Perspectives of psychiatric patients in rural areas of Jordan: Barriers to compliance and pharmacist role.

BACKGROUND: Successful management of psychiatric disorders is affected by patient perspectives and several barriers, that is, conceptual, psychological, social, or logistic reasons that can decrease patient adherence to therapy. In this perspective, pharmacists have a vital role in identifying patients in need of help and in dealing with barriers. OBJECTIVE: The aim of this study was to investigate perspectives of patients diagnosed with psychiatric disorders, living in rural areas in Jerash, Jordan, regarding their awareness about their conditions, including religious and cultural factors, adherence to their treatment and related barriers, with special focus on pharmacist's role. METHODS: This cross-sectional survey study was conducted in Jordan from August to November 2019. A validated questionnaire was administered by two pharmacy students via a structured interview with patients waiting for their appointment in the psychiatric clinic. Data were analysed using the Statistical Package for the Social Sciences. RESULTS: One hundred twenty patients (age 39.4 ± 9.5, 66.7% males) completed the questionnaire. Most of them (71.0%) reported adherence to their medications, and 47.5% reported complete control of their symptoms with treatment. Most patients (59.2%) reported that they perceive their psychiatric problem in terms of religious faith as being counted for their favour in the Hereafter, and 52.5% of them always/usually looked at themselves positively and unaffected by their psychiatric problem; with both factors correlating significantly with better treatment adherence (P < .045 and P < .001; respectively). Barriers affecting adherence included mainly suffering from adverse effects (31.9%) and being unconvinced that they needed a medication (23.3%). Only 14.2% of patients reported that they refer to the pharmacist to get information about their medications. CONCLUSION: This study shows suboptimal symptom control of psychiatric patients in Jerash. Nonadherence is an issue, with barriers identified. Positive religious and self-image perspectives correlated with better adherence. Patient referral to pharmacists is minimal and needs to be optimised.

Hesitancy of Arab Healthcare Workers towards COVID-19 Vaccination: A Large-Scale Multinational Study.

BACKGROUND: Health care workers (HCWs) are at increased risk of acquiring and transmitting COVID-19 infection. Moreover, they present role models for communities with regards to attitudes towards COVID-19 vaccination. Hence, hesitancy of HCWs towards vaccination can crucially affect the efforts aiming to contain the pandemic. Previously published studies paid little attention to HCWs in Arab countries, which have a population of over 440 million. OBJECTIVES: To assess the rates of COVID-19 vaccine hesitancy in Arabic-speaking HCWs residing in and outside Arab countries, and their perceived barriers towards vaccination. METHODS: A cross-sectional study based on an online survey was conducted from 14-29 January 2021, targeting Arabic-speaking HCWs from all around the world. RESULTS: The survey recruited 5708 eligible participants (55.6% males, 44.4% females, age 30.6 ± 10 years) from 21 Arab countries (87.5%) and 54 other countries (12.5%). Our analysis showed a significant rate of vaccine hesitancy among Arabic-speaking HCWs residing in and outside of Arab countries (25.8% and 32.8%, respectively). The highest rates of hesitancy were among participants from the western regions of the Arab world (Egypt, Morocco, Tunisia, and Algeria). The most cited reasons for hesitancy were concerns about side effects and distrust of the expedited vaccine production and healthcare policies. Factors associated with higher hesitancy included age of 30-59, previous or current suspected or confirmed COVID-19, female gender, not knowing the vaccine type authorized in the participant's country, and not regularly receiving the influenza vaccine. CONCLUSION: This is the first large-scale multinational post-vaccine-availability study on COVID-19 vaccine hesitancy among HCWs. It reveals high rates of hesitancy among Arab-speaking HCWs. Unless addressed properly, this hesitancy can impede the efforts for achieving widespread vaccination and collective immunity.

A high rate of COVID-19 vaccine hesitancy in a large-scale survey on Arabs.

Background: Vaccine hesitancy can limit the benefits of available vaccines in halting the spread of COVID-19 pandemic. Previously published studies paid little attention to Arab countries, which has a population of over 440 million. In this study, we present the results of the first large-scale multinational study that measures vaccine hesitancy among Arab-speaking subjects. Methods: An online survey in Arabic was conducted from 14 January 2021 to 29 January 2021. It consisted of 17 questions capturing demographic data, acceptance of COVID-19 vaccine, attitudes toward the need for COVID-19 vaccination and associated health policies, and reasons for vaccination hesitancy. R software v.4.0.2 was used for data analysis and visualization. Results: The survey recruited 36,220 eligible participants (61.1% males, 38.9% females, mean age 32.6 ± 10.8 years) from all the 23 Arab countries and territories (83.4%) and 122 other countries (16.6%). Our analysis shows a significant rate of vaccine hesitancy among Arabs in and outside the Arab region (83% and 81%, respectively). The most cited reasons for hesitancy are concerns about side effects and distrust in health care policies, vaccine expedited production, published studies and vaccine producing companies. We also found that female participants, those who are 30-59 years old, those with no chronic diseases, those with lower level of academic education, and those who do not know the type of vaccine authorized in their countries are more hesitant to receive COVID-19 vaccination. On the other hand, participants who regularly receive the influenza vaccine, health care workers, and those from countries with higher rates of COVID-19 infections showed more vaccination willingness. Interactive representation of our results is posted on our project website at https://mainapp.shinyapps.io/CVHAA. Conclusions: Our results show higher vaccine hesitancy and refusal among Arab subjects, related mainly to distrust and concerns about side effects. Health authorities and Arab scientific community have to transparently address these concerns to improve vaccine acceptance. Funding: This study received no funding.

Associations between patient factors and medication adherence: A Jordanian experience.

OBJECTIVE: To explore the effect of patient characteristics and health beliefs on their medication adherence. METHODS: Patients (n=167) with chronic conditions (mean age 58.9; SD=13.54, 53% males) were recruited from March 2009- to March 2010 using a cross sectional study design. Data collected included patients' demographics, medical conditions, medications therapeutic regimen, frequency of physician visits and health beliefs. Patient self-reported adherence to medications was assessed by the researcher using a validated and published scale. Treatment related problems (TRPs) were evaluated for each patient by competent clinical pharmacists. Associations between patient characteristics/health beliefs with adherence were explored. RESULTS: About half of the patients (46.1%) were non-adherent. A significant association was found between lower adherence and higher number of disease states (p<0.001), higher number of medications (p=0.001), and higher number of identified TRPs (p = 0.003). Patient adherence was positively affected by older age, higher educational level, and higher number of physician visits per month, while it was negatively affected by reporting difficulties with getting prescription refills on time. CONCLUSION: This study identified different factors that may negatively affect adherence, including higher number of medications and disease states, higher number of identified TRPs and inability to getting prescription refills on time. Hence, more care needs to be provided to patients with complex therapeutic regimens in order to enhance adherence.

Associations between patient factors and medication adherence: a Jordanian experience

Objective: To explore the effect of patient characteristics and health beliefs on their medication adherence. Methods: Patients (n=167) with chronic conditions (mean age 58.9; SD=13.54, 53% males) were recruited from March 2009- to March 2010 using a cross sectional study design. Data collected included patients’ demographics, medical conditions, medications therapeutic regimen, frequency of physician visits and health beliefs. Patient self-reported adherence to medications was assessed by the researcher using a validated and published scale. Treatment related problems (TRPs) were evaluated for each patient by competent clinical pharmacists. Associations between patient characteristics/health beliefs with adherence were explored. Results: About half of the patients (46.1%) were nonadherent. A significant association was found between lower adherence and higher number of disease states (p<0.001), higher number of medications (p=0.001), and higher number of identified TRPs (p = 0.003). Patient adherence was positively affected by older age, higher educational level, and higher number of physician visits per month, while it was negatively affected by reporting difficulties with getting prescription refills on time. Conclusion: This study identified different factors that may negatively affect adherence, including higher number of medications and disease states, higher number of identified TRPs and inability to getting prescription refills on time. Hence, more care needs to be provided to patients with complex therapeutic regimens in order to enhance adherence (AU)

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Inhaler technique training and health-care professionals: effective long-term solution for a current problem.

INTRODUCTION: The aims of this study were (1) to assess the ability of a range of health-care professionals (HCPs: specialists [physicians specializing in management of airways disease], general practitioners, pharmacists, pharmacist assistants, nurses, and respiratory therapists) in Jordan to demonstrate the correct use of some commonly used inhalers using standardized checklists, with highest scores indicating optimal use, and (2) to evaluate the short-term and long-term effectiveness of a single educational intervention on the HCPs' skills in using inhalers. METHODS: HCPs' inhaler technique was assessed at baseline. All HCPs were then invited to attend a workshop on asthma management with particular reference to inhaler use. At the workshop, HCP skills in inhaler technique were optimized. Inhaler technique was assessed before and after training. All participants were assessed on their inhaler technique at follow-up (after 4 months). RESULTS: Two hundred HCPs (10 specialists, 46 general practitioners, 79 pharmacists, 15 pharmacist assistants, 40 nurses, and 10 respiratory therapists) participated in the study. Specialists scored highest on baseline inhaler technique demonstration skills. All HCPs scored poorly in demonstrating the correct use of the dry powder inhalers when compared with pressurized metered-dose inhalers (MDIs) (range of mean scores ± SD: MDI, 7.24 ± 0.97 to 8.70 ± 0.67; Diskus, 4.83 ± 0.51 to 6.30 ± 1.7; Turbuhaler, 4.90 ± 0.32 to 6.40 ± 1.7). Participants attending the workshop showed improved inhaler skills (mean scores before and after training: MDI, 4.77 ± 1.60 vs 8.77 ± 0.52; Diskus, 4.40 ± 2.60 vs 8.85 ± 0.41; Turbuhaler, 4.96 ± 2.05 vs 8.63 ± 0.67). Four months after the workshop, the inhaler technique of 129 participants was again assessed. Those who had attended the workshop (n = 48) scored significantly higher mean scores for all devices (score = 7.64) than nonattendees (n = 81, score = 5.99, P < .001), by one-way analysis of covariance. CONCLUSIONS: With the exception of specialists, HCPs in Jordan need to be updated on their inhaler technique skills, specifically the newer dry powder inhalers. A single effective educational workshop on inhaler technique can significantly improve HCPs' long-term ability to demonstrate these skills.

Home medication reviews in a patient care experience for undergraduate pharmacy students.

OBJECTIVES: To evaluate the effectiveness of conducting medication management reviews (MMRs) and home medication reviews (HMRs) on improving undergraduate pharmacy students' pharmaceutical care skills and clinical knowledge. DESIGN: Fifth-year bachelor of science in pharmacy students were enrolled in a structured course in which MMR cases based on real patient scenarios were completed, findings were discussed in groups, and comprehensive feedback was provided by course instructors. Each student was then asked to recruit a real patient through a community pharmacy and conduct an HMR. ASSESSMENT: Students' pre- and post-course scores on the same MMR case improved significantly, with 84.6% of students passing the post-course assessment. Students also completed a new post-course MMR case and 74.8% received a passing score. Students' answers on a post-course self-assessment showed a significant improvement in their scores regarding knowledge and skills in conducting MMRs and HMRs. CONCLUSION: Medication management reviews and home medication reviews are excellent tools for educating pharmacy students and providing them with needed actual clinical practice experience.

Treatment related problems for outpatients with chronic diseases in Jordan: the value of home medication reviews.

BACKGROUND: Research conducted in Jordan has shown that suboptimal use of medications by outpatients along with the suboptimal role played by community pharmacists is currently a big dilemma highlighting the need for the Home Medication Review (HMR) service in the country. OBJECTIVES: To evaluate the prevalence and types of treatment related problems (TRPs) for outpatients with chronic diseases. SETTING: Patient interview was conducted at the patients' community pharmacy initially, then at their home to collect required data. METHODS: 167 patients with chronic conditions (mean age 58.9 ± 13.54, 53 % males) were recruited. Data collected by the graduate pharmacists to conduct a HMR included patient's demographics, income, laboratory data, medical history, medication record, and adherence. A HMR was conducted for each patient by the researchers (experienced clinical pharmacists) to identify the patients' TRPs based on published literature. A focus group interview was conducted to elicit information regarding the feasibility of the HMR process and acceptability of the patient to the service. MAIN OUTCOME MEASURE: Prevalence and nature of identified TRPs, associated diseases and drugs, and patients' acceptability to the HMR service. RESULTS: The mean number of disease conditions per patient was 4.1 ± 1.7, and the mean number of medications taken by each patient was 8.1 ± 2.7. HMR results showed a mean number of TRPs per patient of 7.4 ± 2.8. TRPs prevalence: 34.7 % of patients were found to have unnecessary drug therapy; 68.3 % had untreated conditions, and 74.9 % had ineffective/incomplete drug therapy; 50.3 % had inappropriate dosage regimen; 10.2 % were found to have actual adverse drug effects. A significant correlation between the number of TRPs and the number of disease states the patient had (r = 0.311, p = 0.003; Pearson correlation) and the number of drugs the patient was taking (r = 0.443, p < 0.001) was found. Patients accepted the HMR service well including the home visiting part. CONCLUSION: TRPs in Jordanian outpatients with chronic diseases visiting community pharmacies are of concern and this signifies the integral role of pharmacists to identify these TRPs and hence provide the HMR service in the country.

Ethosuximide and phenobarbital promote wound healing via enhancing collagenization.

The fact that ethosuximide (ETO), phenobarbital (PHO), and barbituric acid (BARB) share structural and pharmacophoric homologies with phenytoin and allantoin, both known to have significant wound-healing properties, prompted us to evaluate them as wound-healing agents. Accordingly, ETO-, PHO-, and BARB-containing ointments were applied onto full-thickness excision and incision wounds created on the dorso-lumbar region of experimental rats. ETO-and PHO-treated incision wounds illustrated significant enhancement in breaking strengths (1380 ± 61 and 1240 ± 42 g, respectively) compared to vehicle controls (1070 ± 18 g) and BARB (1080 ± 45 g). Moreover, biochemical analyses revealed significant increase in hydroxyproline contents in ETO- and PHO-treated wounds compared to vehicle controls. Histological evaluation revealed that both ETO and PHO promoted collagen synthesis and deposition. This is the first time to describe the significant wound-healing merits of ETO and PHO as potential clinical agents for treatment of chronic wounds.

User error with Diskus and Turbuhaler by asthma patients and pharmacists in Jordan and Australia.

BACKGROUND: Use of inhalers requires accurate completion of multiple steps to ensure effective medication delivery. OBJECTIVE: To evaluate the most problematic steps in the use of Diskus and Turbuhaler for pharmacists and patients in Jordon and Australia. METHODS: With standardized inhaler-technique checklists, we asked community pharmacists to demonstrate the use of Diskus and Turbuhaler. We asked patients with asthma to demonstrate the inhaler (Diskus or Turbuhaler) they were currently using. RESULTS: Forty-two community pharmacists in Jordan, and 31 in Australia, participated. In Jordan, 51 asthma patients demonstrated use of Diskus, and 40 demonstrated use of Turbuhaler. In Australia, 53 asthma patients demonstrated use of Diskus, and 42 demonstrated use of Turbuhaler. RESULTS: The pharmacists in Australia had received inhaler-technique education more recently than those in Jordan (P = .03). With Diskus, few pharmacists in either country demonstrated correct technique for step 3 (exhale to residual volume) or step 4 (exhale away from the device), although there were somewhat fewer errors in Australia than Jordan (16% vs 0% in step 3, P = .007, and 20% vs 0% in step 4, P = .003 via chi-square test). With Turbuhaler there were significant differences between the pharmacists from Australia and Jordan, mainly in step 2 (hold the device upright while loading, 45% vs 2% correct, P < .001). Few of the patients had received inhaler-technique education in the previous year. The patients made errors similar to those of the pharmacists in individual steps with Diskus and Turbuhaler. The essential steps with Diskus were performed correctly more often by the Jordanian patients, and with Turbuhaler by the Australian patients. CONCLUSIONS: Despite differences in Jordan's and Australia's health systems, pharmacists from both Australia and Jordan had difficulty with the same Diskus and Turbuhaler steps. In both countries, the errors made by the asthma patients were similar to those made by the pharmacists.

Characterization of agonist stimulation of cAMP-dependent protein kinase and G protein-coupled receptor kinase phosphorylation of the beta2-adrenergic receptor using phosphoserine-specific antibodies.

Agonist-stimulated desensitization of the beta2-adrenergic receptor (beta2AR) is caused by both a potent cAMP-dependent protein kinase (PKA)-mediated phosphorylation and a less potent, occupancy-dependent, G protein-coupled receptor kinase (GRK)-mediated phosphorylation that leads to beta-arrestin binding and internalization. In this study the kinetics of phosphorylation of the third intracellular loop PKA site Ser262 and the putative C-tail GRK sites Ser355, Ser356 of the human beta2AR overexpressed in human embryonic kidney (HEK) 293 cells were characterized using phosphoserine-specific antibodies. Specificity of the antibodies was shown by their lack of reactivity with mutant beta2ARs lacking the respective sites. In addition, overexpression of GRK2 and GRK5 increased basal levels of phosphorylation of the GRK sites Ser355, Ser356 in both COS-7 and HEK 293 cells. Epinephrine, prostaglandin E1, and forskolin at maximum concentrations stimulated phosphorylation of the beta2AR PKA site (Ser262) by 4-fold, whereas PMA stimulated it by 2-fold. Epinephrine stimulated PKA site phosphorylation with an EC50 of 20 to 40 pM. In contrast, epinephrine stimulated GRK site phosphorylation (Ser355,Ser356) with an EC50 of 200 nM (1-min treatments), which is more than 4000-fold higher relative to PKA site phosphorylation, consistent with an occupancy-driven process. After 10 to 30 min, the EC50 for epinephrine stimulation of GRK site phosphorylation was reduced to 10 to 20 nM but was still approximately 200-fold greater than for the PKA site. The EC50 for internalization correlated with GRK site phosphorylation and showed a similar shift with time of epinephrine stimulation. The kinetics of epinephrine-stimulated GRK site phosphorylation were not altered in a mutant of the beta2AR lacking the PKA consensus sites. The initial levels (2 min) of a range of agonist-stimulated GRK site phosphorylations were correlated with their efficacy for activation of adenylyl cyclase, namely epinephrine > or = formoterol = fenoterol > terbutaline = zinterol = albuterol > salmeterol > dobutamine > or = ephedrine. However, after 20 to 30 min of treatment, agonists with intermediate strengths, such as albuterol and salmeterol, stimulate GRK site phosphorylations that are approximately equal to that produced by epinephrine, and the correlation breaks down. The GRK and PKA site antibodies were also effective in detecting phosphorylation of the endogenous beta2AR expressed in A431 human epidermoid carcinoma cells. To summarize, our results show a remarkable amplification of PKA site phosphorylation relative to the putative GRK site phosphorylation, heterologous stimulation of the PKA site phosphorylation, no dependence of GRK site phosphorylation on PKA sites, and a reasonable correlation of initial levels of GRK site phosphorylation with the strength of a range of agonists.