Spontaneous Reporting of Adverse Drug Reaction Among Health Professionals In Kpone-Katamanso District, Ghana

Spontaneous Reporting of Adverse Drug Reaction Among Health Professionals In Kpone-Katamanso District, Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Spontaneous Reporting of Adverse Drug Reaction Among Health Professionals In Kpone-Katamanso District, Ghana Morrison Asiamah, Kwadwo Owusu Akuffo, Pricillia Nortey, Nina Donkor, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-433485/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background: Spontaneous reporting of adverse drug reactions (ADR) is an effective means of ensuring postmarketing surveillance of drugs, and health professionals play a cardinal role through voluntary reporting of ADR. However, the pharmacovigilance system in Ghana is plagued with under-reporting issues, which is of public health concern. Method: A questionnaire-based cross-sectional study involving 268 health professionals at Kpone-Katamanso District was carried out. Data on spontaneous reporting of ADR, demographics of participants, knowledge, and attitudes of professionals towards reporting and factors that may influence ADR reporting were collected. Logistic regression models were used to examine the association of the independent variables with spontaneous reporting of ADR. Result: Overall, 77.6% (208) of the 268 respondents had witnessed ADR; however, only 17.3% of the respondents have ever reported an ADR to the FDA. Health professionals who had adequate knowledge on spontaneous reporting of ADR were 51.9%, while 30.3% had very good knowledge of spontaneous reporting of ADR. After statistical adjustment, Age (AOR=2.26, 95%CI= 1.25–4.10), Fear of Legal Consequences (AOR=0.15, 95%CI=0.41–0.51), Time Constraint (AOR=0.3, 95%CI=0.10–0.91), Pharmacovigilance training (AOR= 18.78, 95%CI= 5.46–64.59) and Unavailability of Reporting form (AOR=0.28, 95%CI=0.09– 0.88) were found to be significantly associated spontaneous reporting of ADR. Conclusion: The proportion of health professionals in the Kpone-Katamanso District who spontaneously report observed ADR is low. Our findings underscore the need for the FDA to intensify awareness through media sensitization and engage all relevant stakeholders on the need for the entire population to report ADR. Environmental Policy Occupational Medicine Adverse drug reaction Reporting Health professionals Ghana Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Pharmaceutical drugs play a significant role in managing diseases in the healthcare sector. However, even when administered within their therapeutic dosing schedule, drugs can lead to unwanted effects, which may pose threats to the life of the patient [1]. These unwanted effects are referred to as adverse drug reactions (ADR) - undesirable effects that may occur as part of a drug's pharmacological action [2]. The economic and social impact of ADR is huge and cannot be overlooked [3]. ADR has been projected as one of the leading causes of morbidity and mortality across all age groups and hospital admissions [4, 5]. In order to reduce the incidence of ADR, the safety of drugs are ascertained through various phases of clinical trials prior to their approval on the market [6]. However, the safety reports from these clinical trials are collated from strictly controlled conditions which may be subject to bias due to strict inclusion and exclusion criteria and limited time. For example, the effects of these drugs are often not studied on some members of the population such as children under 5 years, pregnant women and very old people; thus, yielding outcomes that may not be perfectly generalizable to all who might use the drug [7]. Spontaneous reporting of ADR at the normal condition and setting is the cornerstone of pharmacovigilance [8]. It provides information from real-life clinical practice as opposed to that of clinical trials as subjects are not unnecessarily excluded and the safety of the drug is studied under a limited time [3, 9]. Spontaneous reporting is an inexpensive, flexible and very effective method of collecting information whereby health professionals voluntarily submit case reports of ADR; pharmaceutical companies or consumers to the national pharmacovigilance centres for evaluation in order to mitigate the impact of ADR on society [9]. For a pharmacovigilance system to effectively monitor ADR of both existing and newly introduced drugs, the World Health Organisation (WHO) recommends that the spontaneous reporting of adverse effects should be more than 200 reported cases per 1,000,000 population [10]. In 2019, the National Pharmacovigilance Center of Ghana recorded 2236 reported cases of adverse drug cases representing about 75 reported cases per 1,000,000 population of Ghanaians [10]. Though an improvement in reported cases from previous years, the reporting rates have constantly been below the WHO standard (Figure 1). Underreporting of ADR is a big challenge in pharmacovigilance, especially in countries that utilize the spontaneous or voluntary ADR reporting system such as Ghana [11, 12]. Though health professionals have enough knowledge and are aware of the need to report ADR, smaller proportions of health professionals spontaneously report ADR [13]. Health system factors that influence spontaneous reporting of ADR include health professionals knowledge, attitude and beliefs [14]. Socio-demographic characteristics of the reporting health professional such as their age, gender, qualification, years of practice, number of patients seen in a day, and marital status also influence spontaneous reporting of ADR [15]. Elsewhere, female health professionals were more likely to report ADR than their male counterparts [15, 16]. The health professional's age tends to affect reporting rate, which has been consistent across studies from different geographic locations with older and experienced professionals more likely to report an event [15, 17, 18]. Per WHO recommendations, Kpone-Katamanso district, with a huge population and several health facilities, should report a minimum of 22 cases of ADR a year. However, the number of ADR reported, and the factors influencing reporting are largely unknown. Several studies have identified attitudes such as complacency or doubt about the causal relationship of the event with the drug, procrastination and indifference to report, and apprehension about the legal consequences of reporting ADR as attitudes negatively affecting spontaneous reporting [19]. An assurance of confidentiality of the reporter's identity, legal protection and incentives for reporting have been identified to promote spontaneous reporting [20]. Additionally, indifference, diffidence, complacency, ignorance, lack of monetary incentives, and personal desire to publish cases have been suggested as predictors of low ADR reporting, to the extent that in some cases, less than 50% of health professionals showed a good attitude towards reporting ADR [21]. Also, the lack of knowledge on how to report an ADR and lack of access to reporting forms are major factors contributing to poor reporting rate [22]. The perennial issue of underreporting ADR in the pharmacovigilance system in Ghana and the consequential increase in mortality, hospitalization, congenital anomaly and economic burden as well as paucity of data influenced our decision to conduct this study in an attempt to identify context-specific factors influencing the rate of spontaneous ADR reporting among health professionals. It is anticipated that information obtained from this study would be useful to stakeholders in the formulation of policies and strategies to increase spontaneous reporting of ADR in the country. Methods Study design and location This study used a well-structured, pretested, closed-ended questionnaire to collect data from health professionals involved in ADR reporting in the Kpone-Katamanso District in Ghana. The District, made up of five sub-districts, is located along the coastal part of Tema in the Greater Accra region, not far from Accra (Figure 2). The sub-districts are Kpone (the district capital), Zenu, Gbetsile, Oyibi, and Appolonia. Kpone-Katamanso has a huge population of about 109,864 with several health facilities that are equitably distributed across the District [23]. Study population This study included 268 health professionals within the District, including pharmacists and pharmacy technicians, physicians and physician assistants, nurses, midwives, and disease control officers. These health professionals are directly involved in the diagnosing, dispensing and administration of drugs directly to the patients and are in the position to report any drug-related reactions of the patients. The medical doctors and physician assistants are responsible for the diagnoses and prescription of medications for treatment. The pharmacists and pharmacy technicians are responsible for the dispensing of drugs and provision of drug-related information to the patient. The nurses and midwives are responsible for the administration of prescribed drugs to the patient on the wards. The disease control officer is responsible for the immunization programs at the district level. Considering the responsibilities of these professionals in drug therapies, they receive complaints of and observe some ADR amongst the patients. Thus, they are required to voluntarily report ADR. Inclusion/exclusion criteria Health professionals who have practised for not less than a year, directly involved in the supervision, diagnosis, dispensing and administration of drugs to patients and are to detect ADR were eligible for inclusion in the study. Health professionals who declined participation were excluded. Healthcare service delivery in Ghana Healthcare service delivery in Ghana is based on the primary health care concept that seeks to promote practical and socially acceptable methods universally accessible to individuals and families in the communities through their full participation. The Ghana Health Service is organized in levels of care, with the lowest level being the Community–based Health Planning Services (CHPS). This is the first point of contact with the formal health care service and manned by community health nurses usually with two years of formal training who provide basic curative and immunization services to clients. Cases that cannot be handled at the CHPS compounds are referred to the health centre, but sometimes they are referred directly to the district hospital. The Health Centre, the next level of care delivery, is normally staffed with a Physician Assistant (who has had four years of university training in diagnosis and management of diseases) or an experienced nurse-midwife and supported by enrolled and community health nurses. Most Health Centres lack laboratory facilities, and therefore, treatment for most diseases are usually based on signs and symptoms (presumptive treatment). However, in some situations, patients are asked to go to private laboratories for confirmation of diagnosis. Usually, first aid is provided to serious cases reporting to the health centres before they are referred to the district hospital. The health centres also offer preventive services and run outreach programmes such as immunization, antenatal services and health education to their catchment areas. They also conduct outbreak investigations, usually done by disease control officers. The district hospitals are staffed with one or more qualified medical doctors, nurses and pharmacists. They also have laboratories manned by Biomedical scientists and laboratory technicians, and other support staff. The district hospitals deal with all cases, except specialized care, perform surgical operations and refer serious cases to the regional or tertiary hospitals in the regional capitals. Some district hospitals have specialists who provide specialist care. All district hospitals provide public health services to the towns and villages in their catchment area. The regional and tertiary hospitals provide specialist care and services and specialist diagnostics and provide non-specialized services to communities within their catchment areas. Within the communities, there is a strong presence of private sector participation in the provision of healthcare services by residents or herbalists, traditional birth attendants and drug peddlers. Community pharmacies and chemical shops licensed by the Pharmacy Council provide medicines prescribed for clients. The Ministry of Health (MOH) provides the overall policy and strategic direction for health service delivery in Ghana. The Ghana Health Service (GHS) is a government body established in 1996 as part of the Health Sector Reform in Ghana under the MOH. The GHS develops appropriate strategies and sets technical guidelines to achieve Ghana's national policy goals and objectives. The GHS also undertakes management and administration of the overall Ghana health resources within the service and promotes healthy mode of living and good health habits by people in Ghana. The Pharmacovigilance in Ghana In Ghana, the Food and Drugs Authority (FDA) 's management of drug safety issues is handled under the Public Health Act 851. Thus, the FDA keeps an ADR data repository. The trend of spontaneous reporting has progressively increased since the country joined the International Medicine Safety Monitoring System in 2001 as the 65 th Member State and the 1 st in sub-Saharan Africa [24]. The Pharmacovigilance system of reporting is such that, at the various health facilities, irrespective of the level of health organization, there should be mandated Institutional Contact Persons (ICP) who are supposed to serve as the link between the FDA and the health professionals [25]. Where a patient experiences an ADR, an ADR reporting form (known as the "blue form"), is filled and submitted through the health facilities to the regional offices of the FDA [25]. At the regional offices, there are designated regional Pharmacovigilance officers who receive the report forms, assess the validity of the report and present the report to the national FDA Central Database [24]. However, health professionals from a health facility can forward an ADR report directly to the FDA Central Database through the online reporting page of the FDA website. The FDA has an online database called the Safety Watch System that is International Conference of Harmonization E2B compliant [25]. The reports received at the headquarters are forwarded as an E2B (xml) file [24]. Pharmaceutical Manufacturing Companies are mandated to report ADR of their pharmaceutical products to the FDA. The companies do this through the Qualified Person for Pharmacovigilance (QPPV). The QPPV is a trained individual responsible for reporting all pharmacovigilance for all medicinal products by pharmaceutical companies holding marketing authorizations. Sample size determination The sample size was estimated using the Cochran formula [26], assuming 16% of health professionals have ever reported adverse drug reaction with a 95% confidence interval (CI), 5% precision and 15% non-response rate. The final sample size was 245, representing the minimum number of participants required for this study. However, researchers of this study sampled and enrolled 268 health professionals. These Health professionals are directly involved with the drug administration and consented to be part of the study. Sampling technique Health professionals were selected by multistage random sampling. A list of all health facilities in the various sub-districts was obtained from the Kpone Katamanso District Health Directorate. There were 29 medical facilities in the District comprising six health centers, nine clinics, one polyclinic, one maternal home, seven hospitals and four CHPS. Also, there were 38 community pharmacies in the District. At the first stage of sampling, the 29 medical facilities were numbered and 19 were randomly selected. Again, the 34 community pharmacies were numbered and 17 community pharmacies were randomly selected using an online random number generator with permission from the authorities of these facilities; 363 participants who were eligible for this study were randomly sampled. They were asked to pick from an envelope containing shuffled sheets with yes or no written on them. Participants who picked yes and agreed to participate in the study were informed on the rationale, ethical issues, and purpose of the study. They were assured of privacy and confidentiality. Participants were permitted to ask questions. Those who agreed to be part of the study were then enrolled. A total of 268 health professionals were enrolled in the study. Data collection and management The data were collected using a closed-ended questionnaire developed after reviewing related studies and previous practice experience. The questionnaire captured the health professionals' demographics, knowledge of health professionals on spontaneous reporting, the attitude of health professionals towards reporting, ADR reporting practice, and the factors that they perceived may influence reporting. Provision was also made for suggestions on possible ways to improve ADR reporting. The dependent variable, Spontaneous reporting of ADR, was measured as a composite variable of the following items: having observed a patient with an adverse reaction, reported adverse drug reaction, stated reporting of ADR to Food and Drugs Authority (FDA), having received feedback from the FDA and documented the observed ADR. A score of 1 was awarded to each correct item. A Health professional was said to have reported an ADR if the respondent had ever witnessed an ADR, reported to FDA and had received feedback from FDA or had documented the ADR. Hence, a score equal to or more than three means the participant had reported ADR before. The proportion of health professionals who spontaneously reported an ADR was determined by dividing participants who had ever reported ADR by the number of participants assessed. To measure knowledge of participants, 6 items were used and every correct answer was coded as 1, otherwise 0 for a wrong answer. A score of 5 to 6 was considered as very good, 4 to 3 was average, and 2 to 0 was rated as poor knowledge of a participant on adverse drug reporting. The variable, knowledge was measured as an ordinal one. To measure attitude of professionals as poor or good, 12 items were used. A coding of 1 was scored for ticking Yes and 0 for ticking No. Attitude was classified as poor, if the respondent` scored a value greater than or equal to 6 whilst it was classified as good if the respondent scored a value less than 6. The factors affecting ADR reporting among community pharmacists were assessed based on multiple responses to questions like Concern that the ADR report may be wrong, availability of reporting forms, fear of legal consequences, the workload on participants, etc. These factors were coded 1 for Yes and 0 for No. This provided nominal variables, which were used for the univariate analysis. Data collected were checked, cleaned, coded and entered into Stata version 15. The data were verified independently for errors and accuracy. The researcher of this study encrypted the dataset with password protection and securely stored a copy of the dataset on a study designated pendrive kept in a safe. The paper questionnaires were shredded after the data were locked and securely stored on the pendrive. Data processing and analysis Descriptive statistics were used to summarise the socio-demographic characteristics of the study participants. Categorical predictor variables were summarised using frequencies and percentages, while the continuous predictor variables were summarised using means and medians. Mean and standard deviations were used to describe the central tendency for the continuous variables such as age and the years of practice, whereas frequencies and percentages were used for the categorical variables. A simple logistic regression analysis was carried out to determine the association between the dependent variable (spontaneous reporting of ADR) and the independent variables (unadjusted odds ratio). Multiple logistic regression analysis was then used to test the strength of association between variables that showed a significant effect under the Chi-square test and simple logistic regression analysis. The Adjusted Odds Ratio (AOR) was reported for the multiple logistic regression analyses. The results were expressed with their respective 95% Confidence Intervals (CIs) and p-values. A p-value <0.05 was considered statistically significant. Ethical Considerations Ethical approval for the study was obtained from the Ghana Health Service Ethics Committee (Reference - GHS-ERC032/01/18). Informed consent was obtained from the participants of the study. The researchers ensured that all health professionals were adequately educated on the purpose of the study, risks and benefits of the conduct of the study and the health professionals were allowed to ask questions before their consent was taken. During the conduct of the study, the confidentiality and privacy of the health professionals were assured during the conduct of the study. The study procedures were carried out in accordance with relevant guidelines and regulations. Results Demographic characteristics of participants All 268 health professionals (Table 1) enrolled in the study responded to the questionnaire, giving a response rate of 100%. There were 119 (44.4%) males and 149 (55.6%) females. The representation of the different professionals involved in the study sample were: 35 Medical Officers (13.1%), 21 Pharmacists (7.8%), 53 Pharmacy Technician (19.8%), 93 Nurses (34.7%), 31 midwives (11.6%), 32 Physician Assistants (11.9%) and 3 Disease Control Officers (1.1%), and the average age was 34.1 (SD= 0.47). The oldest age recorded among the 268 participants was 60 years, and the youngest was 20 years. The least experienced had a one-year record of practice, and the most experienced had 36 years of practice; the average years of practice of respondents was 8.5 (SD= 0.62). From the data collected, 208 (77.6%) of the health professionals in the District had observed at least one case of ADR, whereas only 36 (17.3%) had ever reported an ADR to the FDA. Knowledge on spontaneous reporting of ADR Of the 268 participants, 46 (17.1 %) had poor knowledge, 139 (51.9%) had adequate knowledge, and 83 (31.0 %) had Excellent knowledge of spontaneous reporting of ADR (Figure 3). Factors influencing spontaneous reporting of ADR Table 2 presents the results of the simple logistic regression models, showing the factors associated with spontaneous reporting of ADR. Age was independently significantly associated with spontaneous reporting of ADR. It was realized that health professionals who were more than 50years old were 8.8 times more likely to report an adverse event compared to professionals who were less than 30years old (Crude Odds Ratio [COR]=8.75; CI= 2.27 – 33.67). The field of Health Profession was also found to be independently associated with the spontaneous reporting of ADR. Nurses were found to be 84% less likely to report an adverse event compared to medical doctors (COR= 0.16; CI= 0.05 - 0.53). Pharmacy technicians were also 9.1 times less likely to report an adverse event compared to Medical Doctors (COR= 0.11; CI= 0.02 - 0.56). The level of knowledge of health professionals was significantly associated with Spontaneous Reporting of ADR. Health professionals with Excellent Knowledge of Spontaneous ADR reporting are 14.2 times more likely to report an ADR (COR= 14.17; CI= 1.83 – 109.67). Under professional attitudes, it was realized that Health professionals who are Uncertain about the cause of ADR were 68% less likely to report an adverse event compared to professionals who are certain of an ADR (COR= 0.32; CI= 0.15 - 0.70). Health professionals who had inadequate time at work were 4.3 times less likely to report an ADR compared to health professionals who had adequate time (COR= 0.23; CI= 0.11 - 0.48). Health professionals who were afraid of Legal consequences after reporting an ADR were found to be 84% less likely to report an ADR. Compared to health professionals who were not afraid of any legal consequences (COR= 0.16; CI= 0.06 - 0.37). Lastly, under the health professional's attitude, it was found that health professionals who are diffident of the reporting procedure were 71% less likely to report an ADR compared to health professionals who are not diffident about the ADR reporting procedure (COR= 0.29; CI= 0.14 - 0.62). Under the stakeholder's factors, health professionals who were not aware of the availability of reporting form were 79% less likely to report an ADR compared to health professionals who were aware of the availability of the reporting form (COR= 0.21; CI= 0.09 - 0.48). Health professionals who receive Prompt feedback from the FDA are 2.4 more likely to report an ADR compared to health professionals who do not receive (COR= 2.38; CI= 1.38 – 4.98), and health professionals who receive Pharmacovigilance training are 19 times more likely to report an ADR compared to health professionals who do not receive any Pharmacovigilance training (COR= 19.04; CI= 7.07 – 51.27) Table 3 presents the results of the multivariate logistic regression models, showing the factors associated with spontaneous reporting of ADR. After statistical adjustment, Age: 40 - 49 (AOR= 93.10, p-value < 0.01), Reporting by Nurses (AOR= 0.01, p-value < 0.01), the spontaneous reporting of ADR by Disease control officers (AOR= 12.38, p-value = 0.02); Professional attitudes such as Uncertainty about ADR report (AOR= 2.29, p-value < 0.01), No time for reporting (AOR= 0.3, p-value = 0.03), Fear of legal consequences after reporting (AOR= 0.15, p-value < 0.01) and Post qualification training (AOR=18.78, p-value < 0.01); were statistically significant. Figure 4 represents suggested forms of feedback that could improve spontaneous reporting of adverse drug reaction by the Health professionals of Kpone-Katamanso District. From the figure, 66.29% of respondents suggested that the Food and Drugs Authority produce regular reports on recent Adverse Drug Reactions. In addition, 61.36% of the 268 respondents believed that Regular Pharmacovigilance Awareness reports and programs could help improve the spontaneous reporting rate of Adverse Drug Reaction. Some respondents (54.17%) believed that individual feedback by the FDA to ADR reporting could go a long way to enhance reporting of ADR. 26.89% suggested that annual statistic charts of cases of Adverse Drug Reactions would improve the feedback from the FDA, while 25.76% of respondents would prefer a Global Drug Safety reports as feedback from the Food and Drugs Authority. On recommended ways to improve Spontaneous Reporting, most of the respondents (70.08%) recommended that there be awareness creation and sensitization through media. 62.88% of the respondents also believe that establishing Institutional Reporting Centres would improve ADR reporting rate. 53.78% of respondents recommended Continuous Professional Education and Training. About a third of professionals (36.74%) believe that the availability of reporting forms is integral for improving spontaneous reporting of adverse drug reaction. 28.03% of the respondents recommended that pharmacovigilance studies be incorporated into their educational curriculum (Figure 5). Discussion The contribution of healthcare providers in reporting ADR is paramount to the sustenance of every pharmacovigilance system. This study provides germane insight regarding knowledge, practice and impetus of health professionals towards ADR reporting as well as its associated factors. This study revealed that only 36 (17.3%) out of 208 health professionals who had witnessed an ADR in the Kpone-Katamanso District had ever spontaneously reported it to the FDA. Assessing the factors that may influence the abysmal spontaneous reporting of ADR amongst health professionals in the District divulged that the age of health professionals is significantly associated with reporting ADR. Health professionals aged between 30 and 39 were 10.13 times more likely to report an ADR spontaneously than professionals younger than 30 years. In addition, professionals aged between 40 and 49 years are 93.10 times more likely to report an adverse drug reaction than professionals younger than 30 years. It may be implied that as health professionals get older, they tend to gain more experienced and are often conversant with reporting procedures. A factor that could be accounting for the low reporting of ADR, as deduced from this study, is the availability of ADR reporting forms. Health professionals who do not have access to reporting forms are 3.6 times less likely to report an ADR compared to their counterparts with reporting forms available at their health facilities. This finding is consistent with that of Eweuko, which indicated that lack of reporting forms at the various health facilities hampered the rate of spontaneous reporting of adverse drug reactions among health professionals [ 27 ]. Time constraint was identified as a factor hindering Spontaneous reporting of ADR [ 12 , 19 ]. The Annual fact and figures Statistical Report of Ghana reveals a low health professional to patient ratio implying an increase in job demand on health professionals [ 28 ]. It was observed that health professionals who complained of time constraint were 6.7 times less likely to report an ADR than those who did not complain of time constraint. Professionals should be educated on the relevance of spontaneous ADR reporting in ensuring safe medicines for the management of conditions. Regardless of the workload on professionals, they should be educated to view spontaneous reporting with equal importance in ensuring proper patient care. This is because a single report of an ADR may save numerous lives. A significant proportion of Health Professionals attributed the fear of legal repercussions to hesitation in reporting ADR; similar findings were reported in other studies [ 29 ]. Perception of professional error seems to be a major cause of this fear. Health Professionals are scared that they may be prosecuted if ADR experienced are due to administering the wrong drug or wrong diagnosis. After reporting an ADR, assurance of legal protection would go a long way to increase reporting amongst Healthcare providers provided due procedures were adhered to. In addition, stakeholders should assure reporters of confidentiality and anonymity in order to boost the ADR reporting rate. The study found that training on pharmacovigilance improves ADR reporting as health professionals who received some form of training on pharmacovigilance were 5.5 times more likely to report an adverse reaction than those with no training on pharmacovigilance. Pharmacovigilance training was significantly associated with spontaneous reporting of ADR. These findings are consistent with that of Sabblah et al. [ 13 ], who also concluded that professionals' post-professional training positively impacted spontaneous reporting rates. It has been realized that healthcare professionals' pharmacovigilance training and education is one of the strategies proposed to increase ADR reporting rates [ 13 ]. Low rates of feedback from authorities on submitted ADR forms could account for health professionals' lackadaisical attitude to reporting of ADR. A study by Toklu et al. [ 30 ] disclosed that nearly 80% of pharmacists in Cyprus strongly approve that feedback to reports received from the National Pharmacovigilance Centre will go a long way to motivate them to report adverse drug reactions. It was imperative to find out from the respondent's opinions on which forms of feedback would motivate them to report an adverse drug reaction. More than half of respondents from this study suggested that the FDA produce a regular newsletter on recent ADR. Yearly, the FDA releases a newsletter called the Druglens, which seeks to inform health professionals on strides made in the area of spontaneous reporting. These newsletters are disseminated to the various health facilities and made accessible to all health professionals. However, a survey by the FDA revealed that 38.3% of Health professionals were aware of at least one of the letters distributed to all professionals in 2013 [ 25 ]. This finding indicates that most professionals are not aware of any news alert on ADR and other relevant information to improve spontaneous reporting of ADR. On recommended ways to improve Spontaneous ADR Reporting, studies have shown a paucity of empirical data on pharmacovigilance awareness in Africa [ 31 ]. Therefore, it is not surprising that most of the respondent (70.1%) recommended that there be sensitization on ADR reporting through media on the need for health professionals to report ADR. This recommendation is very laudable because sensitization through the media encourages reporting among consumers. Sometimes, especially at the community pharmacy, professionals depend on reports received from consumers to report an ADR. Nwokike & Eghan recommended media publicity following a review of Ghana's pharmacovigilance system [ 32 ]. If these reports are not received or are lacking in vital information for assessments, it negatively affects the professional's ability to report adverse drug reaction. Over 50% of the respondents also believe that establishing ADR Reporting Centers at the various health facilities would improve the ADR reporting rate (Fig. 5 ). The FDA has introduced Institutional Contact Person (ICP) on pharmacovigilance who may be health professionals serving as a liaison between the FDA and the health professionals at the various institutions. This is a measure to improve spontaneous reporting of ADR among health professionals. Health professionals are now able to report ADR directly to the ICP. Nonetheless, there should be Institutional Reporting Centers (IRC), which the ICP could head. This would increase professionals' awareness of the need to report ADR. It would also reduce the fear of legal repercussions after reporting since professionals who report are guaranteed anonymity and confidentially from the regulators FDA. A proportion of 53.78% of respondents recommended Continuous Professional Education and Training to be a sure way of improving spontaneous reporting of ADR. Continuous Professional Development (CPD) can be very beneficial for one's career. Undertaking a CPD programme is a mandatory requirement for some professionals. It helps by advancing the knowledge and skills; professionals need to be confident that they are working at the top end of their profession. Pharmacovigilance training could be held during continuous professional development programs to train professionals on spontaneous reporting. It also offers an appropriate platform to assure professionals that there is no legal liability for reporting an adverse reaction. Professionals would also get adequate opportunity to ask questions pertaining to the spontaneous reporting of ADR. This study is subject to recall bias as some health professionals were unable to adequately remember whether they reported or documented the adverse drug reactions. Additionally, this study is limited to establishing an association and not causal inferences. The information obtained is subjective since some respondents may give false information to look good or be perceived as professionals. Conclusion Though most professionals demonstrated adequate knowledge on spontaneous reporting of ADR, the proportion of professionals who report ADR was low. The knowledge of professionals did not affect their attitude towards spontaneous reporting of adverse drug reaction. Therefore, regulators are called upon to intensify awareness through media sensitization and engagement of all relevant stakeholders on the need for the entire population to report adverse drug reactions they experience. Abbreviations ADR - Adverse Drug Reaction CHPS - Community–based Health Planning Services CPD - Continuous Professional Development FDA - Food and Drugs Authority GHS – Ghana Health Service MOH – Ministry of Health IMU - International Monitoring Unit ICP - Institutional Contact Person IRC - Institutional Reporting Center GHS - Ghana Health Service QPPV – Qualified Person for Pharmacovigilance WHO - World Health Organization Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the Ethical Review Committee of the Ghana Health Service (Reference - GHS-ERC032/01/18). The study procedures were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all health professionals before enrolment in the study. Participants were guaranteed the right to be informed about the outcome of the study. Consent for publication Not applicable Availability of data and materials The dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Authors received no specific funding for this work. Authors' contributions MA and ADA conceived and designed the project. MA carried out data collection. PN, ND, and KOA provided technical support. MA performed data analyses. MA, KOA, PN, ND and ADA interpreted data for this study. MA, KOA, PN, ND and ADA drafted the work and revised it critically for important intellectual content. ADA supervised the study. All authors read and approved the final manuscript. Acknowledgements We acknowledge the efforts of Ronald Amoah Nsoh, Bright Osei, and Shadrach Darko of the Kpone Katamanso Health Directorate for their immense support during the conduct of the study. References Alomar MJ. Factors affecting the development of adverse drug reactions (Review article). Saudi Pharmaceutical Journal. 2014;22(2):83–94. Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. The Lancet. 2000;356(9237):1255–9. Sultana J, Cutroneo P, Trifirò G. Clinical and economic burden of adverse drug reactions. J Pharmacol Pharmacother. 2013;4(Suppl 1):73–7. Goyal M, Bansal M, Yadav S, Grover V, Preetkanwal: To assess the attitude , knowledge and practices of medical professionals about adverse drug reactions and their reporting in a teaching hospital . Indian Journal of Clinical Practice 2013, 24 ( 3 ): 281 – 284 . Suh D-C, Woodall B, Shin S, Santis E. Clinical and economic impact of adverse drug reactions in hospitalized patients. The Annals of Pharmacotherapy. 2001;34(12):1373–9. Nadew SS, Beyene KGM, Beza SW. Adverse drug reaction reporting practice and associated factors among medical doctors in government hospitals in Addis Ababa, Ethiopia. PLoS One. 2020;15(1):e0227712. Martin K, Bégaud B, Latry P, Miremont-Salamé G, Fourrier A, Moore N. Differences between clinical trials and postmarketing use. Br J Clin Pharmacol. 2004;57(1):86–92. Pal SN, Duncombe C, Falzon D, Olsson S. WHO strategy for collecting safety data in public health programmes: complementing spontaneous reporting systems. Drug Saf. 2013;36(2):75–81. The safety of medicines in public healthprogrammes: pharmacovigilance an essential tool . https://www.who.int/medicines/areas/quality_safety/safety_efficacy/Pharmacovigilance_B.pdf?ua=1 . Drug Lense Newsletter Issue 8 . http://www.fdaghana.gov.gh/img/reports/DrugLens%20FINAL%202020--.pdf . Tandon VR, Mahajan V, Khajuria V, Gillani Z. 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Community pharmacists' attitudes towards adverse drug reaction reporting and their knowledge of the new pharmacovigilance legislation in the southern region of Portugal: a mixed methods study. Drugs Therapy Perspectives. 2015;31(9):316–22. Irujo M, Beitia G, Bes-Rastrollo M, Figueiras A, Hernández-Diaz S, Lasheras B. Factors that Influence Under-Reporting of Suspected Adverse Drug Reactions among Community Pharmacists in a Spanish Region. Drug Saf. 2007;30(11):1073–82. Ozcan G, Aykac E, Kasap Y, Nemutlu NT, Sen E, Aydinkarahaliloglu ND. Adverse drug reaction reporting pattern in Turkey: analysis of the national database in the context of the first pharmacovigilance legislation. Drugs - Real World Outcomes. 2016;3(1):33–43. Inman W. Attitudes to adverse drug-reaction reporting. Br J Clin Pharmacol. 1996;41:433–5. Yu YM, Lee E, Koo BS, Jeong KH, Choi KH, Kang LK, Lee MS, Choi KH, Oh JM, Shin WG. Predictive factors of spontaneous reporting of adverse drug reactions among community pharmacists. PLoS One. 2016;11(5):e0155517–7. Gurmesa LT, Dedefo MG. Factors affecting adverse drug reaction reporting of healthcare professionals and their knowledge, attitude, and practice towards ADR reporting in Nekemte town, West Ethiopia. Biomed Res Int. 2016;2016:5728462. Al-Hazmi N, Naylor I. Attitude and awareness of adverse drug reaction reporting by health professionals in seven hospitals in the Holy City of Makkah, Kingdom of Saudi Arabia. Journal of Clinical Trials. 2013;3(3):1–5. 2010 Population and housing census : District analytical report [https:// www2.statsghana.gov.gh/docfiles/2010_District_Report/Greater%20Accra/KPONE%20KATAMANSO.pdf] . Strengthening Pharmaceutical Systems ( SPS ) Program . Indicator - based pharmacovigilance assessment tool : Manual for conducting assessments in developing countries . Submitted to the U . S . 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The knowledge and attitude of the healthcare professionals towards pharmacovigilance and adverse drug reaction reporting in Northern Cyprus . Journal of Pharmacovigilance 2016, 04. Oshikoya KA, Awobusuyi JO. Perceptions of doctors to adverse drug reaction reporting in a teaching hospital in Lagos, Nigeria. BMC Clin Pharmacol. 2009;9(1):14. Nwokike J, Eghan K: Pharmacovigilance in Ghana : A Systems Analysis . Submitted to the US Agency for International Development by the Strengthening Pharmaceutical Systems ( SPS ) Program . Arlington: Management Sciences for Health 2010. Tables Table 1: Socio-demographic Characteristics of Health professionals from Kpone-Katamanso District, Ghana Background Characteristics Mean, (SD) Number Percentage (%) Gender Male 119 44.4 Female 149 55.6 Age (years) Less than 30 76 28.36 30 – 39 34.13, (0.472) 139 51.87 40 – 49 39 14.55 50 – 59 8 2.99 Greater than 59 6 2.24 Profession Medical Officer 35 13.06 Pharmacist 21 7.84 Nurse 93 34.7 Pharm Tech 53 19.78 Midwife 31 11.57 Physician Assistant 32 11.94 Disease Control Officer 3 1.12 Institution Government 88 32.84 Private Hospital 167 62.31 Community Pharmacy 13 4.85 Religion Christian 234 87.97 Muslim 25 9.13 Other 8 3.01 Years of Practice Less than 10 194 72.39 10 – 19 50 18.66 20 – 29 18 6.72 Greater or equal to 30 6 2.24 Marital Status Married 165 61.57 Single 87 32.46 Divorced 16 5.97 Witnessed a case of ADR Yes 208 77.61 No 60 22.39 Spontaneous Reporting Yes 36 13.43 No 232 86.57 Table 2: Simple logistic regression of Spontaneous Adverse Event Reporting and related factors VARIABLES COR, 95% CI Socio-Demographic Sex Male 1 Female 0.77, (0.38 – 1.56) Age (years) Less than 30 1 30 – 39 1.63, (0.61 – 4.31) 40 – 49 2.55, (0.79 – 8.21) Greater than 50 8.75, (2.27–33.67)* Profession Medical Officer 1 Pharmacist 2.17, (0.69 – 6.84) Nurse 0.16, (0.05 – 0.53)* Pharm Tech 0.11, (0.02 – 0.56)* Midwife 0.69, (0.22 – 2.23) Physician Assistant 0.30, (0.07 – 1.22) D. Control Officer 5.78, (0.47 – 71.62) Institution Government 1 Private Hospital 1.23, (0.58 – 2.64) Community Pharmacy Religion Christian Muslim N/A Other Knowledge Poor 1 Adequate 6.16, (0.80 – 47.8) Excellent 14.17, (1.83 – 109.67)* * = Statistically significant COR = Crude Odds Ratio CI = Confidence interval Table 2: Simple logistic regression of Spontaneous Adverse Event Reporting and related factors (Continued) VARIABLES COR, 95% CI Professional Attitudes Uncertainty about cause of ADR No 1 Yes 0.32, (0.15 – 0.70)* Lack of Adequate time No 1 Yes 0.23, (0.11 – 0.48)* Diffident about ADR occurrence No 1 Yes 0.71, (0.34 – 1.49) Fear of legal repercussions No 1 Yes 0.16, (0.06 – 0.37)* Extraneous work No 1 Yes 1.20, (0.55 – 2.54) Ambitious to publish a case report No 1 Yes 0.62, (0.27 – 1.43) Mistrust in PV system No 1 Yes 0.56, (0.27 – 1.13) Negligence No 1 Yes 1.0, (0.49 – 2.03) Diffident about Procedure No 1 Yes 0.29, (0.14 – 0.62)* Indifferent about reporting No 1 Yes 1.87 (0.87 – 4.0) Lack of incentives No 1 Yes 0.94, (0.46 – 1.94) * = Statistically significant COR = Crude Odds Ratio CI = Confidence interval Table 2: Simple logistic regression of Spontaneous Adverse Event Reporting and related factors (Continued) VARIABLES COR, 95% CI Form of ADR reactions Seriousness of reaction No Yes N/A Unusual reaction No 1 Yes 1.63 (0.78 – 3.40) Unknown Reaction to product No 1 Yes 0.95 (0.47 – 1.92) Stakeholder Factor Unavailability of reporting forms No 1 Yes 0.21 (0.09 – 0.48)* Prompt Feedback No 1 Yes 2.38 (1.13 - 4.98)* PV in curriculum No 1 Yes 1.10 (0.53 – 2.26) Post-professional PV Training No 1 Yes 19.04 (7.07 – 51.27)* * = Statistically significant N/A = Not applicable because a cell contains zero, therefore, Odds ratio cannot be obtained COR = Crude Odds Ratio CI = Confidence interval Table 3: Multivariate logistic regression of Spontaneous Adverse Event Reporting and related factors VARIABLE Adj. Odd ratio 95% CI P value Age (years) Less than 30 (Ref) 1 30 – 39 10.13 1.056 - 97.217 0.045 40 – 49 93.10 4.577 - 1893.7 0.003* Greater than 50 2.21 0.0925 - 52.947 0.624 Profession Medical Officer (Ref) 1 Pharmacist 1.93 0.086 - 43.16 0.67 Nurse 0.01 0.001 - 0.185 < 0.01* Pharm Tech 0.18 0.008 - 4.170 0.29 Midwife 3.31 0.161 - 67.852 0.43 Physician Assistant .20 0.0073 - 5.152 0.32 Disease Control Officer 12.382 1.8039 - 8498.495 0.02* Knowledge of Professionals Poor (Ref) 1 Adequate 7.967 0.335 - 189.246 0.2 Excellent 8.311 0.333 207.123 0.2 Uncertainty about cause of ADR No (Ref) 1 Yes 0.34 0.11 – 1.06 0.06 Time constraint to report ADR No (Ref) 1 Yes 0.30 0.10 – 0.91 0.03* Fear of legal repercussions No (Ref) 1 Yes 0.15 0.41 – 0.51 < 0.01* Diffident about reporting procedure No (Ref) 1 Yes 0.77 0.26 – 2.33 0.65 Unavailability of Reporting form No (Ref) 1 Yes 0.28 0.09 – 0.88 0.03* Feedback from FDA No (Ref) 1 Yes 2.12 0.70 – 6.37 0.181 Pharmacovigilance training No (Ref) 1 Yes 18.78 5.46 – 64.59 < 0.01* * Statistically Significant AOR = Adjusted Odds Ratio Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 21 Aug, 2021 Reviewers invited by journal 08 May, 2021 First submitted to journal 16 Apr, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:43:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-433485/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-433485/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":12988514,"identity":"8a812029-0ccf-4252-aaa9-334e253baa29","added_by":"auto","created_at":"2021-09-01 21:45:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":126610,"visible":true,"origin":"","legend":"Trend in adverse event reporting in Ghana from 2015 to 2019","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-433485/v1/91cc3cbfac149da7ba438ade.png"},{"id":12988649,"identity":"cc31eacf-6e92-476b-b4df-56106e5e5b2b","added_by":"auto","created_at":"2021-09-01 21:48:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":83198,"visible":true,"origin":"","legend":"Map of Kpone-Katamanso District including the five sub-districts","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-433485/v1/adb2c239f2f5dbee261e3c49.png"},{"id":12988511,"identity":"4625a864-9644-4a5f-8d33-8c1164288c30","added_by":"auto","created_at":"2021-09-01 21:45:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11858,"visible":true,"origin":"","legend":"Knowledge of Health Professionals","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-433485/v1/3051480770be28e481ec649d.png"},{"id":12988510,"identity":"2ee60c93-e02a-43e6-b653-c7004eeb23de","added_by":"auto","created_at":"2021-09-01 21:45:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":10864,"visible":true,"origin":"","legend":"Expected Forms of Feedback from Pharmacovigilance System","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-433485/v1/83da4725cc31f1ae8a27a1e8.png"},{"id":12988512,"identity":"7c5d3871-b747-4831-bc2b-3859681a78f1","added_by":"auto","created_at":"2021-09-01 21:45:08","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":13858,"visible":true,"origin":"","legend":"Recommended Ways to improve ADR Among Health Professionals","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-433485/v1/ba9899a6a2db8a6b4e905a7f.png"},{"id":13712247,"identity":"5d2c5aef-192c-4874-adcb-918ab23f15ca","added_by":"auto","created_at":"2021-09-17 14:27:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1156452,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-433485/v1/f658b96d-db81-4819-b628-be0fdaf1447b.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eSpontaneous Reporting of Adverse Drug Reaction Among Health Professionals In Kpone-Katamanso District, Ghana\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePharmaceutical drugs play a significant role in managing diseases in the healthcare sector. However, even when administered within their therapeutic dosing schedule, drugs can lead to unwanted effects, which may pose threats to the life of the patient\u0026nbsp;[1]. These unwanted effects are referred to as adverse drug reactions (ADR) - undesirable effects that may occur as part of a drug\u0026apos;s pharmacological action\u0026nbsp;[2]. The economic and social impact of ADR is huge and cannot be overlooked\u0026nbsp;[3]. ADR has been projected as one of the leading causes of morbidity and mortality across all age groups and hospital admissions\u0026nbsp;[4, 5].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn order to reduce the incidence of ADR, the safety of drugs are ascertained through various phases of clinical trials prior to their approval on the market\u0026nbsp;[6].\u0026nbsp;However, the safety reports from these clinical trials are collated from strictly controlled conditions which may be subject to bias due to strict inclusion and exclusion criteria and limited time. For example, the effects of these drugs are often not studied on some members of the population such as children under 5 years, pregnant women and very old people; thus, yielding outcomes that may not be perfectly generalizable to all who might use the drug\u0026nbsp;[7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpontaneous reporting of ADR at the normal condition and setting is the cornerstone of pharmacovigilance\u0026nbsp;[8].\u0026nbsp;It\u0026nbsp;provides information from real-life clinical practice as opposed to that of clinical trials as subjects are not unnecessarily excluded and the safety of the drug is studied under a limited time\u0026nbsp;[3, 9].\u0026nbsp;Spontaneous reporting is\u0026nbsp;an inexpensive, flexible and very effective method of collecting information\u0026nbsp;whereby health professionals voluntarily submit case reports of ADR; pharmaceutical companies or consumers to the national pharmacovigilance centres for evaluation in order to mitigate the impact of ADR on society\u0026nbsp;[9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor a pharmacovigilance system to effectively monitor ADR of both existing and newly introduced drugs, the World Health Organisation (WHO) recommends that the spontaneous reporting of adverse effects should be more than 200 reported cases per 1,000,000 population\u0026nbsp;[10]. In 2019, the National Pharmacovigilance Center of Ghana recorded 2236 reported cases of adverse drug cases representing about 75 reported cases per 1,000,000 population of Ghanaians\u0026nbsp;[10]. Though an improvement in reported cases from previous years, the reporting rates have constantly been below the WHO standard (Figure 1). Underreporting of ADR is a big challenge in pharmacovigilance, especially in countries that utilize the spontaneous or voluntary ADR reporting system such as Ghana\u0026nbsp;[11, 12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThough health professionals have enough knowledge and are aware of the need to report ADR, smaller proportions of health professionals spontaneously report ADR\u0026nbsp;[13]. Health system factors that influence spontaneous reporting of ADR include health professionals knowledge, attitude and beliefs\u0026nbsp;[14]. Socio-demographic characteristics of the reporting health professional such as their age, gender, qualification, years of practice, number of patients seen in a day, and marital status also influence spontaneous reporting of ADR \u0026nbsp;[15]. Elsewhere, female health professionals were more likely to report ADR than their male counterparts\u0026nbsp;[15, 16]. The health professional\u0026apos;s age tends to affect reporting rate, which has been consistent across studies from different geographic locations with older and experienced professionals more likely to report an event\u0026nbsp;[15, 17, 18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePer WHO recommendations, Kpone-Katamanso district, with a huge population and several health facilities, should report a minimum of 22 cases of ADR a year. However, the number of ADR reported, and the factors influencing reporting are largely unknown. Several studies have identified attitudes such as complacency or doubt about the causal relationship of the event with the drug, procrastination and indifference to report, and apprehension about the legal consequences of reporting ADR as attitudes negatively affecting spontaneous reporting [19]. An assurance of confidentiality of the reporter\u0026apos;s identity, legal protection and incentives for reporting have been identified to promote spontaneous reporting [20]. Additionally, indifference, diffidence, complacency, ignorance, lack of monetary incentives, and personal desire to publish cases have been suggested as predictors of low ADR reporting, to the extent that in some cases, less than 50% of health professionals showed a good attitude towards reporting ADR [21]. Also, the lack of knowledge on how to report an ADR and lack of access to reporting forms are major factors contributing to poor reporting rate [22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe perennial issue of underreporting ADR in the pharmacovigilance system in Ghana and the consequential increase in mortality, hospitalization, congenital anomaly and economic burden as well as paucity of data influenced our decision to conduct this study in an attempt to identify context-specific factors influencing the rate of spontaneous ADR reporting among health professionals. It is anticipated that information obtained from this study would be useful to stakeholders in the formulation of policies and strategies to increase spontaneous reporting of ADR in the country.\u003c/p\u003e"},{"header":"Methods ","content":"\u003cp\u003e\u003cstrong\u003eStudy design and location\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used a well-structured, pretested, closed-ended questionnaire to collect data from health professionals involved in ADR reporting in the Kpone-Katamanso District in Ghana. The District, made up of five sub-districts, is located along the coastal part of Tema in the Greater Accra region, not far from Accra (Figure 2). The sub-districts are Kpone (the district capital), Zenu, Gbetsile, Oyibi, and Appolonia. Kpone-Katamanso has a huge population of about 109,864 with several health facilities that are equitably distributed across the District [23].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included 268 health professionals within the District, including pharmacists and pharmacy technicians, physicians and physician assistants, nurses, midwives, and disease control officers. These health professionals are directly involved in the diagnosing, dispensing and administration of drugs directly to the patients and are in the position to report any drug-related reactions of the patients. The medical doctors and physician assistants are responsible for the diagnoses and prescription of medications for treatment. The pharmacists and pharmacy technicians are responsible for the dispensing of drugs and provision of drug-related information to the patient. The nurses and midwives are responsible for the administration of prescribed drugs to the patient on the wards. The disease control officer is responsible for the immunization programs at the district level. Considering the responsibilities of these professionals in drug therapies, they receive complaints of and observe some ADR amongst the patients. Thus, they are required to voluntarily report ADR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion/exclusion criteria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals who have practised for not less than a year, directly involved in the supervision, diagnosis, dispensing and administration of drugs to patients and are to detect ADR were eligible for inclusion in the study. Health professionals who declined participation were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare service delivery in Ghana\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare service delivery in Ghana is based on the primary health care concept that seeks to promote practical and socially acceptable methods universally accessible to individuals and families in the communities through their full participation. The Ghana Health Service is organized in levels of care, with the lowest level being the Community\u0026ndash;based Health Planning Services (CHPS). This is the first point of contact with the formal health care service and manned by community health nurses usually with two years of formal training who provide basic curative and immunization services to clients. Cases that cannot be handled at the CHPS compounds are referred to the health centre, but sometimes they are referred directly to the district hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Health Centre, the next level of care delivery, is normally staffed with a Physician Assistant (who has had four years of university training in diagnosis and management of diseases) or an experienced nurse-midwife and supported by enrolled and community health nurses. Most Health Centres lack laboratory facilities, and therefore, treatment for most diseases are usually based on signs and symptoms (presumptive treatment). However, in some situations, patients are asked to go to private laboratories for confirmation of diagnosis. Usually, first aid is provided to serious cases reporting to the health centres before they are referred to the district hospital. The health centres also offer preventive services and run outreach programmes such as immunization, antenatal services and health education to their catchment areas. They also conduct outbreak investigations, usually done by disease control officers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe district hospitals are staffed with one or more qualified medical doctors, nurses and pharmacists. They also have laboratories manned by Biomedical scientists and laboratory technicians, and other support staff. The district hospitals deal with all cases, except specialized care, perform surgical operations and refer serious cases to the regional or tertiary hospitals in the regional capitals.\u0026nbsp;Some district hospitals have specialists who provide specialist care. All district hospitals\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eprovide public health services to the towns and villages in their catchment area. The regional and tertiary hospitals provide specialist care and services and specialist diagnostics and provide non-specialized services to communities within their catchment areas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWithin the communities, there is a strong presence of private sector participation in the provision of healthcare services by residents or herbalists, traditional birth attendants and drug peddlers. Community pharmacies and chemical shops licensed by the Pharmacy Council provide medicines prescribed for clients. The Ministry of Health (MOH) provides the overall policy and strategic direction for health service delivery in Ghana. The Ghana Health Service (GHS) is a government body established in 1996 as part of the Health Sector Reform in Ghana under the MOH. The GHS develops appropriate strategies and sets technical guidelines to achieve Ghana\u0026apos;s national policy goals and objectives. The GHS also undertakes management and administration of the overall Ghana health resources within the service and promotes healthy mode of living and good health habits by people in Ghana.\u003c/p\u003e\n\u003ch2\u003eThe Pharmacovigilance in Ghana\u003c/h2\u003e\n\u003cp\u003eIn Ghana, the Food and Drugs Authority (FDA) \u0026apos;s management of drug safety issues is handled under the Public Health Act 851. Thus, the FDA keeps an ADR data repository. The trend of spontaneous reporting has progressively increased since the country joined the International Medicine Safety Monitoring System in 2001 as the 65\u003csup\u003eth\u003c/sup\u003e Member State and the 1\u003csup\u003est\u003c/sup\u003e in sub-Saharan Africa [24]. The Pharmacovigilance system of reporting is such that, at the various health facilities, irrespective of the level of health organization, there should be mandated Institutional Contact Persons (ICP) who are supposed to serve as the link between the FDA and the health professionals [25]. Where a patient experiences an ADR, an ADR reporting form (known as the \u0026quot;blue form\u0026quot;), is filled and submitted through the health facilities to the regional offices of the FDA [25]. At the regional offices, there are designated regional Pharmacovigilance officers who receive the report forms, assess the validity of the report and present the report to the national FDA Central Database [24]. However, health professionals from a health facility can forward an ADR report directly to the FDA Central Database through the online reporting page of the FDA website. The FDA has an online database called the Safety Watch System that is International Conference of Harmonization E2B compliant [25]. The reports received at the headquarters are forwarded as an E2B (xml) file [24].\u003c/p\u003e\n\u003cp\u003ePharmaceutical Manufacturing Companies are mandated to report ADR of their pharmaceutical products to the FDA. The companies do this through the Qualified Person for Pharmacovigilance (QPPV). The QPPV is a trained individual responsible for reporting all pharmacovigilance for all medicinal products by pharmaceutical companies holding marketing authorizations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size determination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was estimated using the Cochran formula [26], assuming 16% of health professionals have ever reported adverse drug reaction with a 95% confidence interval (CI), 5% precision and 15% non-response rate. The final sample size was 245, representing the minimum number of participants required for this study. However, researchers of this study sampled and enrolled 268 health professionals. These Health professionals are directly involved with the drug administration and consented to be part of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals were selected by multistage random sampling. A list of all health facilities in the various sub-districts was obtained from the Kpone Katamanso District Health Directorate. There were 29 medical facilities in the District comprising six health centers, nine clinics, one polyclinic, one maternal home, seven hospitals and four CHPS. Also, there were 38 community pharmacies in the District. At the first stage of sampling, the 29 medical facilities were numbered and 19 were randomly selected. Again, the 34 community pharmacies were numbered and 17 community pharmacies were randomly selected using an online random number generator with permission from the authorities of these facilities; 363 participants who were eligible for this study were randomly sampled. They were asked to pick from an envelope containing shuffled sheets with yes or no written on them. Participants who picked yes and agreed to participate in the study were informed on the rationale, ethical issues, and purpose of the study. They were assured of privacy and confidentiality. Participants were permitted to ask questions. Those who agreed to be part of the study were then enrolled. A total of 268 health professionals were enrolled in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were collected using a closed-ended questionnaire developed after reviewing related studies and previous practice experience. The questionnaire captured the health professionals\u0026apos; demographics, knowledge of health professionals on spontaneous reporting, the attitude of health professionals towards reporting, ADR reporting practice,\u0026nbsp;and the factors that they perceived may influence reporting. Provision was also made for suggestions on possible ways to improve ADR reporting. The dependent variable, Spontaneous reporting of ADR, was measured as a composite variable of the following items: having observed a patient with an adverse reaction, reported adverse drug reaction, stated reporting of ADR to Food and Drugs Authority (FDA), having received feedback from the FDA and documented the observed ADR. A score of 1 was awarded to each correct item. A Health professional was said to have reported an ADR if the respondent had ever witnessed an ADR, reported to FDA and had received feedback from FDA or had documented the ADR. Hence, a score equal to or more than three means the participant had reported ADR before.\u003c/p\u003e\n\u003cp\u003eThe proportion of health professionals who spontaneously reported an ADR was determined by dividing participants who had ever reported ADR by the number of participants assessed. To measure knowledge of participants, 6 items were used and every correct answer was coded as 1, otherwise 0 for a wrong answer. A score of 5 to 6 was considered as very good, 4 to 3 was average, and 2 to 0 was rated as poor knowledge of a participant on adverse drug reporting. The variable, knowledge was measured as an ordinal one. To measure attitude of professionals as poor or good, 12 items were used. A coding of 1 was scored for ticking Yes and 0 for ticking No. Attitude was classified as poor, if the respondent` scored a value greater than or equal to 6 whilst it was classified as good if the respondent scored a value less than 6. The factors affecting ADR reporting among community pharmacists were assessed based on multiple responses to questions like\u0026nbsp;Concern that the ADR report may be wrong, availability of reporting forms, fear of legal consequences, the workload on participants, etc. These factors were coded 1 for Yes and 0 for No. This provided nominal variables, which were used for the univariate analysis. Data collected were checked, cleaned, coded and entered into Stata version 15. The data were verified independently for errors and accuracy.\u003c/p\u003e\n\u003cp\u003eThe researcher of this study encrypted the dataset with password protection and securely stored a copy of the dataset on a study designated pendrive kept in a safe. The paper questionnaires were shredded after the data were locked and securely stored on the pendrive.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eprocessing and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to summarise the socio-demographic characteristics of the study participants. Categorical predictor variables were summarised using frequencies and percentages, while the continuous predictor variables were summarised using means and medians. Mean and standard deviations were used to describe the central tendency for the continuous variables such as age and the years of practice, whereas frequencies and percentages were used for the categorical variables. A simple logistic regression analysis\u0026nbsp;was carried out to determine the association between the dependent variable (spontaneous reporting of ADR) and the independent variables (unadjusted odds ratio). Multiple logistic regression analysis was then used to test the strength of association between variables that showed a significant effect under the Chi-square test and simple logistic regression analysis. The Adjusted Odds Ratio (AOR) was reported for the multiple logistic regression analyses. The results were expressed with their respective 95% Confidence Intervals (CIs) and p-values. A p-value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Ghana Health Service Ethics Committee (Reference - GHS-ERC032/01/18). Informed consent was obtained from the participants of the study. The researchers ensured that all health professionals were adequately educated on the purpose of the study, risks and benefits of the conduct of the study and the health professionals were allowed to ask questions before their consent was taken. During the conduct of the study, the confidentiality and privacy of the health professionals were assured during the conduct of the study. The study procedures were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic characteristics of participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 268 health professionals (Table 1) enrolled in the study responded to the questionnaire, giving a response rate of 100%. There were 119 (44.4%) males and 149 (55.6%) females. The representation of the different professionals involved in the study sample were: 35 Medical Officers (13.1%), 21 Pharmacists (7.8%), 53 Pharmacy Technician (19.8%), 93 Nurses (34.7%), 31 midwives (11.6%), 32 Physician Assistants (11.9%) and 3 Disease Control Officers (1.1%), and the average age was 34.1 (SD= 0.47). The oldest age recorded among the 268 participants was 60 years, and the youngest was 20 years. The least experienced had a one-year record of practice, and the most experienced had 36 years of practice; the average years of practice of respondents was 8.5 (SD= 0.62). From the data collected, 208 (77.6%) of the health professionals in the District had observed at least one case of ADR, whereas only 36 (17.3%) had ever reported an ADR to the FDA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge on spontaneous reporting of ADR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 268 participants, 46 (17.1 %) had poor knowledge, 139 (51.9%) had adequate knowledge, and 83 (31.0 %) had Excellent knowledge of spontaneous reporting of ADR (Figure 3).\u003c/p\u003e\n\u003ch2\u003eFactors influencing spontaneous reporting of ADR\u003c/h2\u003e\n\u003cp\u003eTable 2 presents the results of the simple logistic regression models, showing the factors associated with spontaneous reporting of ADR. Age was independently significantly associated with spontaneous reporting of ADR. It was realized that health professionals who were more than 50years old were 8.8 times more likely to report an adverse event compared to professionals who were less than 30years old (Crude Odds Ratio [COR]=8.75; CI= 2.27 \u0026ndash; 33.67). The field of Health Profession was also found to be independently associated with the spontaneous reporting of ADR. Nurses were found to be 84% less likely to report an adverse event compared to medical doctors (COR= 0.16; CI= 0.05 - 0.53). Pharmacy technicians were also 9.1 times less likely to report an adverse event compared to Medical Doctors (COR= 0.11; CI= 0.02 - 0.56). The level of knowledge of health professionals was significantly associated with Spontaneous Reporting of ADR. Health professionals with Excellent Knowledge of Spontaneous ADR reporting are 14.2 times more likely to report an ADR (COR= 14.17; CI= 1.83 \u0026ndash; 109.67). Under professional attitudes, it was realized that Health professionals who are Uncertain about the cause of ADR were 68% less likely to report an adverse event compared to professionals who are certain of an ADR (COR= 0.32; CI= 0.15 - 0.70). Health professionals who had inadequate time at work were 4.3 times less likely to report an ADR compared to health professionals who had adequate time (COR= 0.23; CI= 0.11 - 0.48). Health professionals who were afraid of Legal consequences after reporting an ADR were found to be 84% less likely to report an ADR. Compared to health professionals who were not afraid of any legal consequences (COR= 0.16; CI= 0.06 - 0.37). Lastly, under the health professional\u0026apos;s attitude, it was found that health professionals who are diffident of the reporting procedure were 71% less likely to report an ADR compared to health professionals who are not diffident about the ADR reporting procedure (COR= 0.29; CI= 0.14 - 0.62). Under the stakeholder\u0026apos;s factors, health professionals who were not aware of the availability of reporting form were 79% less likely to report an ADR compared to health professionals who were aware of the availability of the reporting form (COR= 0.21; CI= 0.09 - 0.48). Health professionals who receive Prompt feedback from the FDA are 2.4 more likely to report an ADR compared to health professionals who do not receive (COR= 2.38; CI= 1.38 \u0026ndash; 4.98), and health professionals who receive Pharmacovigilance training are 19 times more likely to report an ADR compared to health professionals who do not receive any Pharmacovigilance training (COR= 19.04; CI= 7.07 \u0026ndash; 51.27) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 presents the results of the multivariate logistic regression models, showing the factors associated with spontaneous reporting of ADR. After statistical adjustment, Age: 40 - 49 (AOR= 93.10, p-value \u0026lt; 0.01), Reporting by Nurses (AOR= 0.01, p-value \u0026lt; 0.01), the spontaneous reporting of ADR by Disease control officers (AOR= 12.38, p-value = 0.02); Professional attitudes such as Uncertainty about ADR report (AOR= 2.29, p-value \u0026lt; 0.01), No time for reporting (AOR= 0.3, p-value = 0.03), Fear of legal consequences after reporting (AOR= 0.15, p-value \u0026lt; 0.01) and Post qualification training (AOR=18.78, p-value \u0026lt; 0.01); were statistically significant. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 4 represents suggested forms of feedback that could improve spontaneous reporting of adverse drug reaction by the Health professionals of Kpone-Katamanso District. From the figure, 66.29% of respondents suggested that the Food and Drugs Authority produce regular reports on recent Adverse Drug Reactions. In addition, 61.36% of the 268 respondents believed that Regular Pharmacovigilance Awareness reports and programs could help improve the spontaneous reporting rate of Adverse Drug Reaction. Some respondents (54.17%) believed that individual feedback by the FDA to ADR reporting could go a long way to enhance reporting of ADR. 26.89% suggested that annual statistic charts of cases of Adverse Drug Reactions would improve the feedback from the FDA, while 25.76% of respondents would prefer a Global Drug Safety reports as feedback from the Food and Drugs Authority.\u003c/p\u003e\n\u003cp\u003eOn recommended ways to improve Spontaneous Reporting, most of the respondents (70.08%) recommended that there be awareness creation and sensitization through media. 62.88% of the respondents also believe that establishing Institutional Reporting Centres would improve ADR reporting rate. 53.78% of respondents recommended Continuous Professional Education and Training. About a third of professionals (36.74%) believe that the availability of reporting forms is integral for improving spontaneous reporting of adverse drug reaction. 28.03% of the respondents recommended that pharmacovigilance studies be incorporated into their educational curriculum (Figure 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe contribution of healthcare providers in reporting ADR is paramount to the sustenance of every pharmacovigilance system. This study provides germane insight regarding knowledge, practice and impetus of health professionals towards ADR reporting as well as its associated factors. This study revealed that only 36 (17.3%) out of 208 health professionals who had witnessed an ADR in the Kpone-Katamanso District had ever spontaneously reported it to the FDA.\u003c/p\u003e \u003cp\u003eAssessing the factors that may influence the abysmal spontaneous reporting of ADR amongst health professionals in the District divulged that the age of health professionals is significantly associated with reporting ADR. Health professionals aged between 30 and 39 were 10.13 times more likely to report an ADR spontaneously than professionals younger than 30 years. In addition, professionals aged between 40 and 49 years are 93.10 times more likely to report an adverse drug reaction than professionals younger than 30 years. It may be implied that as health professionals get older, they tend to gain more experienced and are often conversant with reporting procedures.\u003c/p\u003e \u003cp\u003eA factor that could be accounting for the low reporting of ADR, as deduced from this study, is the availability of ADR reporting forms. Health professionals who do not have access to reporting forms are 3.6 times less likely to report an ADR compared to their counterparts with reporting forms available at their health facilities. This finding is consistent with that of Eweuko, which indicated that lack of reporting forms at the various health facilities hampered the rate of spontaneous reporting of adverse drug reactions among health professionals [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTime constraint was identified as a factor hindering Spontaneous reporting of ADR [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Annual fact and figures Statistical Report of Ghana reveals a low health professional to patient ratio implying an increase in job demand on health professionals [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It was observed that health professionals who complained of time constraint were 6.7 times less likely to report an ADR than those who did not complain of time constraint. Professionals should be educated on the relevance of spontaneous ADR reporting in ensuring safe medicines for the management of conditions. Regardless of the workload on professionals, they should be educated to view spontaneous reporting with equal importance in ensuring proper patient care. This is because a single report of an ADR may save numerous lives.\u003c/p\u003e \u003cp\u003eA significant proportion of Health Professionals attributed the fear of legal repercussions to hesitation in reporting ADR; similar findings were reported in other studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Perception of professional error seems to be a major cause of this fear. Health Professionals are scared that they may be prosecuted if ADR experienced are due to administering the wrong drug or wrong diagnosis. After reporting an ADR, assurance of legal protection would go a long way to increase reporting amongst Healthcare providers provided due procedures were adhered to. In addition, stakeholders should assure reporters of confidentiality and anonymity in order to boost the ADR reporting rate.\u003c/p\u003e \u003cp\u003eThe study found that training on pharmacovigilance improves ADR reporting as health professionals who received some form of training on pharmacovigilance were 5.5 times more likely to report an adverse reaction than those with no training on pharmacovigilance. Pharmacovigilance training was significantly associated with spontaneous reporting of ADR. These findings are consistent with that of Sabblah et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], who also concluded that professionals' post-professional training positively impacted spontaneous reporting rates. It has been realized that healthcare professionals' pharmacovigilance training and education is one of the strategies proposed to increase ADR reporting rates [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLow rates of feedback from authorities on submitted ADR forms could account for health professionals' lackadaisical attitude to reporting of ADR. A study by Toklu et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] disclosed that nearly 80% of pharmacists in Cyprus strongly approve that feedback to reports received from the National Pharmacovigilance Centre will go a long way to motivate them to report adverse drug reactions. It was imperative to find out from the respondent's opinions on which forms of feedback would motivate them to report an adverse drug reaction. More than half of respondents from this study suggested that the FDA produce a regular newsletter on recent ADR. Yearly, the FDA releases a newsletter called the Druglens, which seeks to inform health professionals on strides made in the area of spontaneous reporting. These newsletters are disseminated to the various health facilities and made accessible to all health professionals. However, a survey by the FDA revealed that 38.3% of Health professionals were aware of at least one of the letters distributed to all professionals in 2013 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This finding indicates that most professionals are not aware of any news alert on ADR and other relevant information to improve spontaneous reporting of ADR.\u003c/p\u003e \u003cp\u003eOn recommended ways to improve Spontaneous ADR Reporting, studies have shown a paucity of empirical data on pharmacovigilance awareness in Africa [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Therefore, it is not surprising that most of the respondent (70.1%) recommended that there be sensitization on ADR reporting through media on the need for health professionals to report ADR. This recommendation is very laudable because sensitization through the media encourages reporting among consumers. Sometimes, especially at the community pharmacy, professionals depend on reports received from consumers to report an ADR. Nwokike \u0026amp; Eghan recommended media publicity following a review of Ghana's pharmacovigilance system [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. If these reports are not received or are lacking in vital information for assessments, it negatively affects the professional's ability to report adverse drug reaction.\u003c/p\u003e \u003cp\u003eOver 50% of the respondents also believe that establishing ADR Reporting Centers at the various health facilities would improve the ADR reporting rate (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The FDA has introduced Institutional Contact Person (ICP) on pharmacovigilance who may be health professionals serving as a liaison between the FDA and the health professionals at the various institutions. This is a measure to improve spontaneous reporting of ADR among health professionals. Health professionals are now able to report ADR directly to the ICP. Nonetheless, there should be Institutional Reporting Centers (IRC), which the ICP could head. This would increase professionals' awareness of the need to report ADR. It would also reduce the fear of legal repercussions after reporting since professionals who report are guaranteed anonymity and confidentially from the regulators FDA.\u003c/p\u003e \u003cp\u003eA proportion of 53.78% of respondents recommended Continuous Professional Education and Training to be a sure way of improving spontaneous reporting of ADR. Continuous Professional Development (CPD) can be very beneficial for one's career. Undertaking a CPD programme is a mandatory requirement for some professionals. It helps by advancing the knowledge and skills; professionals need to be confident that they are working at the top end of their profession. Pharmacovigilance training could be held during continuous professional development programs to train professionals on spontaneous reporting. It also offers an appropriate platform to assure professionals that there is no legal liability for reporting an adverse reaction. Professionals would also get adequate opportunity to ask questions pertaining to the spontaneous reporting of ADR.\u003c/p\u003e \u003cp\u003eThis study is subject to recall bias as some health professionals were unable to adequately remember whether they reported or documented the adverse drug reactions. Additionally, this study is limited to establishing an association and not causal inferences. The information obtained is subjective since some respondents may give false information to look good or be perceived as professionals.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThough most professionals demonstrated adequate knowledge on spontaneous reporting of ADR, the proportion of professionals who report ADR was low. The knowledge of professionals did not affect their attitude towards spontaneous reporting of adverse drug reaction. Therefore, regulators are called upon to intensify awareness through media sensitization and engagement of all relevant stakeholders on the need for the entire population to report adverse drug reactions they experience.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eADR -\u0026nbsp;\u003c/strong\u003eAdverse Drug Reaction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCHPS\u003c/strong\u003e - Community\u0026ndash;based Health Planning Services\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCPD\u003c/strong\u003e - Continuous Professional Development\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFDA -\u0026nbsp;\u003c/strong\u003eFood and Drugs Authority\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGHS\u003c/strong\u003e \u0026ndash; Ghana Health Service\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMOH\u003c/strong\u003e \u0026ndash; Ministry of Health\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIMU -\u003c/strong\u003e International Monitoring Unit\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICP -\u0026nbsp;\u003c/strong\u003eInstitutional Contact Person\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIRC -\u0026nbsp;\u003c/strong\u003eInstitutional Reporting Center\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGHS -\u0026nbsp;\u003c/strong\u003eGhana Health Service\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQPPV\u003c/strong\u003e \u0026ndash; Qualified Person for Pharmacovigilance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO -\u0026nbsp;\u003c/strong\u003eWorld Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Ethical Review Committee of the Ghana Health Service (Reference - GHS-ERC032/01/18). The study procedures were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all health professionals before enrolment in the study. Participants were guaranteed the right to be informed about the outcome of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors received no specific funding for this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMA and ADA conceived and designed the project. MA carried out data collection. PN, ND, and KOA provided technical support. MA performed data analyses. MA, KOA, PN, ND and ADA interpreted data for this study. MA, KOA, PN, ND and ADA drafted the work and revised it critically for important intellectual content. ADA supervised the study. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the efforts of Ronald Amoah Nsoh, Bright Osei, and Shadrach Darko of the Kpone Katamanso Health Directorate for their immense support during the conduct of the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlomar MJ. Factors affecting the development of adverse drug reactions (Review article). Saudi Pharmaceutical Journal. 2014;22(2):83\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdwards IR, Aronson JK. 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Adverse drug reaction reporting pattern in Turkey: analysis of the national database in the context of the first pharmacovigilance legislation. Drugs - Real World Outcomes. 2016;3(1):33\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInman W. Attitudes to adverse drug-reaction reporting. Br J Clin Pharmacol. 1996;41:433\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu YM, Lee E, Koo BS, Jeong KH, Choi KH, Kang LK, Lee MS, Choi KH, Oh JM, Shin WG. Predictive factors of spontaneous reporting of adverse drug reactions among community pharmacists. PLoS One. 2016;11(5):e0155517\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurmesa LT, Dedefo MG. Factors affecting adverse drug reaction reporting of healthcare professionals and their knowledge, attitude, and practice towards ADR reporting in Nekemte town, West Ethiopia. Biomed Res Int. 2016;2016:5728462.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Hazmi N, Naylor I. Attitude and awareness of adverse drug reaction reporting by health professionals in seven hospitals in the Holy City of Makkah, Kingdom of Saudi Arabia. Journal of Clinical Trials. 2013;3(3):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cb\u003e2010 Population and housing census\u003c/b\u003e: \u003cb\u003eDistrict analytical report\u003c/b\u003e [https://\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww2.statsghana.gov.gh/docfiles/2010_District_Report/Greater%20Accra/KPONE%20KATAMANSO.pdf]\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cb\u003eStrengthening Pharmaceutical Systems\u003c/b\u003e (\u003cb\u003eSPS\u003c/b\u003e) \u003cb\u003eProgram\u003c/b\u003e. \u003cb\u003eIndicator\u003c/b\u003e-\u003cb\u003ebased pharmacovigilance assessment tool\u003c/b\u003e: \u003cb\u003eManual for conducting assessments in developing countries\u003c/b\u003e. \u003cb\u003eSubmitted to the U\u003c/b\u003e.\u003cb\u003eS\u003c/b\u003e. \u003cb\u003eAgency for International Development by the SPS Program\u003c/b\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pdf.usaid.gov/pdf_docs/PNADS167.pdf\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cb\u003eDrugLens Newsletter Issue 4\u003c/b\u003e. [https://\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003efdaghana.gov.gh/img/reports/Druglens%20Issue%204%202016_FINAL-min.pdf]\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCochran W: \u003cb\u003eSampling techniques\u003c/b\u003e. \u003cb\u003e3rd edition John Wiley\u003c/b\u003e \u0026amp; \u003cb\u003eSons\u003c/b\u003e. New York.; 1977.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzeuko AY, Ebenebe UE, Nnebue CC, Ugoji JO. Factors associated with the reporting of adverse drug reactions by health workers in nnewi Nigeria. Int J Prev Med. 2015;6:25\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cb\u003eThe Health Sector in Ghana Facts and Figures\u003c/b\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ghanahealthservice.org/downloads/Facts+Figures_2018.pdf\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRhonda HG. Patient safety and quality: An evidence-based handbook for nurses.(Prepared with support from the Robert Wood Johnson Foundation). Rockville: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08\u0026ndash;043.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToklu H, Soyalan M, G\u0026uuml;ltekin O, \u0026Ouml;zpolat M, Aydin M, G\u0026uuml;nay A, Yavuz D, Akici A, Demirdamar R. \u003cb\u003eThe knowledge and attitude of the healthcare professionals towards pharmacovigilance and adverse drug reaction reporting in Northern Cyprus\u003c/b\u003e. \u003cem\u003eJournal of Pharmacovigilance\u003c/em\u003e 2016, 04.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshikoya KA, Awobusuyi JO. Perceptions of doctors to adverse drug reaction reporting in a teaching hospital in Lagos, Nigeria. BMC Clin Pharmacol. 2009;9(1):14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNwokike J, Eghan K: \u003cb\u003ePharmacovigilance in Ghana\u003c/b\u003e: \u003cb\u003eA Systems Analysis\u003c/b\u003e.\u003cb\u003eSubmitted to the US Agency for International Development by the Strengthening Pharmaceutical Systems\u003c/b\u003e (\u003cb\u003eSPS\u003c/b\u003e) \u003cb\u003eProgram\u003c/b\u003e. \u003cem\u003eArlington: Management Sciences for Health\u003c/em\u003e 2010.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Socio-demographic Characteristics of Health professionals from Kpone-Katamanso District, Ghana\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"47.82608695652174%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBackground Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean, (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eLess than 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e28.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e30 \u0026ndash; 39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e34.13, (0.472)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e51.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e40 \u0026ndash; 49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e14.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e50 \u0026ndash; 59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eGreater than 59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eMedical Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e13.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e7.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e34.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003ePharm Tech\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e19.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e11.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003ePhysician Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e11.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eDisease Control Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstitution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eGovernment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e32.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003ePrivate Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e62.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eCommunity Pharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e4.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e87.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e9.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of Practice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eLess than 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e72.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e10 \u0026ndash; 19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e18.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e20 \u0026ndash; 29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e6.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eGreater or equal to 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e61.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e32.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e5.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"47.82608695652174%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWitnessed a case of ADR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e77.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e22.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"47.82608695652174%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpontaneous Reporting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e13.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.40993788819876%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.41614906832298%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.099378881987576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.509316770186336%\"\u003e\n \u003cp\u003e232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"19.565217391304348%\"\u003e\n \u003cp\u003e86.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Simple logistic regression of Spontaneous Adverse Event Reporting and related factors\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"64.68797564687975%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVARIABLES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOR, 95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"64.68797564687975%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eSocio-Demographic\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e0.77, \u0026nbsp;(0.38 \u0026ndash; 1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eLess than 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003e30 \u0026ndash; 39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1.63, \u0026nbsp;(0.61 \u0026ndash; 4.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003e40 \u0026ndash; 49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e2.55, \u0026nbsp; \u0026nbsp; (0.79 \u0026ndash; 8.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eGreater than 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.75, \u0026nbsp;(2.27\u0026ndash;33.67)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"64.68797564687975%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eMedical Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e2.17, \u0026nbsp; \u0026nbsp; (0.69 \u0026ndash; 6.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.16, \u0026nbsp;(0.05 \u0026ndash; 0.53)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003ePharm Tech\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.11, \u0026nbsp;(0.02 \u0026ndash; 0.56)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e0.69, \u0026nbsp;(0.22 \u0026ndash; 2.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003ePhysician Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e0.30, \u0026nbsp; \u0026nbsp; (0.07 \u0026ndash; 1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eD. Control Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e5.78, \u0026nbsp;(0.47 \u0026ndash; 71.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"64.68797564687975%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstitution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eGovernment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003ePrivate Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1.23, \u0026nbsp; \u0026nbsp; (0.58 \u0026ndash; 2.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eCommunity Pharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"64.68797564687975%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eKnowledge\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e6.16, \u0026nbsp; \u0026nbsp; (0.80 \u0026ndash; 47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.7869101978691%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"44.90106544901065%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35.31202435312024%\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.17, (1.83 \u0026ndash; 109.67)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* \u0026nbsp; = Statistically significant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOR = Crude Odds Ratio\u003c/p\u003e\n\u003cp\u003eCI \u0026nbsp; \u0026nbsp; \u0026nbsp;= Confidence interval\u003c/p\u003e\n\u003cp\u003eTable 2: Simple logistic regression of Spontaneous Adverse Event Reporting and related factors (Continued)\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVARIABLES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOR, 95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eProfessional Attitudes\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUncertainty about cause of ADR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.32, (0.15 \u0026ndash; 0.70)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of Adequate time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.23, (0.11 \u0026ndash; 0.48)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiffident about ADR occurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e0.71, (0.34 \u0026ndash; 1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFear of legal repercussions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.16, (0.06 \u0026ndash; 0.37)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eExtraneous work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1.20, (0.55 \u0026ndash; 2.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmbitious to publish a case report\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e0.62, (0.27 \u0026ndash; 1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMistrust in PV system\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e0.56, (0.27 \u0026ndash; 1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegligence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1.0, (0.49 \u0026ndash; 2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiffident about Procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.29, (0.14 \u0026ndash; 0.62)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndifferent about reporting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1.87 (0.87 \u0026ndash; 4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.36507936507937%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of incentives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.317460317460316%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.04761904761905%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.63492063492063%\"\u003e\n \u003cp\u003e0.94, (0.46 \u0026ndash; 1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* \u0026nbsp; = Statistically significant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOR = Crude Odds Ratio\u003c/p\u003e\n\u003cp\u003eCI \u0026nbsp; \u0026nbsp; = Confidence interval\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: Simple logistic regression of Spontaneous Adverse Event Reporting and related factors (Continued)\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVARIABLES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOR, 95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eForm\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;of ADR reactions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeriousness of reaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnusual reaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1.63 \u0026nbsp;(0.78 \u0026ndash; 3.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnknown Reaction to product\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e0.95 \u0026nbsp;(0.47 \u0026ndash; 1.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eStakeholder Factor\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnavailability of reporting forms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.21 \u0026nbsp;(0.09 \u0026ndash; 0.48)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrompt Feedback\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.38 \u0026nbsp;(1.13 - 4.98)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePV in curriculum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1.10 \u0026nbsp;(0.53 \u0026ndash; 2.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"59.43396226415094%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-professional\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;PV Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20.28301886792453%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.15094339622642%\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.56603773584906%\"\u003e\n \u003cp\u003e\u003cstrong\u003e19.04 (7.07 \u0026ndash; 51.27)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* \u0026nbsp; = Statistically significant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eN/A = Not applicable because a cell contains zero, therefore, Odds ratio cannot be obtained\u003c/p\u003e\n\u003cp\u003eCOR = Crude Odds Ratio\u003c/p\u003e\n\u003cp\u003eCI \u0026nbsp; \u0026nbsp; = Confidence interval\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003eTable 3: Multivariate logistic regression of Spontaneous Adverse Event Reporting and related factors\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"45.36082474226804%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVARIABLE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdj. Odd ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"21.649484536082475%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.43298969072165%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eLess than 30 (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e30 \u0026ndash; 39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.056 - 97.217\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e40 \u0026ndash; 49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e93.10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.577 - 1893.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eGreater than 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.0925 - 52.947\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.624\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eMedical Officer\u0026nbsp;(Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.086 - 43.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001 - 0.185\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.01*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003ePharm Tech\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.008 - 4.170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.161 - 67.852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003ePhysician Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.0073 - 5.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eDisease Control Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.382\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.8039 - 8498.495\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of Professionals\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003ePoor (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eAdequate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e7.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.335 - 189.246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e8.311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.333 207.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUncertainty about cause of ADR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.11 \u0026ndash; 1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime constraint to report ADR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.10 \u0026ndash; 0.91\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFear of legal repercussions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.41 \u0026ndash; 0.51\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.01*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiffident about reporting procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.26 \u0026ndash; 2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnavailability of Reporting form\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.28\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.09 \u0026ndash; 0.88\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeedback from FDA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e0.70 \u0026ndash; 6.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePharmacovigilance training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"44.89795918367347%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003e18.78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"23.46938775510204%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.46 \u0026ndash; 64.59\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"16.3265306122449%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.01*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Statistically Significant \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;AOR = Adjusted Odds Ratio\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aoph","sideBox":"Learn more about [Archives of Public Health](http://archpublichealth.biomedcentral.com/)","snPcode":"13690","submissionUrl":"https://submission.nature.com/new-submission/13690/3","title":"Archives of Public Health","twitterHandle":"@Archpubhealth","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adverse drug reaction, Reporting, Health professionals, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-433485/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-433485/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSpontaneous reporting of adverse drug reactions (ADR) is an effective means of ensuring postmarketing surveillance of drugs, and health professionals play a cardinal role through voluntary reporting of ADR. However, the pharmacovigilance system in Ghana is plagued with under-reporting issues, which is of public health concern. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eA questionnaire-based cross-sectional study involving 268 health professionals at Kpone-Katamanso District was carried out. Data on spontaneous reporting of ADR, demographics of participants, knowledge, and attitudes of professionals towards reporting and factors that may influence ADR reporting were collected. Logistic regression models were used to examine the association of the independent variables with spontaneous reporting of ADR.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResult: \u003c/strong\u003eOverall, 77.6% (208) of the 268 respondents had witnessed ADR; however, only 17.3% of the respondents have ever reported an ADR to the FDA. Health professionals who had adequate knowledge on spontaneous reporting of ADR were 51.9%, while 30.3% had very good knowledge of spontaneous reporting of ADR. After statistical adjustment, Age (AOR=2.26, 95%CI= 1.25–4.10), Fear of Legal Consequences (AOR=0.15, 95%CI=0.41–0.51), Time Constraint (AOR=0.3, 95%CI=0.10–0.91), Pharmacovigilance training (AOR= 18.78, 95%CI= 5.46–64.59) and Unavailability of Reporting form (AOR=0.28, 95%CI=0.09– 0.88) were found to be significantly associated spontaneous reporting of ADR. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The proportion of health professionals in the Kpone-Katamanso District who spontaneously report observed ADR is low. Our findings underscore the need for the FDA to intensify awareness through media sensitization and engage all relevant stakeholders on the need for the entire population to report ADR.\u003c/p\u003e","manuscriptTitle":"Spontaneous Reporting of Adverse Drug Reaction Among Health Professionals In Kpone-Katamanso District, Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-01 21:45:06","doi":"10.21203/rs.3.rs-433485/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-08-21T08:30:55+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-05-09T03:10:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Public Health","date":"2021-04-16T07:05:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aoph","sideBox":"Learn more about [Archives of Public Health](http://archpublichealth.biomedcentral.com/)","snPcode":"13690","submissionUrl":"https://submission.nature.com/new-submission/13690/3","title":"Archives of Public Health","twitterHandle":"@Archpubhealth","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87300bcb-94ef-4cc9-a335-1208fc12d68a","owner":[],"postedDate":"September 1st, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":6865717,"name":"Environmental Policy"},{"id":6865718,"name":"Occupational Medicine"}],"tags":[],"updatedAt":"2021-12-27T06:54:36+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-01 21:45:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-433485","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-433485","identity":"rs-433485","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}