Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia

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Pharmacists play a key role in ensuring rational antibiotic use, yet the effectiveness of ASP depends on institutional support and multidisciplinary collaboration. Objective This study aimed to evaluate the effect of training on hospital pharmacists’ competence and its correlation with ASP implementation at the hospital level. Methods A quasi-experimental pre–post intervention design without a control group was conducted among 103 pharmacists from 29 hospitals in Riau Islands Province between August 2024 and January 2025. Data were analyzed using Wilcoxon, McNemar, and Spearman correlation tests. Results Pharmacists’ competence significantly improved after the training (Z = -8.825, p < 0.001), with 94.2% showing improvement in competence category. However, no significant correlation was found between pharmacists’ competence improvement and hospital ASP performance (r = 0.046; p = 0.813). These findings indicate that ASP effectiveness depends not only on pharmacists’ capacity but also on hospital structural support, the role of attending physicians, and collaboration among other healthcare professionals. Conclusion ASP training effectively enhances pharmacists’ competence but is insufficient to drive systemic improvement in antimicrobial resistance control. Successful AMS implementation requires a multidisciplinary approach, managerial policy support, and strengthened human resource capacity and microbiology laboratory infrastructure within hospitals. 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F1000Research 2025, 14 :1150 ( https://doi.org/10.12688/f1000research.171864.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] FIFIN OKTAVIANI https://orcid.org/0000-0002-4861-9713 1,2 , Hazrina Binti Hamid 2 FIFIN OKTAVIANI https://orcid.org/0000-0002-4861-9713 1,2 , Hazrina Binti Hamid 2 PUBLISHED 21 Oct 2025 Author details Author details 1 faculty of health sciences, Universitas Batam, Batam, Riau Islands, Indonesia 2 Faculty of Pharmacy, Lincoln University College, Petaling Jaya, Selangor, Malaysia FIFIN OKTAVIANI Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Hazrina Binti Hamid Roles: Supervision OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Antimicrobial Resistance collection. Abstract Background Antimicrobial resistance (AMR) is a global health threat requiring effective control through Antimicrobial Stewardship Programs (ASP). Pharmacists play a key role in ensuring rational antibiotic use, yet the effectiveness of ASP depends on institutional support and multidisciplinary collaboration. Objective This study aimed to evaluate the effect of training on hospital pharmacists’ competence and its correlation with ASP implementation at the hospital level. Methods A quasi-experimental pre–post intervention design without a control group was conducted among 103 pharmacists from 29 hospitals in Riau Islands Province between August 2024 and January 2025. Data were analyzed using Wilcoxon, McNemar, and Spearman correlation tests. Results Pharmacists’ competence significantly improved after the training (Z = -8.825, p < 0.001), with 94.2% showing improvement in competence category. However, no significant correlation was found between pharmacists’ competence improvement and hospital ASP performance (r = 0.046; p = 0.813). These findings indicate that ASP effectiveness depends not only on pharmacists’ capacity but also on hospital structural support, the role of attending physicians, and collaboration among other healthcare professionals. Conclusion ASP training effectively enhances pharmacists’ competence but is insufficient to drive systemic improvement in antimicrobial resistance control. Successful AMS implementation requires a multidisciplinary approach, managerial policy support, and strengthened human resource capacity and microbiology laboratory infrastructure within hospitals. READ ALL READ LESS Keywords Antimicrobial resistence, AMS training, hospital pharmacist, stewardship program, multidisciplinary Corresponding Author(s) FIFIN OKTAVIANI ( [email protected] ) Close Corresponding author: FIFIN OKTAVIANI Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 OKTAVIANI F and Binti Hamid H. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: OKTAVIANI F and Binti Hamid H. Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.12688/f1000research.171864.1 ) First published: 21 Oct 2025, 14 :1150 ( https://doi.org/10.12688/f1000research.171864.1 ) Latest published: 21 Oct 2025, 14 :1150 ( https://doi.org/10.12688/f1000research.171864.1 ) Introduction Antimicrobial Resistance (AMR) has emerged as a critical global health threat contributing to increased morbidity and mortality, with projections estimating up to 10 million deaths annually by 2050 ( Bajpai et al. 2025 ; Belay et al. 2025 ). The rise of multidrug-resistant bacterial infections leads to prolonged hospital stays, higher mortality rates, and limited treatment options. Standard therapeutic regimens are becoming less effective as drug-resistant pathogens complicate the management of common infections, rendering routine medical procedures such as surgeries, childbirth, and treatments for immunocompromised patients significantly riskier ( Stewart, Wright, and Hajkowicz 2019 ; Tang, Millar, and Moore 2023 ). Furthermore, the emergence and spread of multidrug-resistant “superbugs” exacerbate the challenge of infection control, particularly within healthcare settings, posing a serious barrier to achieving optimal health outcomes and sustainable antimicrobial management ( Bava et al. 2024 ; Hossein and Ripanda 2025 ). Antimicrobial Resistance (AMR) significantly increases healthcare costs due to prolonged hospitalizations, the need for intensive care, and the use of costly alternative drugs, with projections indicating a potential global GDP decline of 1.1% to 3.8% by 2050 ( Bajpai et al. 2025 ; Dadgostar 2019 ; Majumder et al. 2020 ). The growing prevalence of antimicrobial resistance (AMR) is largely driven by the excessive and inappropriate use of antibiotics that often fail to adhere to clinical guidelines, creating selective pressure that fosters the emergence of resistant bacterial strains ( Getahun 2023 ; Romero-Rodríguez et al. 2024 ; Singh et al. 2024 ). This issue is further intensified by the limited availability of laboratory facilities for antimicrobial sensitivity testing, compelling healthcare professionals to depend on empirical or broad-spectrum antibiotic therapy ( Khaitovych et al. 2025 ; Koroma et al. 2023 ; Mathew, Ranjalkar, and Chandy 2020 ). Such practices accelerate the survival and propagation of resistant bacteria, thereby exacerbating the global AMR crisis and highlighting the urgent need for strengthened antibiotic stewardship, improved diagnostic infrastructure, and stricter adherence to evidence-based prescribing practices ( Sain, Manohar, and Gowda 2020 ; Sharma et al. 2024 ; Sinha and Upadhyay 2025 ). Pharmacists play a pivotal role in Antimicrobial Stewardship (AMS) programs by optimizing antimicrobial use and contributing to the global effort to reduce antimicrobial resistance ( Donaldson and Mefford 2024 ; Parente and Morton 2018 ; Wong et al. 2021 ). Their involvement has been shown to significantly improve patient outcomes, enhance the appropriateness of antibiotic prescribing, and support the rational use of antimicrobials ( Qian et al. 2025 ; Sadeq et al. 2021 ). However, challenges such as limited training opportunities, insufficient institutional support, and interprofessional collaboration barriers continue to hinder their full participation in AMS initiatives. Building mutual understanding among pharmacists, nurses, and physicians is essential to ensure the success of antimicrobial stewardship efforts ( Manning et al. 2022 ; Wakob, Schiek, and Bertsche 2023 ). Therefore, sustained institutional support, specialized education, and the development of innovative, collaborative care models are essential to strengthen and expand the pharmacists’ role in advancing effective AMS implementation ( Sneddon, Gilchrist, and Wickens 2014 ; Waters 2015 ; Wong et al. 2021 ). National efforts to strengthen the implementation of the Antimicrobial Stewardship Program (ASP) in Indonesia have been initiated through the development of locally adapted, evidence-based antibiotic use guidelines. The application of these guidelines has been shown to reduce antibiotic consumption by up to 77% in intensive care units, decrease mortality rates, and shorten patients’ length of hospital stay ( Herawati et al. 2020 ; Karyanti, Pudjiadi, and Faisal 2020 ; Lutfiyati et al. 2022 ). Surveys indicate that although most pharmacists in Indonesia demonstrate high awareness of the importance of ASP, many still lack confidence in performing their clinical roles due to limited training opportunities and insufficient institutional support ( Muteeb et al. 2023 ; Wali et al. 2025 ). Enhancing pharmacists’ competencies through continuous professional education and structured ASP training is essential to reinforce antimicrobial resistance control efforts in Indonesian hospitals ( Qian et al. 2025 ; Tahoon et al. 2020 ; Teoh et al. 2020 ). Therefore, this study aims to evaluate the impact of ASP training interventions on the improvement of hospital pharmacists’ competencies and to examine their relationship with the achievement of ASP objectives at the institutional level. Methods Study design and population This study employed a quasi-experimental pre–post intervention design without a control group. This design was chosen to assess changes in pharmacists’ competencies before and after participating in the Antimicrobial Stewardship Program (ASP) training without interfering with their actual work environment. The study was conducted from August 2024 to January 2025 across 29 hospitals in the Riau Islands Province, Indonesia, encompassing both public and private hospitals with various accreditation levels. The target population consisted of all pharmacists working in hospitals within the Riau Islands Province, totaling 140 individuals. The sample size was calculated using the Raosoft online calculator with a 95% confidence level, a 5% margin of error, and an assumed response rate of 50%. Based on this calculation, the minimum required sample size was 103 respondents. Sampling technique A purposive sampling technique was employed to select participants who met specific inclusion criteria relevant to the study objectives. Eligible participants were pharmacists who had been actively working in hospitals for at least six months, were involved or had the potential to be involved in the implementation of the Antimicrobial Stewardship Program (ASP), and were willing to participate in all training sessions and evaluation phases. Pharmacists who did not complete all stages of the training or failed to submit either the pre-test or post-test assessments were excluded from the study. This sampling approach ensured that participants possessed sufficient professional experience and relevance to the ASP context, thereby enhancing the validity of the intervention outcomes. Intervention design The intervention consisted of a structured Antimicrobial Stewardship Program (ASP) training utilizing a participatory and competency-based learning approach. The training aimed to strengthen pharmacists’ knowledge, skills, and interprofessional collaboration in optimizing antimicrobial use within hospital settings. It was conducted in three sequential sessions: - Session 1 Data Preparation. This session focused on collecting baseline data and identifying antibiotic use patterns in participating hospitals to establish a foundation for contextual analysis and tailored training content. - Session 2 Core Materials. which provided comprehensive instruction on key topics including the principles of antimicrobial resistance and stewardship, rational prescribing and antibiotic utilization monitoring, quantitative and qualitative analysis of antibiotic use, the pharmacist’s role in AMS teams and interprofessional collaboration, case-based learning in infection management, and strategies to overcome barriers to AMS implementation in hospitals. - Session 3 Evaluation and Follow-up. This session emphasized reflection on the outcomes of ASP implementation, assessment of competency improvement, and the formulation of hospital-specific follow-up action plans to ensure program sustainability. Each session integrated data-driven exercises and collaborative discussions facilitated by academic supervisors and expert trainers in clinical pharmacy and antimicrobial resistance control. This structured design ensured a balance between theoretical understanding and practical application, thereby enhancing pharmacists’ capacity to contribute effectively to hospital-based antimicrobial stewardship initiatives. Instruments and measurements The study employed two primary instruments to evaluate both individual and institutional outcomes over a six-month pre-post intervention period. The first instrument was a Pharmacist Competency Questionnaire, designed to assess three key domains knowledge, skills, and attitudes related to the implementation of the Antimicrobial Stewardship Program (ASP). Each item was rated using a five-point Likert scale, and the total score was converted into a standardized competency index ranging from 0 to 1. The second instrument was a Hospital ASP Evaluation Form, used to measure the performance of ASP implementation across participating hospitals, focusing on policy components, antibiotic utilization audits, and healthcare staff education activities. Data were collected at two time points before (pre-test) and after (post-test) the six-month training intervention allowing for a comprehensive assessment of both pharmacists’ competency improvement and institutional progress in ASP implementation. Data analysis Data analysis was conducted using SPSS version 26.0 following a structured analytical framework to evaluate the effectiveness of the intervention. The Shapiro–Wilk test was first applied to assess the normality of data distribution. Differences in pharmacists’ competency scores before and after the intervention were analyzed using the Wilcoxon Signed-Rank test, while categorical changes in competency levels (improved vs. not improved) were examined using the McNemar test. The paired t-test was employed to compare hospital-level ASP performance scores between the pre- and post-intervention phases. Furthermore, the Spearman correlation test was used to determine the relationship between improvements in pharmacists’ competencies and corresponding enhancements in hospital ASP performance indicators. This analytical approach enabled a comprehensive evaluation of both individual and institutional impacts of the ASP training intervention. Result Demographic characteristics This study involved 103 pharmacists from 29 hospitals across the Riau Islands Province, encompassing both public and private hospitals accredited at the national level. The demographic and professional characteristics of these participants are presented in Table 1 . Table 1. Demographic and professional characteristics of pharmacist participants (n = 103). Variable Category n % Gender Male 23 22.3 Female 80 77.7 Age (years) 20–29 26 25.2 30–39 59 57.3 ≥40 18 17.5 Educational Background Bachelor of Pharmacy (Pharmacist) 96 93.2 Master of Clinical Pharmacy 4 3.9 Master of Pharmacy Management 3 2.9 Years of Work Experience 10 years 25 24.3 Previous AMS Training Attended 15 14.6 Not attended 88 85.4 Hospital Type Public 14 48.3 Private 15 51.7 Hospital classification levels A 0 0 B 10 34.5 C 12 41.4 D 7 24.1 The majority of respondents were female (approximately 80%), with the largest age group ranging from 30 to 39 years. Most participants held a Bachelor of Pharmacy degree with a professional pharmacist qualification, while only about 6% possessed a Master’s degree in clinical pharmacy. Approximately 85% of respondents had never participated in prior AMS training, and the majority had between 5 and 15 years of work experience in hospital pharmacy departments. These findings indicate that the level of prior exposure to AMS training among hospital pharmacists was relatively low before the intervention. Effect of AMS training on pharmacists’ competence The results of the descriptive analysis revealed a notable increase in pharmacists’ competence scores after the ASP training intervention. Details of the comparison between pre- and post-intervention scores are presented in Table 2 . Table 2. Comparison of pharmacists’ competence scores before and after ASP training intervention. Variable Pre-Intervention (Mean ± SD) Post-Intervention (Mean ± SD) Z/χ 2 p-value Pharmacist Competence (Total Score) 0.07 ± 0.25 0.94 ± 0.23 –8.825 (Wilcoxon) .000 “Improved” Category 7 (6.8%) 97 (94.2%) χ 2 = 88.011 (McNemar) .000 Δ Pharmacist Score (Post–Pre) – 0.67 ± 0.15 – – The mean pre-intervention score was 0.07 (SD = 0.25), which increased substantially to 0.94 (SD = 0.23) after the intervention. The McNemar test indicated a statistically significant change in the proportion of pharmacists categorized as “improved” after the AMS training (χ 2 = 88.011, p < 0.001). This finding was further supported by the Wilcoxon Signed-Rank Test (Z = –8.825, p < 0.001), confirming a strong intervention effect. All participants showed positive improvement (positive ranks = 103) with no decrease in competence scores. These results indicate that the AMS training program effectively enhanced pharmacists’ cognitive abilities, confidence, and readiness to perform stewardship roles within hospital settings. Enhancement of Antimicrobial Stewardship program (AMS) implementation at the institutional level At the institutional level, the Antimicrobial Stewardship Program (AMS) implementation scores significantly increased following the intervention. Details of the changes in hospital-level AMS implementation before and after the intervention are presented in Table 3 . Table 3. Changes in hospital-level AMS implementation scores before and after the intervention. Variable Pre-Intervention (Mean ± SD) Post-Intervention (Mean ± SD) Z/χ 2 p-value Hospital AMS Implementation Score 23.59 ± 9.12 33.45 ± 8.47 -4.72 (Wilcoxon) .000 Δ AMS Score (Post–Pre) – 9.86 ± 3.20 – – The mean AMS implementation score increased from 23.59 ± 9.12 before the intervention to 33.45 ± 8.47 after, with an average increase of 9.86 ± 3.20 points. The Wilcoxon Signed-Rank Test (Z = -4.72, p < 0.001) confirmed a statistically significant enhancement in AMS implementation across participating hospitals. This improvement reflects strengthened antibiotic prescription monitoring, the establishment of active AMS teams, and better interprofessional collaboration among healthcare providers. The shift from a “low-to-moderate” to a “good” implementation category demonstrates a tangible institutional impact of the training. Interrelationship between individual competence and institutional AMS performance Correlation analysis indicated that improvements in pharmacists’ competence were significantly associated with higher hospital AMS implementation scores. The results of this relationship are presented in Table 4 . Table 4. Correlation between pharmacists’ competence improvement and hospital AMS implementation scores. Variable Correlation coefficient (Hospital) p-value Δ Pharmacist Competence vs. Δ Hospital AMS Score 0.046 0.813 The Spearman’s rho correlation analysis between changes in pharmacists’ competence and changes in hospital AMS implementation scores yielded a correlation coefficient of Hospital = 0.046, p = 0.813 (n = 29), indicating no statistically significant relationship between the two variables. This finding suggests that while the training effectively enhanced pharmacists’ individual competencies, improvements in hospital-level AMS implementation are likely influenced by additional institutional factors, such as managerial support, interprofessional coordination, and the availability of organizational resources. Therefore, sustained AMS progress at the hospital level requires not only competent pharmacists but also systemic reinforcement through multidisciplinary collaboration and institutional commitment. Discussion This study demonstrated that the Antimicrobial Stewardship Program (ASP) training intervention significantly enhanced hospital pharmacists’ competence, particularly in qualitative and quantitative antibiotic use audits. Nearly all participants exhibited improved knowledge, analytical skills, and understanding of rational antibiotic use principles. However, this increase in individual competence did not translate into a statistically significant improvement in hospital-level ASP implementation scores. Similar to findings by Setiawan et al, challenges such as hierarchical culture, limited interprofessional collaboration, and power asymmetry between physicians and pharmacists may hinder the translation of individual learning into institutional change ( Setiawan et al. 2022 ). Hashad et al. also emphasized that successful ASP implementation depends not only on the competence of pharmacists but also on leadership engagement, structured planning, and effective communication among ASP teams ( Hashad et al. 2023 ). While training successfully improved pharmacists’ capabilities especially in performing qualitative and quantitative antimicrobial audits sustainable ASP progress in hospitals requires stronger managerial support, resource allocation, and an integrated, multidisciplinary culture that empowers pharmacists to apply their enhanced competencies in practice ( Chitavi et al. 2025 ). Most of the pharmacists who participated in this study were graduates of professional pharmacy programs, while the number of those with master’s degrees remained very limited. Only a small proportion held a Master’s degree in Clinical Pharmacy, a discipline crucial for integrating clinical pharmacology and microbiology knowledge to support evidence-based antibiotic therapy decisions. The scarcity of pharmacists with advanced clinical expertise limits their active involvement in antimicrobial stewardship (AMS) teams. This finding aligns with the conclusions of Sakeena et al., who emphasized that in many developing countries, pharmacists’ roles in AMS remain suboptimal due to the lack of advanced clinical training and institutional barriers that restrict their participation ( Sakeena, Bennett, and McLachlan 2018 ). Similarly, Vrinda et al. found that pharmacists in India and South Africa often face challenges such as insufficient AMS education, limited empowerment, and weak interprofessional recognition, which constrain their ability to lead stewardship programs ( Nampoothiri et al. 2024 ). Enhancing structured clinical education and formal AMS training pathways for hospital pharmacists in Indonesia could substantially strengthen their competence and active participation in stewardship initiatives. This study revealed that most hospitals in the study region lacked clinical microbiologists and adequately equipped microbiology laboratories. The absence of such facilities resulted in limited access to reliable microbiological data such as pathogen culture results, antibiotic susceptibility profiles, and antibiograms which are essential for guiding evidence-based antimicrobial therapy. Consequently, empirical antibiotic prescribing remains the predominant practice, often conducted without culture confirmation or local resistance data. Consistent with these findings, Hellen et al. reported that in resource-limited settings such as Kenya, approximately 40% of empirically prescribed antibiotics for urinary tract infections were inappropriate due to the absence of susceptibility testing, underscoring the urgent need to enhance diagnostic capacity ( Onyango et al. 2024 ). Likewise, Sautter-Thomson emphasized that the consolidation or underdevelopment of clinical microbiology laboratories in low- and middle-income countries significantly limits the timeliness and accessibility of diagnostic information, thereby impeding effective antimicrobial stewardship implementation ( Bielicki, Cromwell, and Sharland 2017 ). Collectively, these findings highlight that strengthening diagnostic infrastructure and ensuring the availability of clinical microbiology expertise are pivotal to optimizing antibiotic utilization and mitigating antimicrobial resistance at the institutional level. Another identified weakness is the limited structural support from hospitals, both in policies and resources. In many institutions, AMS programs are not yet strategic priorities and are handled administratively by committees. Only a few hospitals have structured teams, clear SOPs, and measurable indicators. According to WHO, AMS success depends on organizational commitment, funding, and managerial oversight ( WHO 2023 ). Alghamdi et al. showed that top management support was crucial for successful ASP implementation in Saudi hospitals ( Alghamdi et al. 2021 ). Likewise, Sato et al. found that many São Paulo hospitals lacked consistent feedback and evaluation metrics ( Sato 2021 ). Both studies highlight leadership engagement as a determinant of program sustainability. Sautter and Thomson added that consolidated microbiology laboratories enhance diagnostic efficiency supporting AMS decisions ( Sautter n.d. ). Before the intervention, most pharmacists had never received formal training on antimicrobial resistance prevention programs. The lack of continuous education resulted in low awareness and self-confidence among pharmacists to actively participate in AMS activities. The training conducted in this study proved effective in improving both knowledge and individual skills. The Wilcoxon test demonstrated a significant increase in competence scores, while the McNemar test confirmed that nearly all participants showed an improvement in their competence categories. These findings are consistent with those of Wong et al., who reported that structured training programs significantly enhanced pharmacists’ abilities to assess the rationality of antibiotic use, communicate clinical recommendations, and collaborate effectively within AMS teams ( Wong et al. 2021 ). The Spearman correlation analysis indicated that the increase in pharmacists’ competence was not significantly associated with improvements in hospital ASP outcomes (r = 0.046; p = 0.813). This suggests that although pharmacists demonstrated significant individual skill enhancement, such progress has not yet been effectively reflected in systemic implementation at the hospital level. These findings reaffirm that ASPs are inherently multidisciplinary programs, whose success depends on the synergy between various professional roles and organizational structures. As highlighted by Morency et al., antimicrobial stewardship represents a set of integrated interventions designed to optimize antimicrobial use through collaboration among infectious disease physicians, clinical pharmacists, and microbiologists. Clinical microbiologists, in particular, contribute critically by providing cumulative susceptibility reports, guiding pre-analytical processes, ensuring rapid diagnostic testing, and supporting continuous provider education and surveillance systems ( Morency-potvin, Schwartz, and Weinstein 2017 ). The effective implementation of Antimicrobial Stewardship Programs (ASPs) requires active engagement of hospital stakeholders, including leadership, physicians, nurses, and pharmacists. Hospital management establishes policies and allocates resources, while physicians and nurses ensure appropriate prescribing and monitoring. Pharmacists act as key stewards to promote evidence-based antimicrobial use and optimize patient outcomes. However, pharmacist competence alone is insufficient without multidisciplinary collaboration and managerial commitment. In Japan, Samura et al. demonstrated that ward-based infectious disease–certified pharmacists improved antimicrobial practices even without infectious disease physicians ( Samura 2019 ). Similarly, Hashad et al. emphasized that leadership engagement and interprofessional collaboration were vital facilitators of ASP success in UAE hospitals. These findings highlight that effective ASPs depend on empowered clinical pharmacists supported by strong institutional governance ( Hashad et al. 2023 ). The structured three-session training model implemented in this study—comprising data preparation, core face-to-face instruction, and online evaluation—proved highly effective in enhancing professional awareness and promoting the integration of AMS principles into daily practice. This practice-oriented approach not only improved theoretical understanding but also cultivated proactive and collaborative attitudes among healthcare professionals, essential for the sustainability of AMS initiatives. Similar to findings by Schrier et al., who emphasized that continuous education and interdisciplinary training are critical for effective antimicrobial stewardship across healthcare settings, this study supports embedding AMS education throughout professional development ( Schrier et al. 2018 ). Furthermore, Suzanne et al. highlighted that experiential learning and case-based training significantly improve participants’ confidence in antibiotic decision-making and adherence to stewardship protocols ( Kuijpers et al. 2025 ). Collectively, these findings suggest that structured, practice-based AMS training should be institutionalized as part of mandatory Continuing Professional Development (CPD) programs for hospital pharmacists, particularly in resource-limited settings. To ensure the successful and sustainable implementation of antimicrobial stewardship (AMS), establishing regional collaborative networks among hospitals is imperative. Hospitals with well equipped microbiology laboratories can function as referral and surveillance centers, facilitating regional antibiogram-based decision-making and promoting evidence-informed antibiotic practices. Such collaborations not only bridge disparities in institutional resources but also accelerate the translation of local data into actionable policies and clinical guidelines. Consistent with the findings of Nori et al., effective ASP implementation depends on sustained partnerships among hospital administration, clinical departments, pharmacy, infection prevention units, and microbiology services, as well as external collaborations with national health authorities and professional organizations ( Nori, Guo, and Ostrowsky 2018 ). These cooperative frameworks enable the development of harmonized policies, enhance research capacity, and expand the regional impact of stewardship initiatives. Overall, the present study underscores that while pharmacist-focused AMS training effectively strengthens individual competence, systemic and enduring improvements in hospital ASP performance can only be achieved through coordinated multidisciplinary engagement and robust institutional support. Conclusion This study found that structured antimicrobial stewardship (AMS) training significantly improved pharmacists’ competence in knowledge, skills, and professional attitudes, demonstrating its effectiveness as a capacity-building strategy. However, these individual improvements did not translate into systemic progress in hospital ASP implementation, emphasizing the need for stronger institutional and managerial support. Sustainable AMS outcomes require multidisciplinary collaboration, leadership commitment, and adequate diagnostic infrastructure. Integrating AMS education into mandatory Continuing Professional Development (CPD) programs and expanding regional hospital collaboration can enhance implementation consistency. These findings highlight that empowering pharmacists must be aligned with organizational and policy reforms to ensure long-term antimicrobial resistance control. Ethical considerations Ethical clearance for this study was obtained in the form of an exemption from the Health Research Ethics Committee, Faculty of Medicine, Andalas University, Indonesia (Ref. No. 561.layaketik/KEPKFKEPUNAND). The committee reviewed the research protocol and determined that the study met the criteria for exemption, as it involved minimal risk, non-invasive procedures, and voluntary participation of adult pharmacists. All procedures were conducted in accordance with the ethical standards of the committee and the principles outlined in the Declaration of Helsinki (2013 revision). Written informed consent was obtained from all pharmacists who took part in the study before their participation. Each participant received a clear explanation of the study’s purpose, procedures, voluntary nature, and the measures taken to maintain data confidentiality. The study did not involve any minors or vulnerable populations. Data availability All data supporting the findings of this study are openly available in the Zenodo repository and can be accessed without restriction. The datasets include anonymized pre- and post-intervention data on pharmacists’ competence and hospital-level Antimicrobial Stewardship Program (AMS) implementation outcomes. Both datasets are released under the Creative Commons Attribution 4.0 International (CC BY 4.0) license, allowing unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. • Pharmacists’ Competence Dataset: Contains pre- and post-training competence scores of hospital pharmacists, including demographic and professional background information. Zenodo DOI: https://doi.org/10.5281/zenodo.17067674 ( Oktaviani, 2025 ) • Hospital-Level AMS Implementation Dataset: Includes institutional AMS implementation scores collected before and after the training intervention, used to evaluate hospital-level program improvement. Zenodo DOI: https://doi.org/10.5281/zenodo.17300354 ( Oktaviani & Hamid, 2025 ) No embargo or access restrictions apply to these datasets. Acknowledgments The authors would like to express their sincere gratitude to the hospital management teams, pharmacists, and healthcare professionals who actively participated in the Antimicrobial Stewardship Program (AMS) training and evaluation. Special appreciation is extended to the Riau Islands Provincial Health Office and the participating hospitals for their collaboration and logistical support throughout the study. The authors also thank the expert facilitators and academic mentors who contributed to the development and delivery of the AMS training modules, as well as all staff members who assisted in data collection and coordination across 29 hospitals in the province. References Alghamdi S, Berrou I, Bajnaid E, et al. : Antimicrobial Stewardship Program Implementation in a Saudi Medical City: An Exploratory Case Study.2021. 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Wong LH, Tay E, Heng ST, et al. : Hospital Pharmacists and Antimicrobial Stewardship: A Qualitative Analysis. Antibiotics. 2021; 10 (12). PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 21 Oct 2025 ADD YOUR COMMENT Comment Author details Author details 1 faculty of health sciences, Universitas Batam, Batam, Riau Islands, Indonesia 2 Faculty of Pharmacy, Lincoln University College, Petaling Jaya, Selangor, Malaysia FIFIN OKTAVIANI Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Hazrina Binti Hamid Roles: Supervision Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 21 Oct 2025, 14:1150 https://doi.org/10.12688/f1000research.171864.1 Copyright © 2025 OKTAVIANI F and Binti Hamid H. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article OKTAVIANI F and Binti Hamid H. Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.12688/f1000research.171864.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 21 Oct 2025 Views 0 Cite How to cite this report: Mickelsson M. Reviewer Report For: Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.5256/f1000research.189523.r453428 ) The direct URL for this report is: https://f1000research.com/articles/14-1150/v1#referee-response-453428 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 03 Mar 2026 Martin Mickelsson , Department of Earth Sciences, University of Gothenburg Department of Earth Sciences, Gothenburg, Västra Götaland County, Sweden Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.189523.r453428 Summary: The paper focuses on a often neglected group of health practitioners, the pharmacists. Engaging with the key sustainable health challenge of AMR the paper presents a competence building intervention aimed at pharmacists, exploring in a valuable ... Continue reading READ ALL Summary: The paper focuses on a often neglected group of health practitioners, the pharmacists. Engaging with the key sustainable health challenge of AMR the paper presents a competence building intervention aimed at pharmacists, exploring in a valuable way the relationship between competence development and AMR institutional implementation. The paper discusses the challenges relating to AMS of 1. limited training opportunities, 2. insufficient institutional support, 3. interprofessional collaboration barriers. The main insight of the paper is how the effect of improving one of these is not enough and that all three need to be improved together. The paper has great potential in making a meaningful contribution to perspectives on AMS and need to for institutional support beyond individual competence. Meanwhile, there are some relatively minor comments. 1. Already in the introduction the authors state that "sustained institutional support, specialized education, and the development of innovative, collaborative care models are essential to strengthen and expand the pharmacists’ role in advancing effective AMS implementation". Then the reader wonders what is the contribution of the paper if this is already known. Perhaps it can be further clarified that the authors are outlining how these factors together are necessary rather than if they are so. This would make it clearer what the study adds. 2. When presented the pharmacist training studied in the paper is describes as focused on strengthen pharmacists’ 1. knowledge, 2. skills, and 3. interprofessional collaboration. However later on the questionnaire used is described as designed to assess 1. Knowledge, 2. Skills and 3. Attitudes. It is unclear why the questionnarie would not be designed to assess what is stated to be the three key aspects of the training. 3. The abstract states “no significant correlation was found between pharmacists’ competence improvement and hospital ASP performance”. Later on it is stated that Antimicrobial Stewardship Program (AMS) implementation scores significantly increased following the intervention. Under the headline “Interrelationship between individual competence and institutional AMS performance” it is stated that correlation analysis indicated that improvements in pharmacists’ competence were significantly associated with higher hospital AMS implementation scores. This might be a difference whether it was a correlation and a statistically significant relationship. However, it could be worded a bit clearer to avoid confusion. On the whole a very promising paper and with some relatively smaller edits can make a valuable contribution to AMS research. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Antimicrobial resistance, One health, health literacy, determinants of health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mickelsson M. Reviewer Report For: Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.5256/f1000research.189523.r453428 ) The direct URL for this report is: https://f1000research.com/articles/14-1150/v1#referee-response-453428 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Sharma S. Reviewer Report For: Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.5256/f1000research.189523.r441824 ) The direct URL for this report is: https://f1000research.com/articles/14-1150/v1#referee-response-441824 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Jan 2026 Sangeeta Sharma , Institute of Human Behaviour & Allied Sciences Dilshad Garden, Delhi, New Delhi, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.189523.r441824 This manuscript addresses an important and timely issue of AMR and evaluates the impact of Antimicrobial Stewardship Program training on pharmacists’ competence and hospital-level implementation. The study is well-structured, employs appropriate statistical methods, and provides practical insights for resource-limited ... Continue reading READ ALL This manuscript addresses an important and timely issue of AMR and evaluates the impact of Antimicrobial Stewardship Program training on pharmacists’ competence and hospital-level implementation. The study is well-structured, employs appropriate statistical methods, and provides practical insights for resource-limited settings. However, limitations in generalizability, incomplete data presentation, and insufficient detail on measurement tools reduce the strength of the conclusions. Measurement Instruments The manuscript lacks details on the validation and reliability of the Pharmacist Competency Questionnaire and Hospital ASP Evaluation Form. Data Presentation Tables referenced in the text (e.g., demographic characteristics, pre/post scores) are incomplete or missing. Ensure all tables and figures are fully presented for transparency. Correlation Analysis The discussion of the non-significant correlation between pharmacist competence and hospital ASP performance is brief. Consider exploring potential confounders such as hospital size, resource availability, and leadership engagement. Institutional Barriers While barriers are mentioned, the discussion could benefit from deeper analysis or qualitative insights to explain why competence improvements did not translate into systemic change. Limitations Limitation should be acknowledged more explicitly and discuss its implications for interpreting results. Terminology Consistency The manuscript alternates between AMS and ASP terminology. Standardize usage throughout for clarity. Minor Comments Language and Style Improve readability by addressing minor grammatical errors and abrupt transitions, particularly in the Results and Discussion sections. References Ensure all cited studies are formatted consistently and verify that recent references are correctly linked to the discussion points. Policy Recommendations Expand on practical steps for integrating AMS training into national CPD frameworks and hospital governance policies. Formatting Check alignment of tables, headings, and subheadings for professional presentation. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pharmacology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Sharma S. Reviewer Report For: Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.5256/f1000research.189523.r441824 ) The direct URL for this report is: https://f1000research.com/articles/14-1150/v1#referee-response-441824 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 21 Oct 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 21 Oct 25 read read Sangeeta Sharma , Institute of Human Behaviour & Allied Sciences Dilshad Garden, Delhi, India Martin Mickelsson , University of Gothenburg Department of Earth Sciences, Gothenburg, Sweden Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Mickelsson M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 03 Mar 2026 | for Version 1 Martin Mickelsson , Department of Earth Sciences, University of Gothenburg Department of Earth Sciences, Gothenburg, Västra Götaland County, Sweden 0 Views copyright © 2026 Mickelsson M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Summary: The paper focuses on a often neglected group of health practitioners, the pharmacists. Engaging with the key sustainable health challenge of AMR the paper presents a competence building intervention aimed at pharmacists, exploring in a valuable way the relationship between competence development and AMR institutional implementation. The paper discusses the challenges relating to AMS of 1. limited training opportunities, 2. insufficient institutional support, 3. interprofessional collaboration barriers. The main insight of the paper is how the effect of improving one of these is not enough and that all three need to be improved together. The paper has great potential in making a meaningful contribution to perspectives on AMS and need to for institutional support beyond individual competence. Meanwhile, there are some relatively minor comments. 1. Already in the introduction the authors state that "sustained institutional support, specialized education, and the development of innovative, collaborative care models are essential to strengthen and expand the pharmacists’ role in advancing effective AMS implementation". Then the reader wonders what is the contribution of the paper if this is already known. Perhaps it can be further clarified that the authors are outlining how these factors together are necessary rather than if they are so. This would make it clearer what the study adds. 2. When presented the pharmacist training studied in the paper is describes as focused on strengthen pharmacists’ 1. knowledge, 2. skills, and 3. interprofessional collaboration. However later on the questionnaire used is described as designed to assess 1. Knowledge, 2. Skills and 3. Attitudes. It is unclear why the questionnarie would not be designed to assess what is stated to be the three key aspects of the training. 3. The abstract states “no significant correlation was found between pharmacists’ competence improvement and hospital ASP performance”. Later on it is stated that Antimicrobial Stewardship Program (AMS) implementation scores significantly increased following the intervention. Under the headline “Interrelationship between individual competence and institutional AMS performance” it is stated that correlation analysis indicated that improvements in pharmacists’ competence were significantly associated with higher hospital AMS implementation scores. This might be a difference whether it was a correlation and a statistically significant relationship. However, it could be worded a bit clearer to avoid confusion. On the whole a very promising paper and with some relatively smaller edits can make a valuable contribution to AMS research. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Antimicrobial resistance, One health, health literacy, determinants of health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Mickelsson M. Peer Review Report For: Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.5256/f1000research.189523.r453428) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1150/v1#referee-response-453428 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Sharma S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Jan 2026 | for Version 1 Sangeeta Sharma , Institute of Human Behaviour & Allied Sciences Dilshad Garden, Delhi, New Delhi, India 0 Views copyright © 2026 Sharma S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This manuscript addresses an important and timely issue of AMR and evaluates the impact of Antimicrobial Stewardship Program training on pharmacists’ competence and hospital-level implementation. The study is well-structured, employs appropriate statistical methods, and provides practical insights for resource-limited settings. However, limitations in generalizability, incomplete data presentation, and insufficient detail on measurement tools reduce the strength of the conclusions. Measurement Instruments The manuscript lacks details on the validation and reliability of the Pharmacist Competency Questionnaire and Hospital ASP Evaluation Form. Data Presentation Tables referenced in the text (e.g., demographic characteristics, pre/post scores) are incomplete or missing. Ensure all tables and figures are fully presented for transparency. Correlation Analysis The discussion of the non-significant correlation between pharmacist competence and hospital ASP performance is brief. Consider exploring potential confounders such as hospital size, resource availability, and leadership engagement. Institutional Barriers While barriers are mentioned, the discussion could benefit from deeper analysis or qualitative insights to explain why competence improvements did not translate into systemic change. Limitations Limitation should be acknowledged more explicitly and discuss its implications for interpreting results. Terminology Consistency The manuscript alternates between AMS and ASP terminology. Standardize usage throughout for clarity. Minor Comments Language and Style Improve readability by addressing minor grammatical errors and abrupt transitions, particularly in the Results and Discussion sections. References Ensure all cited studies are formatted consistently and verify that recent references are correctly linked to the discussion points. Policy Recommendations Expand on practical steps for integrating AMS training into national CPD frameworks and hospital governance policies. Formatting Check alignment of tables, headings, and subheadings for professional presentation. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Pharmacology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Sharma S. Peer Review Report For: Effectiveness of Antimicrobial Stewardship Training on Pharmacists’ Competence and Hospital ASP Implementation : A Multidisciplinary Approach in Riau Islands Province, Indonesia [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :1150 ( https://doi.org/10.5256/f1000research.189523.r441824) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1150/v1#referee-response-441824 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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