Empowering patients as co-researchers in social pharmacy: Lessons learned and practical tips for meaningful partnership and impact.

Engaging patients as co-researchers in health service research, involving them in the design, planning, and implementation rather than treating them as mere participants, can yield positive outcomes and generate value for patients' health. It also increases patients' health literacy and empowerment, leading to more meaningful studies and substantial research impact. However, deeper levels of engagement as partners throughout the research lifecycle come with ethical and methodological challenges. This commentary provides actionable advice for Patient Engagement and Involvement (PEI) in social pharmacy research through a rapid review of models, frameworks, and guidelines and by gathering lessons from four recent social pharmacy research initiatives conducted in Nordic settings. It also identifies and discusses ethical and methodological challenges to conducting authentic and sustained patient-driven research. Deeper levels of engagement where patients take the lead in shaping the social pharmacy research question(s) are rare due to the intensity of resources required. With these 24 tips and the lessons learned, we aim to make this approach more accessible to social pharmacy researchers interested in PEI.

Online and Blended Learning Courses for Healthcare Professionals and Policymakers on Patients' Perspectives on Medicine: A Project Report.

In order for healthcare professionals to better engage with patients, they need to understand and integrate the perspectives of patients into their daily work. In this project, we developed two courses for healthcare professionals on patients' perspectives on medicine. One course was an online course that introduced the patients' perspectives on medicine and explained its importance for healthcare and health policy. The second course was a blended learning course, consisting of online modules and face-to-face webinars, which specified how to explore patients' perspectives in qualitative interviews, and how to develop implementation plans. Patients participated in the development, execution, and evaluation of both courses. Overall, more than 2000 healthcare professionals enrolled in the first course and, in just over a year, 191 participants completed the online course; 57 healthcare professionals registered in the second blended learning course and six participants completed both components of the course. The relevance of knowledge gained was positively evaluated. Participants especially appreciated the participation of patients. Based on the feedback, the second blended learning course was adapted to run online and both courses continue to be freely available to all interested healthcare professionals on the Coursera platform.

A Qualitative Analysis of the Culture of Antibiotic Use for Upper Respiratory Tract Infections Among Patients in Northwest Russia.

Introduction: Due to the globally persistent threat of Antimicrobial Resistance (AMR), the purpose of this study was to gain an in-depth understanding of the antibiotic (AB) practices, knowledge and attitudes among patients residing in five regions in the northwest part of Russia. Given the high prevalence, this study focused on ABs for Upper Respiratory Tract Infections (URTI). Methods: The qualitative, semi-structured interviews followed a guide organized by major themes such as common symptoms, consultations with doctors and external influences in decision-making. Patient participants were recruited via convenience sampling. Fifty-five interviews were conducted among patients using ABs for URTIs purchased with or without prescription. Data was analyzed using a direct content analysis and validation rounds were conducted between interviewers and data analyzers. Results: Self-medication with ABs seemed a common practice across all five Russian regions; in some cases, patients tried to persuade pharmacists into selling them ABs without prescription. Factors, such as time spent going to the doctor, need of a sick leave or self-persuasion, influenced the decisions of whether or not to seek the doctor for symptoms of URTIs. Knowledge of ABs and AMR was generally low; however, some patients with seemingly good knowledge practiced self-medication from time to time. Family members and friends were often involved in decisions about how to handle symptoms of URTIs, especially among those patients using ABs without prescription. Few patients had noticed ABs awareness campaigns, and very few reported having learned something important from them. Conclusion: Despite enforced regulation of AB use in Russia, self-medication still exists. Knowledge is not always linked to appropriate use of AB, and the few campaigns conducted were not always noticed.

Community involvement and awareness raising for better development, access and use of medicines: The transformative potential of photovoice.

Photovoice is a qualitative research method where people, through images (photography, drawings or paintings), capture, represent, and communicate their experiences and perspectives about issues that are important to them with the final goal of raising awareness and triggering social change. Photovoice is informed by participatory action research approaches, feminist theory, Paulo Freire's critical pedagogy, and the theory of photography. Developed with the explicit purpose of gathering voices to advocate for structural social change in the early 1990s, the application of Photovoice in projects related to social pharmacy research started approximately 15 year later. The first Photovoice studies within social pharmacy aimed at understanding patients' experiences with their medications. Photovoice has also been integrated in interventions mainly focused on enhancing adherence to pharmacological treatments. There is still, however, room to fully unfold the empowering and emancipatory potential of Photovoice within social pharmacy research. This article briefly presents the theories underlying Photovoice, a guide for its appropriate methodological and ethical implementation, and with the aim to serve as inspiration for future social pharmacy research projects, it also includes three previously published studies that used Photovoice to understand, raise awareness and trigger social change to facilitate better lives when in need of pharmacological treatments.

Vitamin D Knowledge, Attitudes, and Behaviors in Young Danish Women with a Non-Western Ethnic Minority Background-A Questionnaire Survey.

The prevalence of vitamin D deficiency in women with a non-Western ethnic minority background in Nordic countries is high. The aim of this study was to assess vitamin D knowledge, attitudes, and behaviors in women with a non-Western ethic minority background living in Denmark. A validated vitamin D knowledge, attitudes, and behaviors' questionnaire was translated into Danish, piloted, and distributed via relevant Facebook groups. The responses were analyzed using parametric and non-parametric tests for descriptive and bivariate analyses. In total, 254 women who considered themselves having a non-Western ethnic minority background responded to the questionnaire. The median age (IQR) was 25 (23-33) years old; 32% had a professional bachelor's, 28% had high school, and 22% had a master's or higher university education. Participants scored higher on vitamin D general knowledge (scores above 80 on the scale 0-100) compared to vitamin D nutrition knowledge or vitamin D attitudes and behaviors (scores around 60 on the scale 0-100). In conclusion, the vitamin D knowledge among study participants-i.e., young well-educated non-Western ethnic minority women in Denmark-was pretty good. The further examination of vitamin D knowledge, attitudes, and behaviors should explore specifics related to nationality and religion and focus on less-educated non-Western ethnic minority women in Denmark and other Nordic countries.

Young Muslim Women Living with Asthma in Denmark: A Link between Religion and Self-Efficacy.

Asthma is a chronic respiratory disease that can be controlled with appropriate medicinal treatment. Adherence to pharmacological treatment is therefore critical. Self-efficacy plays a key role in adherence to medicine in chronic diseases, including asthma. Additionally, ethnic minorities have poor adherence to medicines. However, the impact of religion on self-efficacy and adherence is understudied. Therefore, the aim of this study was to explore the role of self-efficacy in adherence to asthma medicine treatment and the influence of religion on self-efficacy among young, Muslim minority women. A focus group and individual interviews with 10 Muslim minority women (14⁻24 years of age) living in Denmark were conducted. Data analysis was deductive using Bandura's theory of self-efficacy and modes of agency. Overall, religion was shown to affect self-efficacy. The women reported changes in self-perceived self-efficacy during the holy month of Ramadan. In addition, praying was used as an alternative to medicine for controlling asthma symptoms. However, the women did not perceive religion and treating asthma with medicine as mutually exclusive, but rather as coexisting for the shared goal of controlling asthma symptoms. It is important for healthcare professionals (HCPs) to be aware of the link between self-efficacy, religion and adherence to asthma medicine treatment. This awareness can aid HCPs in giving advice regarding adherence to asthma treatment, and when monitoring treatment to improve the quality of asthma care for young Muslim minority women.

Ethnic Differences in Persistence with COPD Medications: a Register-Based Study.

BACKGROUND: Long-acting bronchodilators (LABDs) are recommended as a first-line maintenance therapy in patients with moderate or severe chronic obstructive pulmonary disease (COPD). The aim of the study was to explore potential ethnic differences in persistence with LABD in COPD patients. METHODS: A cohort of COPD patients diagnosed in 2003-2007 in Copenhagen, Denmark, was followed for 2 years in the Danish national registers. According to the number of the LABD medications dispensed, individuals were categorized into three therapy groups: monotherapy, drug combination therapy, and multiple drug therapy. Persistence was defined as the period from the first prescription date to the date of discontinuation. Treatment was considered discontinued if the interval between the two prescriptions was longer than the number of days of cumulative medication supply according to defined daily doses plus 7 days. RESULTS: In total, 1129 incident COPD patients using LABDs were included; 6.7% had other than Danish ethnic background. Survival analyses showed that in the cases where LABD medication combination presented COPD maintenance therapy, ethnic background was associated with the higher risk of the therapy discontinuation: HR = 1.40, 95% CI = 1.03-1.90, p = 0.03. There were no ethnic differences in persistence in the monotherapy or multiple therapy groups. CONCLUSIONS: COPD patients with other than Danish ethnic background discontinued COPD maintenance therapy more often than ethnic Danes. Attention to the barriers of persistent COPD medication use in COPD patients from ethnic minorities should be payed to facilitate better COPD management.

Parental knowledge of antibiotic use in children with respiratory infections: a systematic review.

OBJECTIVE: Antimicrobial resistance (AMR) is an increasing global problem. AMR threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. The misuse and overuse of antibiotics (AB) is the major contributor to the emergence of resistant bacteria in humans. To present and describe characteristics in parents' knowledge about when and how to use AB for an upper respiratory tract infection (URTI), their attitudes towards doctors and AB use in general, and their behaviour when their child suffers from an URTI. KEY FINDINGS: The database search was conducted in EMBASE and PubMed for articles published in English, French, Spanish and Scandinavian languages from the inception until May 2016. Qualitative and quantitative studies with focus on parent' knowledge, attitude and behaviour concerning treatment with AB for URTIs among children and adolescents were included. Extracted information included date of study, design, focus, location and population, parental knowledge, attitudes and behaviours regarding paediatric AB use and parental socioeconomic and sociodemographic characteristics. Parental knowledge about the causes of URTIs and when to use AB, education and parental and children's age affect attitudes and behaviours. However, good level of knowledge about AB (when and how to use it), often correlated with living in a Western country and belonging to high socioeconomic position, does not always imply judicious use of AB for URTIs among children. Providing parents with a contingency plan and clarifications on why an AB is not needed for common colds improves parental satisfaction with their physicians. SUMMARY: Evidence gathered from 20 countries from studies published in the last 20 years shows that parental knowledge still plays a major role in when and how to use AB for URTIs among children. However, parents are not disappointed if the physician does not prescribe AB, provided that proper explanations and a contingency plan are given.

Ethnic Inequalities in COPD Outcomes: a Register-Based Study in Copenhagen, Denmark.

The aim of this study was to investigate the differences in age at diagnosis and survival time after diagnosis between Chronic Obstructive Pulmonary Disease (COPD) patients with native Danish and other ethnic backgrounds. Individuals diagnosed with COPD in a hospital setting in Copenhagen in the period 2003-2007 were identified from annual hospital contact records. The cohort was restricted to COPD patients older than 35 years old at diagnosis. Follow-up was available until the end of 2010. ANOVA was conducted to test if mean age at diagnosis differed between the patient groups with different ethnicity. Kaplan-Meier estimator was used to estimate survival time after diagnosis. Cox proportional hazards models were conducted to calculate hazards of death according to ethnicity. A total of 2845 COPD patients were included; 131 (4.6%) were with non-Western ethnic minority backgrounds. Patients with non-Western ethnic backgrounds were diagnosed at a younger age and had a better survival probability compared to ethnic Danish patients; hazard ratio HR (95% CI) for death during follow-up in non-Western vs. ethnic Danish patients was 0.33 (0.18-0.62). Our study showed marked differences in age at diagnosis and survival time after diagnosis between the COPD patients with different ethnic backgrounds residing in Copenhagen. Further studies are needed to find out the reasons for younger age of COPD diagnosis in non-Western minorities and for shorter survival time after diagnosis in ethnic Danish COPD patients.

Traditional medicine among people of Pakistani descent in the capital region of Copenhagen.

ETHNOPHARMACOLOGICAL RELEVANCE: Studies show that ethnic minorities continue to use their cultural traditional medicines also after migration to the West. Research in this field is necessary, given that little is known about traditional medicines' impact on health-related problems. This study sheds light on the issue through a qualitative study among ethnic Pakistanis residing in Denmark. AIM OF THE STUDY: The study addresses perception, knowledge and attitudes regarding the use of medicinal plants among Pakistanis living in Copenhagen. We furthermore document and identify the medicinal plants used in households. MATERIALS AND METHODS: Data were collected through in-depth, semi-structured interviews with sixteen ethnic Pakistanis aged 30-80 years. Interviews were transcribed verbatim and analysed through Emerson's two-phased analysis method. Medicinal plant products in the interviewees' households were collected, photographed, identified and deposited at Museum of Natural Medicine at University of Copenhagen. RESULTS: A total number of 121 Pakistani traditional medicines were identified, and found to represent both medicinal plants and foods. The average number of quoted Pakistani Traditional Medicines was 18 (N=16). Interviewees independently reported the same traditions for preparation and consumption of Pakistani traditional medicines. Factors that play a role in choosing to use Pakistani traditional medicines are frequent visits to Pakistan, belief in the healing power of totkas (homemade medicinal preparation), religious knowledge and the occurrence of recent illness within the family. Further, the upkeep of traditional use depends on the availability of Pakistani traditional medicines. CONCLUSION: The study enhanced understanding of ethnic Pakistanis' perception and continued use of traditional medicines within the household after migration to the West. In the context of Western biomedicine, little is known of the potential toxicity and side-effects of many of the Pakistani traditional medicines found to be used in households in Copenhagen.

Ethnic differences in asthma treatment among Swedish adolescents: A multilevel analysis of individual heterogeneity.

AIMS: Adolescents with immigrant or ethnic minority background suffering from asthma receive on average less appropriate anti-asthmatic medication (AAM) than the majority population. However, those findings are based on analyses of differences between group averages which prevents our understanding of individual heterogeneity around the averages. Taking into account individual socioeconomic factors and medical needs, we performed multilevel analysis in order to evaluate if maternal country of birth (MCOB) accurately identifies adolescents with inappropriate AAM use. METHODS: Using the Swedish Medical Birth Register, we identified all singleton children born between 1988 and 1991 who were residing in the country until they turned 17 and had complete information on the study variables. We applied a two-level multilevel logistic regression analysis with 62 MCOBs at the second and 755,894 children at the first level. Adjusting for socioeconomic and medical factors using a risk score, and including the socioeconomic characteristics of the MCOBs, we obtained both measures of association (odds ratio (OR)) and measures of variance (Intra-class correlation (ICC)). RESULTS: Comparing with adolescents born from Swedish mothers, all other children had a lower AAM use, especially those whose mothers were from upper-middle- and low-income countries (OR = 0.47, 95% confidence interval: 0.35-0.61). However, the ICC was low (i.e., ICC ≈ 3%) for both preventive and relief AAM. CONCLUSIONS: MCOB was associated to adolescent use of AAM. However, the small ICC indicates that MCOB is an inaccurate categorization for identifying inappropriate use of AAM among Swedish adolescents.

Ethnic differences in adverse drug reactions to asthma medications: a systematic review.

BACKGROUND: Information on ethnic diversity of adverse drug reactions (ADRs) to asthma medications is rare despite evidence suggesting higher risk for African Americans when using ß2-adrenergic receptor agonists. The objectives are to investigate how ethnic background was involved in ADR assessment and to examine the relationship between ethnic background and ADRs to asthma medications. METHODS: MEDLINE was searched until March 2014. All types of studies reporting ADRs to asthma medications involving more than one ethnic group were included. Extracted information includes study designs, ethnic backgrounds, intervention, and types and severities of ADRs. RESULTS: Among the selected 15 randomised clinical trials, six pooled analyses of randomized clinical trials, and five prospective observational studies, only six studies compared ADRs across different ethnic groups. The majority of the comparisons were either statistically insignificant or inconclusive. CONCLUSIONS: Ethnicity was largely overlooked. Most studies neglected to report ADRs by ethnicity. Lack of consistency in defining ethnicities complicated further pooled analyses. Despite the higher prevalence of asthma among specific ethnic minority groups, few studies disaggregated information by ethnic background, and reports of ADRs to asthma medications in different ethnic groups were rare. We suggest that the inclusion of ADR analysis by different ethnic backgrounds is desirable.

Social Pharmacy Research in Copenhagen-Maintaining a Broad Approach.

Social Pharmacy (SP) is a multidisciplinary field to promote the adequate use of medicine. The field of SP is increasingly important due to a numbers of new trends all posing challenges to society. The SP group at the University of Copenhagen has for several years used a broad approach to SP teaching and research, often illustrated by the four levels: individual, group, organizational, and societal. In this paper the relevance of maintaining a broad approach to SP research is argued for and examples of the importance of such type of research is presented.

Ethnic background and human papillomavirus vaccine uptake in Denmark: A countrywide retrospective cohort study including 274,154 women aged 19-28 years.

AIM: We examined ethnicity-related differences in the uptake of a temporary free-of-charge HPV vaccine (HPVV) catch-up programme offered in Denmark from August 2012 to December 2013 to women born from 1985-1992 and compared it with the previous self-payment system in place. METHODS: We conducted a nationwide retrospective cohort study. We performed logistic regression analyses to examine the relationship between ethnic background and HPV vaccine (HPVV) programme initiation. RESULTS: The free programme increased the vaccination uptake from 16% to 75%. Descendants (Denmark-born women with both parents of foreign origin) and immigrants in Denmark for more than 5 years were less likely to initiate the free HPVV programme than Denmark-born women ((aOR=0.56; 95% CI: 0.54-0.59) and (aOR=0.39; 95% CI: 0.38-0.40), respectively). The likelihood of HPVV programme initiation among immigrants increased with time in Denmark ((aOR=2.28; 95% CI: 2.11-2.48) for immigrants living in Denmark for 16-20 years compared to 6-10 years)). CONCLUSION: The initiation of the free-of-charge HPVV programme was satisfactory. However, large differences in uptake were demonstrated, indicating that some target groups are harder to reach than others. The integration process (as related to use of health services) occurs over many years where differences between the different population groups seem to vanish.

Determinants in the Uptake of the Human Papillomavirus Vaccine: A Systematic Review Based on European Studies.

BACKGROUND: Cervical cancer is the fourth most common cancer affecting women worldwide. Since 2006, two human papillomavirus vaccines (HPVV) have been licensed to protect women against the virus that causes cervical cancer. However, worldwide coverage remains unequal. Studies from the USA found strong evidence for differences in HPVV uptake by ethnicity and healthcare coverage. As the profile of ethnic groups and the healthcare system in the USA differ from countries in Europe where HPVV is free in most of the countries, we conducted a systematic review in order to analyze the determinants of HPVV uptake in Europe. METHODS: We performed a systematic Pubmed, Scopus, and Science Direct search to find articles published from HPVV availability in European countries until April 2014. No age restriction was applied. We included all studies assessing factors associated with HPVV uptake. Uptake refers to either initiation and/or completion of the three dose vaccination program. RESULTS: Out of the 23 eligible studies, 14 were retrospective reviews of data, six were cross-sectional surveys, and three were prospective cohort studies. Higher HPVV uptake was associated with ethnic majority populations, higher socio-economic status, regular cervical screening participation by the mother, and having received previous childhood vaccinations. CONCLUSION: Since the vaccine is offered for free in most of the European countries, the findings suggest that ethno-cultural and educational factors play an important role when it comes to HPVV uptake. Girls who were undervaccinated had also a lower uptake of standard childhood vaccines and mothers who were less likely to attend cervical cancer screening. This may indicate that only few parents have specific concerns with HPVV, and that preventive health care should seek ways to target these vulnerable groups.

A culturally competent education program to increase understanding about medicines among ethnic minorities.

BACKGROUND: It has been previously suggested that the risk of medicine-related problems-i.e., negative clinical outcomes, adverse drug reactions or adverse drug events resulting from the use (or lack of use) of medicines, and human error including that caused by healthcare personnel-is higher among specific ethnic minority groups compared to the majority population. OBJECTIVE: The focus of this study was on reducing medicine-related problems among Arabic-speaking ethnic minorities living in Denmark. The aim was twofold: (1) to explore the perceptions, barriers and needs of Arabic-speaking ethnic minorities regarding medicine use, and (2) to use an education program to enhance the knowledge and competencies of the ethnic minorities about the appropriate use of medicines. SETTINGS: Healthcare in Denmark is a tax-financed public service that provides free access to hospitals and general practitioners. In contrast to the USA or the UK, serving ethnically diverse populations is still a relatively new phenomenon for the Danish healthcare system. Ethnic minorities with a non-Western background comprised a total of 6.9 % of the Danish population. METHODS: Data were collected through qualitative research. Four focus group interviews were conducted before and four after the education program. Thirty Arabic-speaking participants were recruited from language and job centers in Copenhagen. Participants received teaching sessions in Arabic on appropriate medicine use. The education program was evaluated by two methods: a written quiz for knowledge evaluation and focus group interviews for process evaluation. It took place during the first semenester of 2012. Results The majority of the participants were dissatisfied with the knowledge about medicines inherited from their parents. They also expressed their frustrations due to communication problems with Danish doctors. According to the impressions and quiz results of participants, the program was relevant, rich in information and effective. The program helped bridge the gap between participants and doctors. The commonality of the culture, language and gender shared by the researcher pharmacist and participants enhanced the success of the program. CONCLUSION: The education program may potentially reduce medicine-related problems by providing participants with knowledge and competencies about appropriate medicine use. We recommend implementing education programs for ethnic minorities using the cultural competence approach to the appropriate use of medicines. Ideally, programs should be implemented in places that are frequented by ethnic minorities, and taught by health professionals with the same ethnic background as participants.

Ethnic and migrant differences in the use of anti-asthmatic medication for children: the effect of place of residence.

BACKGROUND: Ethnic differences in the use of anti-asthmatic medication have been reported, with ethnic minorities being at a higher risk of suboptimal asthma control. As contextual socioeconomic characteristics may play a role, we analysed whether ethnic differences in the use of anti-asthmatic medication among children residing in the Capital Region of Denmark varied by place of residence. METHODS: Data were obtained from the Danish Civil Registration System, the Central Taxpayers' Register and the Danish National Prescription Register and were linked at the individual level. Population used was the entire child population in the Capital Region from 0 to 17 years old in 2008 (n = 342,403). Use of anti-asthma medicine was defined as at least one prescription having been filled in 2008. The analyses included multiple multilevel logistic regression models. RESULTS: Children living in low-income places of residence had lower odds of being prescribed preventive anti-asthmatics compared with children living in higher-income places of residence [odds ratio (OR) = 0.87, 95% confidence interval (CI) 0.84-0.91]. Immigrant children had the lowest OR of being prescribed anti-asthmatics medication, both relief (OR = 0.50, 95% CI 0.20-0.77) and preventive (OR = 0.47, 95% CI 0.24-0.82) compared with ethnic Danes. Similar associations were found among descendants of immigrant children (OR for preventive medication = 0.70, 95% CI 0.62-0.78). Place of residence contributed to but did not account for the ethnic differences in the use of anti-asthmatic medication. CONCLUSIONS: Ethnic differences in the use of anti-asthmatic medication were documented, and they cannot be explained by socioeconomic characteristics of place of residence. The lower prevalence of anti-asthmatic medication among ethnic minority children suggests poor asthma management control.