study at anytime.

Statistical Analysis
The collected data was analyzed by using SPSS (version 22), then analyzed descriptively and Chi-square test was used for categorical variables' associations, Logistic regression used for studying relationships between variables, at P. value ≤ 0.05.The correlation between variables was examined using the correlation coefficiency method.

Results
Table 1 presents socio-demographic characteristics of the study sample.It was found that, the age of more than half (54.35%) of the mothers is more than 30 years.Also more than half (52.6%) of them were college graduated.As regards, 73.3% were married.In relation to family income about 51.7% were moderate income.More than half (54.3%) were have from 1-3 children.37.9 were working at the health field.Table 2 presents that the most common diseases for which mothers used OTC drugs were Fever, cough, , flu, diarrhea, itching, and vomiting, colic with percent 80.1%, 57.7%, 51.7%, 25.8%, 19.8%, 19.8%, and 35.3% respectively.The table also indicates The most common drug used without prescription self-medication were Antibiotics, antipyretics, cough syrup, antidiarrheal, vitamins, aspirin, traditional drugs, and others with percent 94.8%, 64.6%,62.9%,59.4%,35.3%,22.4%,18.9% 12.9%, and respectively.Figure 1 reflects the sources of mothers ' information, as pharmacist constitute 33.6% followed by relatives 32.8% then internet 13.8%.Table 3 portrays that, there are highly statistically significance improvements in mothers' knowledge immediately-post and at follow-up phases of coaching program implementation as regards all knowledge items about using of OTC drugs.Figure 2 indicates the total knowledge score of the studied mothers.It was clear that the majority of mothers (75%) had low level of knowledge before the implementation of the coaching program, which improved to good in 90% immediately post and 85% at the following-up phase of the coaching program implementation.

Table (4):
points out that there are highly statistically significance improvements in mothers reported practices immediately post and at follow-up phases of a coaching program implementation as regards all practices items.Figure (3) illustrates the studied mothers' total reported practices score.It was evident that, most of the studied mothers (90%) had unsatisfactory level before the coaching program implementation, which improved for most of them (90%) to have satisfactory practices immediately post coaching program.Table 5 reveals that, there is an improvement in mothers' total attitude immediately after, and at follow up phase of coaching program.Additionally, this data demonstrates a change in mothers overall attitude both immediately following and at follow-up following the execution of the coaching program, with a highly statistically significant difference (P < 0.001).Table 6 shows a significant association between mothers' attitudes about OTC to their children and mothers' sociodemographic data.

Discussion
Child safety is the highest priority for healthcare professionals and caregivers.Errors in medication usage rank among the most common threats to child safety.In addition to the burden of medical costs, medication errors cause appreciable morbidity and mortality in children.The misuses of medications are a significant global concern in the pediatric population because young children, who usually have their medication administered by their parents (Silva B .P. 2017).
This study aimed to determine the effect of a coaching program on mothers' knowledge, attitudes, and practice about administration of over the counter drugs to their children.Regarding mothers' information about over the counter drugs were pharmacist followed by relatives then internet, and the least sources were social media, friends, and doctors.This result in agreement with Adraa H. Shawq ( 2020) who studied attitudes of mothers towards OTC antibiotics for their children in Baghdad city and found that the highest percent of mothers' information were pharmacist.This result may be related to lack of mass media in medical and nursing fields so; there are lack of awareness about OTC drugs and its harm in the country.
In Cyprus a similar result were documented that most of mothers depend on the pharmacist as source of drug administration.(Rouusounides A 2011).This result in disagreement with (Mansour S and Mohamed M) who found that majority of parents (86.7%) depend on the physician as a source of medication consultation (Soleimani G.2016) As regards mothers' knowledge about OTC drugs, the current study portrayed that the majority of mothers had low level of knowledge before the program.This might be due to the mothers' lack of knowledge about the nature of the issue, the media's inadequate portrayal of the effects of OTC drugs, and the inadequate counseling programs at pediatric outpatient clinic.There are highly statistically significant improvements in the mothers' knowledge immediately post and at follow-up phases of implementing coaching program as regards all knowledge items about OTC drugs.This could be attributed to the highly educated mothers had the ability to read pamphlets and understand the instruction from the health team regarding oral drugs administration.Moreover, younger age women had less than five children were interested in oral drug administration because they planned to have other children in the future.Also, they were new mothers concentrate more than old mothers and they less occupied with problems and life stressors.This result in line with Regarding mothers' total attitude, there is an improvement in mothers' total attitude.The majority of them had positive attitude towards not using OTC drugs at immediate post and follow up phases, while, at the preprogram phase, the majority behaved negatively.The result of the present study before coaching program is in agreement with Adraa H. Shawq (2020) who explained that regarding mothers` attitudes it was reported that the mean score reflects agreement of mothers about the acceptance practice of OTC antibiotics in Iraqi country, it was observed that many persons used this action, parent used medication for their sick child without physician consultation and their child get better.In Iraqi society generally, the behavior of OTC medicine was accepted and ongoing.A study in Jordan about parents self-medication reported that majority of them agreed that OTC medications were safe and effectively.Yu M 2014.The coaching program play a role in increasing individuals' awareness about using of OTC drugs and its adverse outcomes.

Conclusion:
Implementing coaching program for mothers' improved their knowledge regarding.
Mothers' reported practice of OTC was enhanced.Application of a coaching program had a positive effect of mothers' attitude.All of these improvement had significant improvement of mothers' awareness.coaching program improved the mothers' awareness regarding OTC medications administration for their young children and decreased drug misuse with a statistically significant difference between pre and posttest as regard their total score.

Recommendations
(Mansour S 2015, Mukattash, T.L 2014, Rashwan Z., 2014).Nurses can play a good role through mothers' education for proper use of OTC (Rinke L., 2014.Rouusounides A 2011).Identifying the reasons for these behaviors is helpful to correct some unhealthy practices among mothers Siddiqui S, 2014) The aim of this study was to determine the effect of a coaching program on mothers' knowledge, attitudes, and practice about administration of over the counter drugs to their children.Research hypothesis -Mothers' knowledge, are expected to be improved after receiving coaching PROGRAM -Mothers' reported practice are expected to be improved after receiving coaching program -Mothers' attitudes are expected to be improved after receiving coaching program Materials and Methods Study design: A quasi-experimental design was utilized in this study.Setting: The study was conducted at Alshamla Pediatric Outpatient Clinic at Tanta University.Subjects: A convenience sample of Mothers (116) at Tanta city was included in the study in pediatric outpatient clinic-Tanta Main University hospital.The fieldwork conducted over a period of 8 months from May 2022 to the end of December 2022.Tool of the study: Data was gathered using three tools before, immediately after, after one month the coaching program's implementation.Tool (1): Assessment Over the counter drugs questionnaire: It was created by researchers and written in straight forward Arabic.It is divided into the following parts: Part 1: Mothers' Socio-demographic characteristics; Such as age, marital status, educational level, economic status, and mothers' occupation.
Three experts in the field of pediatric nursing used test-retest reliability to verify the content validity and application of the material, The questionnaire Alpha Cronbach's reliability test equal 0.84 The checklist's Alpha Cronbach's reliability test equal 0.86.Pilot Study To assess the applicability of the developed tools and the clarity of the included questions, a pilot research was conducted on 10% of Mothers who attend the aforementioned settings.Fieldwork The actual fieldwork for this study took place over 8 months period, specifically from May 2022 to the end of December 2022.The researcher was available for the aforementioned setting shift two days per week.To acquire the essential information for the study, each mother underwent Individualized interview.
Figure (2): Percentage Distribution of mothers Total Knowledge about OTC drugs throughout the Coaching Program Phases (n= 116).
(Hassan A, et al., 2018) they assessed impact of an educational program for mothers about preventing oral medications misuse for children under five years, and they found that the majority of the mothers had a poor score of knowledge about practice before the program while most of them had a good score after the program.Tareq L.2018 In Egypt a study done by Basheir A. and Mohamed G. ( 2014) showed that over-the-counter (OTC) drugs in the form of cold medications and cough suppressants were found to be the cause of poisoning in minority of poisoned children.World Medical, A 2013 Also, Alazab R. (2012) study "the risk factors of acute poisoning among children at a poisoning unit of a university hospital in Egypt" indicated that analgesics and cough drugs were responsible for 2.7% and 1.4% of acute poisoning in children.You M., 2015.The present study results indicated that the most OTC drugs used by mothers were as follow; from the highest percent to the low percent for fever, cough, and common cold, and colic, diarrhea, itching, and vomiting.This result congruent with Hassan A, et al., (2018), they found that the majority of mothers gave antipyretics, cough & cold and antibiotics medications without a prescription.Yu M 2014.Concerning the studied mothers' total reported practices score, most of the studied mothers had unsatisfactory level of practice before the coaching program implementation, which improved to satisfactory practices immediately post and at follow up phases of coaching program implementation.In the same line, the study done by Hassan A, et al., (2018), they found that the majority of the mothers had a poor score of knowledge about practice before the program while most of them had a good score after the program.Hassan A, et al., (2018),

Table 2 :
Distribution of the mothers according to knowledge related to most common diseases and frequent medicines used by Mothers self-medication

The most common diseases and frequent medicines Study subject No= 116 No (%) The most common diseases
Figure 1: Mothers'

Table ( 3
): Percentage Distribution of the Studied Mothers According to their Knowledge about OTC drugs (n = 116).

Table ( 5
): Total Parents' Attitude toward Coaching Program about using of OTC drugs throughout Implementation Phases (n=116).