Impact of pharmaceutical care interventions in improving clinical outcomes among patients with pulmonary tuberculosis: a systematic review.

Background: Pharmacists can play an important role in the fight against tuberculosis (TB) through optimising medication use and safety, promoting adherence to anti-TB drugs, and providing patient education. Limited evidence is available on the effectiveness of pharmacist's interventions on health outcomes in patients with pulmonary TB. This systematic review aims to assess the effectiveness of pharmaceutical care interventions in the management of pulmonary TB. Methods: English language studies assessing the impact of pharmaceutical care interventions in TB management were searched across three electronic databases (PubMed, Embase, Cochrane), a RCT registry ClinicalTrial.gov, a peer-reviewed journal 'The Lancet Infectious Diseases', and the references of retrieved articles. Interventions delivered by pharmacists alone or as part of multidisciplinary teams were included in the review. Data were extracted using the modified Cochrane EPOC standardised data collection tool. The Cochrane Risk of Bias 2 and the NIH quality assessment tools were used to assess the risk of bias among included studies. Data were synthesised narratively. (PROSPERO Protocol Registration CRD42022325771). Results: Thirteen studies, including two randomised controlled trials (RCTs) with a total of 3886 patients were included. Many of the included studies had a high risk of bias and lacked cohert reporting of treatment outcomes. The most common pharmaceutical care interventions were education and counselling regarding adverse drug reactions and resolution of drug-related problems. Five studies showed a relatively high TB completion rate yet only one study reached the targeted treatment success goal of (>90%). Conclusion: The current evidence suggests that pharmaceutical care interventions can potentially improve treatment outcomes among patients with pulmonary TB. However, no definitive conclusion can be drawn given the low methodological quality of the included studies and lack of long-term follow-up data. Well-designed RCTs with careful attention to study methodology, standardised outcomes assessment aligned with the World Health Organization's guidelines are warranted to guide future practice and policy.

Correction: Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis.

[This corrects the article DOI: 10.1371/journal.pone.0253588.].

Correction: Using Assessment Design Decision Framework in understanding the impact of rapid transition to remote education on student assessment in health-related colleges: A qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0254444.].

Minimizing prescribing errors: A phenomenological exploration of the views and experiences of independent prescribing pharmacists.

AIMS: This study aims to explore the views and experiences of independent prescribing (IP) pharmacists regarding prescribing errors and strategies to mitigate errors in practice. METHODS: One-to-one online semi-structured interviews were conducted with IP pharmacists across the United Kingdom. Verbatim transcripts of the interview were generated and coded using NVivo® 12 software for thematic analysis. A mixed inductive and deductive approach was used to generate themes and sub-themes which were then mapped onto the framework of factors that influence clinical practice proposed by Vincent et al. RESULTS: A total of 14 interviews were conducted. Participants linked the risk-averse nature of a pharmacist, self-perception of their roles as medicines experts, and previous experience of keeping checks on doctors' prescriptions as a dispenser often made them feel confident in prescribing. However, lacking adequate diagnostic skills, inadequate prescribing training programmes, and dealing with complex patients often made them feel vulnerable to committing errors. Organizational and system-related factors such as work interruptions and increased workload were identified as other factors linked to prescribing errors. CONCLUSIONS: Independent prescribing pharmacists use a variety of strategies to reduce the risk of prescribing errors. Promoting diagnostic competency in their area of practice, strengthening undergraduate and prescribing curricula, and addressing known organizational and system-related factors linked to prescribing errors can minimize errors and promote patient safety.

Comparative efficacy and safety among high-intensity statins. Systematic Review and Meta-Analysis.

Aim: To summarize the evidence in terms of efficacy and safety of head-to-head studies of high-intensity statins regardless of the underlying population. Materials & methods: A systematic review and meta-analysis was conducted to summarize the effect sizes in randomized controlled trials and cohort studies that compared high-intensity statins. Results: Based on 44 articles, similar effectiveness was observed across the statins in reducing LDL levels from baseline. All statins were observed to have similar adverse drug reactions (ADRs), although higher dosages were associated with more ADRs. Based on a pooled quantitative analysis of atorvastatin 80 mg versus rosuvastatin 40 mg, rosuvastatin was statistically more effective in reducing LDL. Conclusion: This review further confirms that high-intensity statins reduce LDL by ≥50%, favoring rosuvastatin over atorvastatin. Additional data are needed to confirm the clinical significance on cardiovascular outcomes using real-world studies.

Attitudes and beliefs regarding the use of herbs and supplementary medications with COVID-19: A systematic review.

BACKGROUND AND AIM: There is growing interest in using herbs and supplementary medications to treat and/or prevent COVID-19, evidenced by multiple reports exploring their effectiveness and safety. From a health psychology perspective, the desire to use herbs and supplementary medications to prevent and/or treat COVID-19 is a health behavior which is attributed to attitudes and beliefs. This systematic review critically appraised and synthesized the data from studies investigating these attitudes and beliefs. METHODS: EMBASE, PubMed, ScienceDirect, Scopus, Cochrane (library), and WebOfScience were searched from inception to December 13, 2021 for studies investigating attitudes and beliefs on the use of herbs and supplementary medications to treat and/or prevent COVID-19. RESULTS: A total of 17 articles were identified for inclusion. All except one were of cross-sectional design. Participants across most studies had a positive attitude towards using herbs and supplementary medications. They believed that herbs and supplementary medications were effective and were confident in their value in preventing and/or treating COVID-19 symptoms. The majority of included studies had significant flaws in study design and reporting, including inconsistent definitions of herbs and supplementary medications, a lack of theoretical models and conceptual frameworks underpinning the study of beliefs and attitudes, in addition to methodological issues of robustness affecting the validity and reliability of data. CONCLUSION: The use of herbs and supplementary medicines to prevent and/or treat COVID-19 could well be driven by a positive attitude stemming from beliefs of effectiveness and safety. There is a need for well-designed studies on attitudes and beliefs that are driven by health behavior theories to permit generalizability of findings and establish more conclusive relationships between beliefs, attitudes and the decision to use herbs and supplementary medications to treat and/or prevent COVID-19.

A Systematic Review of Cost-Effectiveness of Non-Statin Lipid-Lowering Drugs for Primary and Secondary Prevention of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus.

Although studies of nonstatin lipid-lowering therapies have demonstrated cardiovascular benefits; whether these benefits provide good value has not been evaluated in type 2 diabetes mellitus patients. A systematic review was performed to include studies on the cost-effectiveness of non-statin lipid-lowering therapies in type 2 diabetes mellitus patients with/without cardiovascular disease. Thirteen studies were included; ezetimibe (n = 8), proprotein convertase subtilisin/kexin type 9 inhibitors (n = 4), fenofibrate (n = 2), nicotinic acid (n = 1), extended-release niacin/laropiprant (n = 1), and icosapent ethyl (n = 1). Six studies considered ezetimibe + statin to be a cost-effective compared to statins monotherapy, three studies suggested that proprotein convertase subtilisin/kexin type 9inhibitors + statins were not cost-effective compared to statin + ezetimibe. Fenofibrate was a cost-effective either as monotherapy or combined with a statin compared to statin or fenofibrate monotherapy. Nicotinic acid and proprotein convertase subtilisin/kexin type 9 compared to statin monotherapy were also cost-effective. Icosapent ethyl was cost-effective compared to standard care but not using the wholesale acquisition cost.

A systematic review of the use of simulation and reflection as summative assessment tools to evaluate student outcomes following interprofessional education activities.

Despite the increasing emphasis on interprofessional education (IPE) in curricula and the potential benefits for student learning, there appears to be a lack of evidence directing authentic and accurate assessment of student-learning outcomes and translation of assessment data into scores and grades. Given the increasing importance of reflection and simulation in IPE, the purpose of this systematic review was to identify, appraise, and synthesize published literature using reflection and simulation as summative assessment tools to evaluate student outcomes following IPE activities. The Crowe Critical Appraisal Tool was used to appraise the included articles for quality. This systematic review yielded only five studies of marginal quality that could highlight the limited rigorous use of either reflection or simulation for summative assessment purposes. This review has identified a need for summative IPE assessment alongside formative assessments. Furthermore, training needs to be offered to both faculty assessors, to ensure they are competent and results are reproducible, and students, to equip them with the knowledge, critical thinking skills, and attitude for becoming reflective practitioners who are able to practice interprofessionally. The assessment of IPE remains a challenge, and there is a clear gap in the literature where research needs to grow.

Use of the Delphi technique in pharmacy practice research.

Consensus research methods are used in health services research to generate evidence through systematic means of measuring collective agreement and developing consensus from experts of a subject matter. Delphi technique is the most commonly reported consensus research method and is a structured, multistage interaction method to determine consensus using repetitive administration of anonymous questionnaires across two or three rounds. The Delphi technique is increasingly being used in pharmacy practice research. Despite its wide use in the development of statements of policies, guidelines, and performance indicators, there is lack of standardized guidelines and criteria to support the Delphi technique study design, conduct, and reporting, leading to inconsistent approaches and methodological difficulties among researchers. In this themed article, we provide the reader with a collation of best practices and highlight key methodological issues and areas of uncertainty of the Delphi method, especially as it pertains to pharmacy practice research.

Using Assessment Design Decision Framework in understanding the impact of rapid transition to remote education on student assessment in health-related colleges: A qualitative study.

Maintaining integrity and validity with online assessment is a significant issue that is well documented. Overt policies encouraging educators to adopt e-Learning and implement digital services coupled with the dramatic change in the education system in response to the challenges posed by COVID-19, has furthered the demand for evidence-based approaches for the planning and delivery of assessments. This study employed the Assessment Design Decision Framework (ADDF), a theoretical model that considers key aspects of assessment design, to retrospectively investigate from a multi-stakeholder perspective the assessments implemented following the rapid transition to remote learning during the COVID-19 pandemic. One-to-one semi-structured interviews were conducted with faculty and students from the Colleges of Pharmacy, Medicine and Health Sciences. After inductive and deductive thematic analysis three major themes were identified. These reflected on the impact of sudden transition on assessment design and assessment plan; changing assessment environment; and faculty-student assessment related interactions which included feedback. The use of a comprehensive validated framework such as ADDF, to plan assessments can improve validity and credibility of assessments. The strengths of this study lie in the innovative adoption of the ADDF to evaluate assessment design decisions from both an educator and student perspective. Further, the data yielded from this study offers novel validation of the use of ADDF in circumstances necessitating rapid transition, and additionally identifies a need for greater emphasis to be attributed to the significance of timeliness of the various activities that are advocated within the framework.

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis.

INTRODUCTION: Medication errors are avoidable events that can occur at any stage of the medication use process. They are widespread in healthcare systems and are linked to an increased risk of morbidity and mortality. Several strategies have been studied to reduce their occurrence including different types of pharmacy-based interventions. One of the main pharmacist-led interventions is educational programs, which seem to have promising benefits. OBJECTIVE: To describe and compare various pharmacist-led educational interventions delivered to healthcare providers and to evaluate their impact qualitatively and quantitatively on medication error rates. METHODS: A systematic review and meta-analysis was conducted through searching Cochrane Library, EBSCO, EMBASE, Medline and Google Scholar from inception to June 2020. Only interventional studies that reported medication error rate change after the intervention were included. Two independent authors worked through the data extraction and quality assessment using Crowe Critical Appraisal Tool (CCAT). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Research protocol is available in The International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42019116465. RESULTS: Twelve studies involving 115058 participants were included. The two main recipients of the educational interventions were nurses and resident physicians. Educational programs involved lectures, posters, practical teaching sessions, audit and feedback method and flash cards of high-risk abbreviations. All studies included educational sessions as part of their program, either alone or in combination with other approaches, and most studies used errors encountered before implementing the intervention to inform the content of these sessions. Educational programs led by a pharmacist were associated with significant reductions in the overall rate of medication errors occurrence (OR, 0.38; 95% CI, 0.22 to 0.65). CONCLUSION: Pharmacist-led educational interventions directed to healthcare providers are effective at reducing medication error rates. This review supports the implementation of pharmacist-led educational intervention aimed at reducing medication errors.

Critical appraisal of tobacco dependence treatment guidelines.

Background Tobacco use is a leading preventable cause of morbidity and mortality globally. Clinical practice guidelines for the treatment of tobacco use dependence are of varied scope and quality, making it challenging for users to select and apply recommendations. Objective The study objective is to identify and critically appraise the quality of existing clinical practice guidelines for tobacco cessation. Setting The study occurred between collaborative academic institutions located in Qatar and New Zealand. Methods A systematic literature search was performed for the period 2006-2018 through the following databases: PubMed, EMBASE, CINAHL, ISI Web of Science, Scopus, National Guideline Clearing House, Campbell Library, Health System Evidence, Joanna Briggs Institute Evidence-Based Practice Database, Academic Search Complete, ProQuest, PROSPERO, and Google Scholar. Relevant professional societies' and health agencies' websites were also searched. Two reviewers independently extracted and assessed guidelines' quality using Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument. Main outcome measure Standardized domain scores according to the AGREE II instrument. Results 7741 hits were identified. After removing duplicates and screening, 24 guidelines were included. Highest guideline quality was for National Institute for Health and Care Excellence (NICE) guideline with an overall ranking score of 87.56% and least quality was for Japanese Circulation Society Joint Working Group with an overall score of 29.34%. Domain 4 of AGREE II (clarity of presentation) had the highest average quality score (70.95%), while the lowest average quality scores were for Domain 2 (Rigour of Development) (50.21%) and Domain 5 (Applicability) (45.05%). Conclusion Seven guidelines were judged to be of high quality (overall score of ≥ 70%). Future guidelines for tobacco dependence treatment should use rigorous methods of development and provide applicable recommendations.

Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.

Background Medication errors are avoidable events that may occur at any stage of the medication use process. Implementing a clinical pharmacist is one strategy that is believed to reduce the number of medication errors. Pediatric patients, who are more vulnerable to medication errors due to several contributing factors, may benefit from the interventions of a pharmacist. Aim of the review To qualitatively and quantitatively evaluate the impact of clinical pharmacist interventions on medication error rates for hospitalized pediatric patients. Methods PubMed, EMBASE, Cochrane Controlled Trials Register and Google Scholar search engines were searched from database inception to February 2020. Study selection, data extraction and quality assessment was conducted by two independent reviewers. Observational and interventional studies were included. Data extraction was done manually and the Crowe Critical Appraisal Tool was used to critically appraise eligible articles. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Results 19 studies were systematically reviewed and 6 studies (29,291 patients) were included in the meta-analysis. Pharmacist interventions involved delivering educational sessions, reviewing prescriptions, attending rounds and implementing a unit-based clinical pharmacist. The systematic review indicated that the most common trigger for pharmacist interventions was inappropriate dosing. Pharmacist involvement was associated with significant reductions in the overall rate of medication errors occurrence (OR 0.27; 95% CI 0.15 to 0.49). Conclusion Pharmacist interventions are effective for reducing medication error rates in hospitalized pediatric patients.

Does the delivery of interprofessional education have an effect on stereotypical views of healthcare students in Qatar?

Interprofessional education (IPE) is an evolving educational approach for preparing healthcare professional students to provide patient care in a collaborative team atmosphere. One of the important outcomes to be achieved is understanding the stereotypical views of health professionals held by themselves and by others to eventually reduce negative and harmful stereotypes and to foster an environment of mutual respect and trust amongst healthcare professionals. The primary aim of this study was to investigate whether there is a change in healthcare students' stereotypical belief about the characteristics of healthcare professionals before and after an IPE activity focused on smoking cessation. The Student Stereotype Rating Questionnaire (SSRQ) was used to assess the students' stereotype ratings of their professions and other healthcare professions before and after the IPE activity. The ratings were made in relation to nine attributes. Sixty-eight students from five different majors (Medicine, Nursing, Pharmacy, Public Health, and Respiratory Therapy) participated in the IPE activity. All the students involved in the activity responded to both the pre and post surveys (response rate, 100%). The participating students' combined ratings revealed a significant change in the perspectives of medical, pharmacy, and respiratory therapy students in all of the nine attributes. While for public health students, differences were significant in two aspects: professional competence and practical skills. Three central themes emerged after the IPE session from the open-ended questions: roles and responsibilities, patient-centered care, and integrated healthcare team. Overall, the findings from this study suggest that stereotyping exists among different healthcare profession student groups in Qatar and that IPE can impact both hetero-stereotypes and auto-stereotypes. The positive change in perception following the IPE activity indicates the effectiveness and the value of these short duration IPE activities in negating stereotypical views.

A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers.

PURPOSE: To develop an in-depth understanding of the barriers to medication adherence among patients with uncontrolled diabetes attending primary health care (PHC) centers in Qatar by exploring and integrating patients' and health care providers' perspectives. PARTICIPANTS AND METHODS: A descriptive qualitative methodology was used in this study. A trained researcher conducted semi-structured face-to-face interviews at two PHC centers. Patients with uncontrolled diabetes (with varied sociodemographic characteristics) and their respective health care providers (physicians, pharmacists, nurses, dieticians, and others) were purposively selected from the two PHC centers. All interviews were audio recorded, transcribed verbatim, and analyzed using thematic content analysis. RESULTS: Thirty interviews (14 patients and 16 health care providers) were conducted. A number of barriers to medication adherence were identified and classified broadly under three main themes: 1) patient-related factors, which included patients' individual characteristics and patients' perception, attitude, and behavior; 2) patient-provider factors, which included communication and having multiple health care providers caring for the patient; and 3) societal and environmental factors, which included social pressure and traveling to visit friends and relatives. CONCLUSION: Patients with uncontrolled diabetes face multiple barriers to medication adherence. Similar themes emerged from both patients and their care providers. This research highlights the need for concerted multidimensional efforts and series of interventions to overcome these barriers. One vital intervention is expanding the scope of pharmacists' role within the PHC centers through providing medication reconciliation, patient-tailored medication counseling, and medicines use review, which may improve treatment outcomes among patients with diabetes.

A holistic conceptual framework model to describe medication adherence in and guide interventions in diabetes mellitus.

BACKGROUND: Nonadherence to medications in patients with diabetes, which results in poor treatment outcomes and increased healthcare costs, is commonly reported globally. Factors associated with medication adherence have also been widely studied. However, a clear and comprehensive, disease-specific conceptual framework model that captures all possible factors has not been established. OBJECTIVE: This study aimed to develop a conceptual framework that addresses the complex network of barriers to medication adherence in patients with diabetes. METHODS: Fourteen databases and grey literature sources were systematically searched for systematic reviews reporting barriers to medication adherence in patients with diabetes. A thematic approach was used to categorize all identified barriers from the reviews and to create a matrix representing the complex network and relations of the different barriers. RESULTS: Eighteen systematic reviews were identified and used for the development of the conceptual framework. Overall, six major themes emerged: patient-, medication-, disease-, provider-, system-, and societal-related factors. Each of these themes was further classified into different sub-categories. It was noted that most interactions were identified to be within the patient-related factors, which not only interact with other themes but also within the same theme. Patient's demographics as well as cultural beliefs were the most notable factors in terms of interactions with other categories and themes. CONCLUSIONS: The intricate network and interaction of factors identified between different themes and within individual themes indicate the complexity of the problem of adherence. This framework will potentially enhance the understanding of the complex relation between different barriers for medication adherence in diabetes and will facilitate design of more effective interventions. Future interventions for enhancing medication adherence should look at the overall factors and target multiple themes of barriers to improve patient outcomes.

Effect of pharmacist care on medication adherence and cardiovascular outcomes among patients post-acute coronary syndrome: A systematic review.

BACKGROUND: The impact of collaborative and multidisciplinary health care on the outcomes of care in patients with acute coronary syndromes (ACS) is well-established in the literature. However, there is lack of high quality evidence on the role of pharmacist care in this setting. OBJECTIVE: This systematic review aimed to evaluate the impact of pharmacist care on patient outcomes (readmission, mortality, emergency visits, and medication adherence) in patients with ACS at or post-discharge. METHODS: The following electronic databases and search engines were searched from their inception to September 2016: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ISI Web of Science, Scopus, Campbell Library, Database of Abstracts of Reviews of Effects (DARE), Health System Evidence, Global Health Database, Joanna Briggs Institute Evidence-Based Practice Database, Academic Search Complete, ProQuest, PROSPERO, and Google Scholar. Studies were included if they evaluated the impact of pharmacist's care (compared with no pharmacist's care or usual care) on the outcomes of rehospitalization, mortality, and medication adherence in patients post-ACS discharge. Comparison of the outcomes with relevant statistics was summarized and reported. RESULTS: A total of 17 studies [13 randomized controlled trials (RCTs) and four non-randomized clinical studies] involving 8391 patients were included in the review. The studies were of variable quality (poor to good quality) or risk of bias (moderate to critical risk). The nature and intensity of pharmacist interventions varied among the studies including medication reconciliation, medication therapy management, discharge medication counseling, motivational interviewing, and post-discharge face-to-face or telephone follow-up. Pharmacist-delivered interventions significantly improved medication adherence in four out of 12 studies. However, these did not translate to significant improvements in the rates of readmissions, hospitalizations, emergency visits, and mortality among ACS patients. CONCLUSIONS: Pharmacist care of patients discharged after ACS admission was not associated with significant improvement in medication adherence or reductions in readmissions, emergency visits, and mortality. Future studies should use well-designed RCTs to assess the short- and long-terms effects of pharmacist interventions in ACS patients.

Assessing prevalence of and barriers to medication adherence in patients with uncontrolled diabetes attending primary healthcare clinics in Qatar.

BACKGROUND: Studies conducted in Qatar have reported a high prevalence of diabetic nephropathy, retinopathy, and neuropathy. These complications are often associated with poor medication adherence and uncontrolled diabetes. The objectives of this study were to determine the rate of medication adherence among patients with uncontrolled diabetes, and to compare the characteristics and identified barriers between patients with good and those with poor medication adherence. METHOD: A cross-sectional quantitative study was conducted among patients living in Qatar with uncontrolled diabetes attending primary healthcare clinics from October 2016 to January 2017. An interviewer-administered questionnaire comprising three sections was utilized in the study: patients' characteristics, Adherence to Refill and Medications Scale in Diabetes (ARMS-D), and barriers to medication adherence. ARMS-D is a validated tool that is used to identify adherence level among patients with diabetes. Descriptive and inferential statistics including regression analysis were used for data analysis. RESULTS: A total of 260 patients were included in the analysis. Overall, 73% (n=191) were nonadherent to their diabetes medications (ARMS-D score above 11). Nonadherent patients reported the majority of the pre-determined barriers to medication adherence with forgetfulness being the most commonly reported barrier. Multivariate linear regression analysis found age, ethnicity, education level, income level and HbA1c to be independent predictors of adherence. CONCLUSION: The findings of this study reaffirm the notion that non-adherence to medications among patients with uncontrolled diabetes within primary care setting is higher than the general diabetes population. This high prevalence is concerning and necessitates urgent interventions. Nonetheless, an in-depth understanding of barriers to medication adherence often requires qualitative research approach as these barriers are very complex and multifactorial in nature.

Synthesizing and Appraising the Quality of the Evidence on Factors Associated with Medication Adherence in Diabetes: A Systematic Review of Systematic Reviews.

BACKGROUND: Nonadherence to medications is a common phenomenon in patients with diabetes. Several studies and systematic reviews have investigated the barriers to medication adherence in diabetes. However, no study has evaluated the quality of the existing literature and synthesized the plethora of evidence with a goal to design holistic conceptual frameworks and interventions. OBJECTIVES: The aims of this review were to systematically evaluate existing systematic reviews focusing on factors associated with medication adherence in diabetes in an effort to synthesize the evidence, determine their methodological quality, and identify the gaps in the current literature. METHODS: Fourteen databases and gray literature sources were systematically searched through June 2016. Systematic reviews reporting factors associated with medication adherence (barriers and facilitators) in patients with diabetes were selected on the basis of predetermined criteria. Studies were appraised for quality using AMSTAR (A Measurement Tool to Assess Systematic Reviews). RESULTS: Seventeen systematic reviews including 542 primary studies, most of which were cross-sectional quantitative studies, were included. All the reviews were rated as moderate to low quality and exhibited common methodological pitfalls. Factors influencing medication adherence identified were categorized as patient-, medication-, disease-, health care provider-, health care system-, and social-related factors. CONCLUSIONS: Factors influencing medication adherence are multifactorial with remarkably consistent findings across the existing reviews; yet, most reviews were judged to be of low to moderate quality. Further comprehensive and well-conducted original studies and systematic reviews on this topic shall be conducted taking into consideration the drawbacks of existing ones.

Factors associated with medication adherence among patients with diabetes in the Middle East and North Africa region: A systematic mixed studies review.

Multiple systematic reviews were conducted investigating factors associated with medication adherence worldwide. However, investigations from the Middle East and North Africa (MENA) region were largely underrepresented in those reviews. Therefore, the objective of this systematic review is to identify the factors influencing medication adherence among patients with diabetes in the MENA region. A systematic literature search was conducted through Cochrane Library, EBSCO, EMBASE, Google Scholar, ISI Web of Science, PubMed, ScienceDirect, SCOPUS, and ProQuest. Studies were included if they determined factors associated with medication adherence among patients with diabetes within the MENA region. Quality was assessed using Crow Critical Appraisal Tool. Thirty primary studies from 10 MENA countries were included. The factors associated with medication adherence were categorized into demographics-related; disease- and medication-related; perception, attitude and psychological feelings-related; and societal-related factors. Positively associated factors included knowledge about the disease and medications, regular follow-up visits, and patients' positive beliefs about effectiveness and motivations about medications, while negatively associated factors included forgetfulness, side effects, and polypharmacy. Factors associated with medication adherence among patients with diabetes in the MENA region are highly diverse. The identified factors can serve as potential targets for culturally-relevant interventions to improve medication adherence and overall health outcomes.