Clinical pharmacists' perspective of medication adherence support in Ethiopian hospital settings: a qualitative study.

BACKGROUND: Hospital pharmacists can assist patients with medication adherence in a hospital setting. No studies have explored the views of hospital pharmacists on medication adherence. OBJECTIVES: The study aimed to explore Ethiopian clinical pharmacists' understanding of and experience with medication adherence, and identify strategies for medication adherence support. METHODS: Semi-structured interviews were conducted via ZOOM/Skype. Hospital pharmacists were recruited through a professional network and snowball sampling. All interviews were audio recorded, transcribed verbatim, translated into English and analysed using thematic analysis techniques. The data coding followed a hybrid deductive and inductive approach. KEY FINDINGS: Fourteen Ethiopian clinical pharmacists participated in the study. Analysis yielded five main themes including: medication adherence definition and measurement; pharmacists' perceived roles; enablers of medication adherence; barriers to medication adherence; and ways forward. Participants indicated that accurately assessing medication adherence was complicated because of an absence of cost-effective and validated tools. Pharmacist education, clinical pharmacy services, physical structure, sources of medication information, and government initiatives to reduce financial burdens were the facilitators identified. Eight barriers were identified, and these were broadly classified as factors intrinsic or extrinsic to the patient. CONCLUSIONS: Medication adherence support could face barriers intrinsic or extrinsic to patients. Strategies were proposed to overcome the identified barriers and to harness existing facilitators. These strategies included the need for validated local language medication adherence tools, instituting regular adherence measurement and prioritizing patients for available interventions. Patient's preferred dosage form should be considered along with medication complexity and medication knowledge when supporting medication adherence.

Measurement Properties of Patient-Reported Outcome Measures for Medication Adherence in Cardiovascular Disease: A COSMIN Systematic Review.

BACKGROUND AND OBJECTIVE: Several medication adherence patient-reported outcome measures (MA-PROMs) are available for use in patients with cardiovascular disease (CVD); however, little evidence is available on the most suitable MA-PROM to measure medication adherence in patients with CVD. The aim of this systematic review is to synthesise the measurement properties of MA-PROMs for patients with CVD and identify the most suitable MA-PROM for use in clinical practice or future research in patients with CVD. METHODS: An electronic search of nine databases (PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsychInfo, Scopus, Embase, and Web of Science) was conducted to identify studies that have reported on at least one of the measurement properties of MA-PROMs in patients with CVD. The methodological quality of the studies included in the systematic review was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. RESULTS: A total of 40 MA-PROMs were identified in the 84 included studies. This review found there is a lack of moderate-to-high quality evidence of sufficient content validity for all MA-PROMs for patients with CVDs. Only eight MA-PROMs were classified in COSMIN recommendation category A. They exhibited sufficient content validity with very low-quality evidence, and moderate-to-high quality evidence for sufficient internal consistency. The 28 MA-PROMs that meet the requirements for COSMIN recommendation category 'B' require further validation studies. Four MA-PROMs including Hill-Bone Compliance Medication Scale (HBMS), the five-item Medication Adherence Report Scale (MARS-5), Maastricht Utrecht Adherence in Hypertension (MUAH), and MUAH-16 have insufficient results with high quality evidence for at least one measurement property and consequently are not recommended for use in patients with CVD. Two MA-PROMs (Adherence to Refills and Medications Scale [ARMS] and ARMS-7) are comprehensive and have moderate to high quality evidence for four sufficient measurement properties. CONCLUSION: From the eight MA-PROMs in COSMIN recommendation category A, ARMS and ARMS-7 were selected as the most suitable MA-PROMs for use in patients with CVD. They are the most comprehensive with be best quality evidence to support their use in clinical practice and research.

Prevalence of electronic nicotine delivery systems and electronic non-nicotine delivery systems in children and adolescents: a systematic review and meta-analysis.

BACKGROUND: There are concerns that the use of electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS) in children and adolescents could potentially be harmful to health. Understanding the extent of use of these devices is crucial to informing public health policy. We aimed to synthesise the prevalence of ENDS or ENNDS use in children and adolescents younger than 20 years. METHODS: In this systematic review and meta-analysis, we undertook an electronic search in five databases (MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Embase, and Wiley Cochrane Library) from Jan 1, 2016, to Aug 31, 2020, and a grey literature search. Included studies reported on the prevalence of ENDS or ENNDS use in nationally representative samples in populations younger than 20 years and collected data between the years 2016 and 2020. Studies were excluded if they were done in those aged 20 years or older, used data from specialist panels that did not apply appropriate weighting, or did not use methods that ensured recruitment of a nationally representative sample. We included the most recent data for each country. We combined multiple national estimates for a country if they were done in the same year. We undertook risk of bias assessment for all surveys included in the review using the Joanna Briggs Institute Critical Appraisal Checklist (by two reviewers in the author list). A random effects meta-analysis was used to pool overall prevalence estimates for ever, current, occasional, and daily use. This study was prospectively registered with PROSPERO, CRD42020199485. FINDINGS: The most recent prevalence data from 26 national surveys representing 69 countries and territories, with a median sample size of 3925 (IQR 1=2266, IQR 3=10 593) children and adolescents was included. In children and adolescents aged between 8 years and younger than 20 years, the pooled prevalence for ever (defined as any lifetime use) ENDS or ENNDS use was 17·2% (95% CI 15-20, I2=99·9%), whereas for current use (defined as use in past 30 days) the pooled prevalence estimate was 7·8% (6-9, I2=99·8%). The pooled estimate for occasional use was 0·8% (0·5-1·2, I2=99·4%) for daily use and 7·5% (6·1-9·1, I2=99·4%) for occasional use. Prevalence of ENDS or ENNDS use was highest in high-income geographical regions. In terms of study quality, all surveys scored had a low risk of bias for the sampling frame used, due to the nationally representative nature of the studies. The most poorly conducted methodological feature of the included studies was subjects and setting described in detail. Few surveys reported on the use of flavours or types of ENDS or ENNDS. INTERPRETATION: There is significant variability in the prevalence of ENDS and ENNDS use in children and adolescents globally by country income status. These findings are possibly due to differences in regulatory context, market availability, and differences in surveillance systems. FUNDING: World Health Organization and the Bill & Melinda Gates Foundation.

Self-reported medication adherence tools in cardiovascular disease: protocol for a systematic review of measurement properties.

OBJECTIVE: The aim of this review is to identify high-quality, self-reported medication adherence tools for adults with cardiovascular disease to improve health outcomes. INTRODUCTION: Medication adherence is a complex concept affected by multiple factors and positively associated with clinical outcomes. Poor adherence to cardiovascular medications is a hindrance to the effective management of cardiovascular disease, leading to poor disease prognosis or increased risk of death. Valid and reliable measurement is crucial to identify patients with poor adherence, preferably before an adverse outcome occurs. INCLUSION CRITERIA: This review will consider studies that include adults, aged 18 years and over, with a diagnosis of cardiovascular disease. The construct of medication adherence has three phases: initiation, implementation and discontinuation. Included tools need to measure at least one of these phases. The review will consider studies of any study design that report on the measurement properties of self-reported medication adherence tools among adults with cardiovascular disease. METHODS: The following databases will be searched from inception to present: PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsycINFO, Scopus, Embase and Web of Science. Articles published in any language will be included, with no date limit. Data extraction will be performed by one reviewer and cross-checked by another reviewer. Data from the included studies will be synthesized using tables for the quality of methods, and measurement property results. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019124291.

Improving Information to Enable Effective Tobacco Control Intervention and Measure Progress Over Time: The Cambodia Country Experience.

Tobacco is a leading cause of noncommunicable diseases (NCDs) which kill about 41 million people each year. Of these, 15 million die prematurely between the ages of 30 and 69 years, most of which occur in low- and middle-income countries (LMICs). The adoption of the Sustainable Development Goals and their targets under the 2030 Agenda for Sustainable Development provides a new impetus for countries to accelerate tobacco control efforts as they specifically call for strengthening implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control and striving to achieve a one-third reduction in premature deaths from NCDs. While NCD prevention and control is a priority in the national strategic plans and policies for health in most countries in the Western Pacific Region, few have formally adopted a national target for reducing tobacco use. Article 20 of the WHO FCTC calls on all countries to improve tobacco surveillance to enable monitoring and evaluation of tobacco control efforts. The increase in timely and standardized comparable data presents new opportunities to set scientifically valid and achievable national indicators and targets for development and implementation of strong tobacco control measures. Cambodia is yet to establish national targets and full implementation of legislative measures. However, with strong tobacco surveillance mechanism in place, it can provide the country experience for a LMIC that has developed its own capacity to conduct periodic monitoring and surveillance of tobacco use and for using national data to advocate successfully for stronger tobacco control policies.

Implementation of policies and practices to increase physical activity among children attending centre-based childcare: A cross-sectional study.

ISSUE ADDRESSED: Supporting centre-based childcare services to create physical activity (PA) environments is a recommended strategy to improve child PA. This study aimed to describe the implementation of PA policies and practices by these services, and to examine the associations with service characteristics. METHODS: Nominated supervisors of childcare services (n = 309) in the Hunter New England region, New South Wales, Australia, completed a telephone interview. Using previously validated measures, the interview assessed the implementation of evidence-based practices shown to be associated with child PA. This includes: (a) provision of active play opportunities, (b) portable play equipment availability, (c) delivery of daily fundamental movement skills, (d) having at least 50% of staff trained in promoting child PA the past 5 years and (e) having written PA and small screen recreation policies. RESULTS: Although 98% (95% CI 96, 99) of childcare services provided active play opportunities for at least 25% of their daily opening hours, only 8% (95% CI 5, 11) of services fully implemented all policies and practices; with no service characteristic associated with full implementation. Long day care service had twice the odds of having a written PA policy (OR 2.0, 95% CI 0.7, 5.8), compared to preschools (adjusted for service size, socio-economic disadvantage and geographical location). CONCLUSIONS: Improvements could be made to childcare services' operations to support the promotion of child PA. SO WHAT?: To ensure the benefits to child health, childcare services require support to implement a number of PA promoting policies and practices that are known to improve child PA.

Global economic cost of smoking-attributable diseases.

BACKGROUND: The detrimental impact of smoking on health has been widely documented since the 1960s. Numerous studies have also quantified the economic cost that smoking imposes on society. However, these studies have mostly been in high income countries, with limited documentation from developing countries. The aim of this paper is to measure the economic cost of smoking-attributable diseases in countries throughout the world, including in low- and middle-income settings. METHODS: The Cost of Illness approach is used to estimate the economic cost of smoking attributable-diseases in 2012. Under this approach, economic costs are defined as either 'direct costs' such as hospital fees or 'indirect costs' representing the productivity loss from morbidity and mortality. The same method was applied to 152 countries, which had all the necessary data, representing 97% of the world's smokers. FINDINGS: The amount of healthcare expenditure due to smoking-attributable diseases totalled purchasing power parity (PPP) $467 billion (US$422 billion) in 2012, or 5.7% of global health expenditure. The total economic cost of smoking (from health expenditures and productivity losses together) totalled PPP $1852 billion (US$1436 billion) in 2012, equivalent in magnitude to 1.8% of the world's annual gross domestic product (GDP). Almost 40% of this cost occurred in developing countries, highlighting the substantial burden these countries suffer. CONCLUSIONS: Smoking imposes a heavy economic burden throughout the world, particularly in Europe and North America, where the tobacco epidemic is most advanced. These findings highlight the urgent need for countries to implement stronger tobacco control measures to address these costs.

Secondhand smoke exposure at home among one billion children in 21 countries: findings from the Global Adult Tobacco Survey (GATS).

OBJECTIVE: Children are vulnerable to secondhand smoke (SHS) exposure because of limited control over their indoor environment. Homes remain the major place where children may be exposed to SHS. Our study examines the magnitude, patterns and determinants of SHS exposure in the home among children in 21 countries (19 low-income and middle-income countries and 2 high-income countries). METHODS: Global Adult Tobacco Survey (GATS) data, a household survey of people 15 years of age or older. Data collected during 2009-2013 were analysed to estimate the proportion of children exposed to SHS in the home. GATS estimates and 2012 United Nations population projections for 2015 were also used to estimate the number of children exposed to SHS in the home. RESULTS: The proportion of children younger than 15 years of age exposed to SHS in the home ranged from 4.5% (Panama) to 79.0% (Indonesia). Of the approximately one billion children younger than 15 years of age living in the 21 countries under study, an estimated 507.74 million were exposed to SHS in the home. China, India, Bangladesh, Indonesia and the Philippines accounted for almost 84.6% of the children exposed to SHS. The prevalence of SHS exposure was higher in countries with higher adult smoking rates and was also higher in rural areas than in urban areas, in most countries. CONCLUSIONS: A large number of children were exposed to SHS in the home. Encouraging of voluntary smoke-free rules in homes and cessation in adults has the potential to reduce SHS exposure among children and prevent SHS-related diseases and deaths.

Methodology of the Global Adult Tobacco Survey - 2008-2010.

In 2008, the Centers for Disease Control and Prevention (CDC) and the World Health Organization developed the Global Adult Tobacco Survey (GATS), an instrument to monitor global tobacco use and measure indicators of tobacco control. GATS, a nationally representative household survey of persons aged 15 years or older, was conducted for the first time during 2008-2010 in 14 low- and middle-income countries. In each country, GATS used a standard core questionnaire, sample design, and procedures for data collection and management and, as needed, added country-specific questions that were reviewed and approved by international experts. The core questionnaire included questions about various characteristics of the respondents, their tobacco use (smoking and smokeless), and a wide range of tobacco-related topics (cessation; secondhand smoke; economics; media; and knowledge, attitudes, and perceptions). In each country, a multistage cluster sample design was used, with households selected proportionate to the size of the population. Households were chosen randomly within a primary or secondary sampling unit, and one respondent was selected at random from each household to participate in the survey. Interviewers administered the survey in the country's local language(s) using handheld electronic data collection devices. Interviews were conducted privately, and same-sex interviewers were used in countries where mixed-sex interviews would be culturally inappropriate. All 14 countries completed the survey during 2008-2010. In each country, the ministry of health was the lead coordinating agency for GATS, and the survey was implemented by national statistical organizations or surveillance institutes. This article describes the background and rationale for GATS and includes a comprehensive description of the survey methods and protocol.

The environmental and health impacts of tobacco agriculture, cigarette manufacture and consumption.

The health consequences of tobacco use are well known, but less recognized are the significant environmental impacts of tobacco production and use. The environmental impacts of tobacco include tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste. The World Health Organization's Framework Convention on Tobacco Control addresses environmental concerns in Articles 17 and 18, which primarily apply to tobacco agriculture. Article 5.3 calls for protection from policy interference by the tobacco industry regarding the environmental harms of tobacco production and use. We detail the environmental impacts of the tobacco life-cycle and suggest policy responses.

Les conséquences du tabagisme sur la santé sont notoires. En revanche, les impacts environnementaux considérables de la production et de la consommation de tabac sont moins connus. Ces impacts environnementaux sont liés à la culture et au séchage du tabac, à la fabrication des produits du tabac et à leur distribution, au tabagisme et aux déchets générés après consommation. La Convention-cadre de l'OMS pour la lutte antitabac évoque ces problèmes environnementaux dans ses Articles 17 et 18, qui s'appliquent avant tout à la culture du tabac. L'Article 5.3 préconise de ne pas laisser l'industrie du tabac influencer les mesures politiques en ce qui concerne les effets négatifs de la production et de la consommation du tabac sur l'environnement. Nous détaillons dans ce dossier les impacts environnementaux sur tout le cycle de vie du tabac et formulons plusieurs suggestions en termes de réponse politique.

Las consecuencias sanitarias del consumo de tabaco son bien conocidas, pero no tanto los significativos efectos que el cultivo y consumo de tabaco tienen en el medio ambiente. Los efectos medioambientales del tabaco incluyen el crecimiento y la cura del tabaco, la producción y distribución del producto, el consumo del producto y los residuos resultantes de su consumo. El Convenio Marco de la OMS para el Control del Tabaco aborda las preocupaciones medioambientales en los Artículos 17 y 18, los cuales se aplican principalmente en el cultivo del tabaco. El Artículo 5.3 exige medidas cautelares respecto a las políticas de interferencia de la industria del tabaco en lo que se refiere a los daños medioambientales del cultivo y el consumo de tabaco. Se enumeran los efectos medioambientales del ciclo de vida del tabaco y se sugieren respuestas políticas.

Socioeconomic inequality in smoking in low-income and middle-income countries: results from the World Health Survey.

OBJECTIVES: To assess the magnitude and pattern of socioeconomic inequality in current smoking in low and middle income countries. METHODS: We used data from the World Health Survey [WHS] in 48 low-income and middle-income countries to estimate the crude prevalence of current smoking according to household wealth quintile. A Poisson regression model with a robust variance was used to generate the Relative Index of Inequality [RII] according to wealth within each of the countries studied. RESULTS: In males, smoking was disproportionately prevalent in the poor in the majority of countries. In numerous countries the poorest men were over 2.5 times more likely to smoke than the richest men. Socioeconomic inequality in women was more varied showing patterns of both pro-rich and pro-poor inequality. In 20 countries pro-rich relative socioeconomic inequality was statistically significant: the poorest women had a higher prevalence of smoking compared to the richest women. Conversely, in 9 countries women in the richest population groups had a statistically significant greater risk of smoking compared to the poorest groups. CONCLUSION: Both the pattern and magnitude of relative inequality may vary greatly between countries. Prevention measures should address the specific pattern of smoking inequality observed within a population.

Social determinants of smoking in low- and middle-income countries: results from the World Health Survey.

INTRODUCTION: Tobacco smoking is a leading cause of premature death and disability, and over 80% of the world's smokers live in low- or middle-income countries. The objective of this study is to assess demographic and socioeconomic determinants of current smoking in low- and middle-income countries. METHODS: We used data, from the World Health Survey in 48 low-income and middle-income countries, to explore the impact of demographic and socioeconomic factors on the current smoking status of respondents. The data from these surveys provided information on 213,807 respondents aged 18 years or above that were divided into 4 pooled datasets according to their sex and country income group. The overall proportion of current smokers, as well as the proportion by each relevant demographic and socioeconomic determinant, was calculated within each of the pooled datasets, and multivariable logistic regression was used to assess the association between current smoking and these determinants. RESULTS: The odds of smoking were not equal in all demographic or socioeconomic groups. Some factors were fairly stable across the four datasets studied: for example, individuals were more likely to smoke if they had little or no education, regardless of if they were male or female, or lived in a low or a middle income country. Nevertheless, other factors, notably age and wealth, showed a differential effect on smoking by sex or country income level. While women in the low-income country group were twice as likely to smoke if they were in the lowest wealth quintile compared with the highest, the association was absent in the middle-income country group. CONCLUSION: Information on how smoking is distributed among low- or middle-income countries will allow policy makers to tailor future policies, and target the most vulnerable populations.

Higher risk of stillbirth among lower and middle income women who do not use tobacco, but live with smokers.

OBJECTIVE: To investigate pregnancy outcomes among women living with smokers. DESIGN: Data were from a cohort study of 1,217 women recruited during 3-7th month of pregnancy and 96% followed-up after delivery. The main objective was to investigate effects of smokeless tobacco on pregnancy outcomes. SETTING: Lower and middle-class neighborhoods in Mumbai, India. Community health volunteers who had good rapport with the local population collaborated with the study personnel to help locate and interact with potential participants. POPULATION: Singleton births from non-tobacco users; n = 924/903/802 for stillbirth/gestational age/birthweight analysis. Non-smoking women who lived with smokers (28%) were categorized as 'exposed' to second hand smoke (SHS). METHODS: House-to-house surveys with questionnaire administration and medical records abstraction by trained personnel at recruitment and follow-up. OUTCOME MEASURES: Stillbirth (no evidence of life at birth after at least 20 weeks of gestation), low birthweight (

Unexplained fetal death: are women with a history of fetal loss at higher risk?

AIMS: To identify factors, including the loss of a previous pregnancy before 20 weeks gestation, which are associated with increased risk of singleton antepartum unexplained fetal death (UFD) in Western Australia (WA) using information recorded in routine data collections. METHODS: All fetal deaths in WA from 1990 to 1999 that underwent thorough post-mortem investigations were classified using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. All UFDs were selected as cases and unmatched controls were randomly drawn from all live births in WA occurring during the study period. Demographic and clinical information on cases and controls was obtained from the WA Midwives' Notification System. Multivariable logistic regression was carried out to determine the independent effect of risk factors and calculate odds ratios. RESULTS: Almost one quarter (22%) of stillbirths were unexplained. Primigravid and primiparous women with a history of pregnancy loss before 20 weeks were at higher risk of UFD than multiparous women who had not experienced any loss. Women with a history of fetal death (after 20 weeks) had the highest risk of UFD. CONCLUSION: The current practice of closely monitoring pregnant women with a history of fetal loss or death should continue as this study suggests they may have a higher risk of poor obstetric outcome. Larger studies are needed to confirm the association between previous pregnancy loss and UFD.

Trends in sudden infant death syndrome in Australia from 1980 to 2002.

Analysis was undertaken of trends in sudden infant death syndrome (SIDS) in Australia from 1980 to 2002 using Australian Bureau of Statistics data. The results showed a decline in the SIDS mortality rate from an average of 195.6 deaths per 100,000 live births in the period 1980-1990 to an average of 96.5 deaths per 100,000 live births in the period 1991-1996 and 51.7 deaths per 100,000 live births in the period 1997-2002. The Poisson regression coefficients for SIDS fitted to the rates at the Australia level indicated that the Reduce the Risks (RTR) campaign led to a significant decline of almost 40% when contrasting the pre- and post-campaign periods. Despite recent suggestions that the fall in SIDS rate has been due to natural variations in incidence, the data clearly show that the decline in SIDS rates coincided almost immediately with the introduction of the RTR campaign and has been sustained over time. There was no evidence of diagnostic transfer or of a postponement of death from infancy to early childhood years. Unless this dramatic fall was caused by as yet undetected factors, the campaign is the only plausible explanation for the markedly reduced SIDS rate in Australia.

Coexistent chronic conditions and asthma quality of life: a population-based study.

OBJECTIVE: Reports of the prevalence and impact of comorbid conditions among people with asthma have been limited to certain population groups or convenience samples. Our aim was to examine the prevalence of major comorbidity in asthma and associations with quality of life and functional status in the general population. STUDY DESIGN/SETTING: The WANTS Health and Well-being Survey is a cross-sectional representative population household telephone interview survey in three Australian states. PARTICIPANTS: Representative sample of noninstitutionalized adults in three Australian states. MEASUREMENT AND RESULTS: From the available sample of 10,080 patients, 7,619 interviews were completed (participation rate, 74.8%), with 834 people reporting current doctor-diagnosed asthma (11.2%). People with asthma were more likely to report one of the selected comorbid conditions: diabetes, arthritis, heart disease, stroke, cancer, osteoporosis (adjusted odds ratio, 1.9; 95% confidence interval, 1.5 to 2.2). Among people with asthma, there were statistically and clinically significant decreases in usual activity levels and in Short Form-12 physical component summary scores when another chronic condition was also present. For those with any of the chronic conditions, the additional presence of asthma was associated with significant further impairment in quality of life in those aged > 35 years but not in younger adults. CONCLUSION: The significant reduction in quality of life associated with comorbidity in asthma has implications for disease management and organization of care, as well as for the design and external validity of single-disease clinical trials.