Sustainability challenges concerning the effects of high-priced drugs on the day-to-day operations of community pharmacies in Finland.

BACKGROUND: High-priced drugs pose a challenge for health budgets, policies, and patient safety. One of the key roles of community pharmacies is to ensure availability to prescription drugs regardless of their price. This has been identified as challenging in certain situations concerning high-priced drugs. OBJECTIVES: The aim is to investigate the views of proprietary pharmacists regarding the effects of high-priced drugs on the day-to-day operations of pharmacies. METHODS: The data collection of the study was performed as a national cross-sectional online survey. The inclusion criteria were being a proprietary pharmacist and a member of the Association of Finnish Pharmacies. The survey contained questions yielding both quantitative and qualitative answers. The study focused on the qualitative data which was analysed by deductive thematic analysis. RESULTS: In total 604 proprietary pharmacists were sent the survey, and 174 eligible answers were included in the study, giving a response rate of 29%. The result describes the relationships between the economic, social, and environmental dimensions of sustainable development based on a framework by Wanamaker, with respect to high-priced drugs and community pharmacy operations as viewed by proprietary pharmacists. The main findings of the study show that proprietary pharmacists find the implementation of real-time reimbursement payments, a further reform of the pharmacy tax, and the abolishment of return bans to the wholesaler as risk mitigations and means to attain sustainability with respect to high-priced drugs and pharmacy practice. They experience that these changes would diminish high-priced drugs unnecessarily ending up as medical waste and improve the working conditions of the pharmacy staff by alleviating stress. CONCLUSIONS: According to the respondents, high-priced drugs pose challenges for community pharmacies and the legislation and reimbursement system need to adapt to these challenges. If not, community pharmacies in Finland continue to face severe financial declines based on the study results.

A qualitative study on the views of experts on the social impact of the high-priced orphan drug nusinersen.

Background: Escalating medical costs due to the increasing occurrence of high-priced orphan drugs is a topic discussed in the media and specialist literature. However, there is no study investigating the social impact of such drugs through the views of experts. Objectives: The aim was to demonstrate the social impact of the orphan drug nusinersen based on the views of experts within the community. Methods: The study was conducted using two methods for data collection: a media analysis and qualitative semi-structured interviews. In the media analysis, expert comments on nusinersen were extracted from the Finnish media. Interviews were conducted with experts from the fields of pharmacy, medicine, politics/academia, law/economics, hospital management and patient organisations from different parts of Finland, who encountered nusinersen in their profession. Participants were recruited through purposive and snowball sampling. Interviews were audio-recorded, transcribed verbatim, and the overall data were analysed thematically. Results: Twenty-nine media references were collected, and 16 interviews conducted. Three main themes were identified: ethical aspects, financial aspects, and call for new strategies. Expert views were divided between the ethical and financial aspects of nusinersen. These existed alongside each other, showing that different attitudes and values compete with each other, and may be classified in different ways depending on the situation. However, the discussion quickly evolved into a call for new strategies in order to find solutions to issues concerning orphan drugs and the social impact created as a result. Conclusions: This study reveals the social impact of nusinersen thus far within the community and it appears somewhat different when seen from the perspectives of patients and decision-makers. Even though impact has been created, such as the establishment of a disease-specific patient organisation, other issues still require further research. Among these are the potential establishment of international collaboration forums for price negotiations with pharmaceutical companies.

Mentor Mothers Zithulele: exploring the role of a peer mentorship programme in rural PMTCT care in Zithulele, Eastern Cape, South Africa.

Background: The majority of global HIV infections in children under 10 years of age occur during pregnancy, delivery or breastfeeding, despite improved coverage of 'prevention of mother-to-child transmission' (PMTCT) guidelines to reduce vertical transmission. This article looks closer at one community-based peer mentorship programme [Mentor Mothers Zithulele (MMZ)] in the Eastern Cape, South Africa which aims to supplement the existing heavily burdened antenatal programmes and improve PMTCT care.Methods: Semi-structured interviews were undertaken with HIV-positive women participating in MMZ and women receiving standard PMTCT care without any intervention. A focus group discussion (FGD) was conducted with women working as Mentor mothers (MMs) for MMZ to explore their experience of the impact of peer mentoring on the rural communities they serve.Results: Six main themes were identified in the interviews with antenatal patients: (i) MMs were a key educational resource, (ii) MMs were important in promoting exclusive breastfeeding, (iii) encouraging early HIV testing during pregnancy and (iv) providing psychosocial support to patients in their homes, thereby reducing stigma and sense of alienation. Respondents requested (v) additional focus on HIV education. MMs can (vi) function as a link between patients and health-care providers, improving treatment adherence. During the FGD two themes emerged; MMs fill the gap between patients and health services, and MMZ should focus on HIV awareness and stigma reduction.Conclusion: Peer mentoring programmes can play an important role in reducing vertical HIV transmission in resource-limited, rural settings by providing participants with education, psychosocial support, and a continuum of care.

Access to Healthcare among People with Physical Disabilities in Rural Louisiana.

The aim was to explore the perceptions about factors that impede and facilitate access to healthcare among rural residents in Louisiana with physical disabilities. The participants were recruited through local churches and word of mouth. Nine in-depth interviews were conducted. The interviews were analyzed using content analysis. Seven categories containing barriers and facilitators were found. The interviewees described lack of transportation, lack of specialized care locally, limits in insurance coverage, lack of financial resources, and lack of knowledge about health care to be the main barriers. The main facilitators were social support, mainly from family and friends, transportation assistance, continuity of care, trust in doctors, and insurance coverage. People with disabilities in rural areas face several barriers when accessing health care but also multiple facilitators. A group that was identified as particularly vulnerable were low-income households that were not eligible for Medicare/Medicaid but still had high expenditures on health care due to disabilities.

Being perceived as 'a real woman' or following one's own convictions: a qualitative study to understand individual, family, and community influences on the place of childbirth in Busia, Kenya.

Despite potentially playing a key role in improving maternal and child health, including the prevention of mother-to-child transmission (PMTCT) of HIV, health facility delivery rates remain low in Kenya. Understanding how place of childbirth is determined is therefore important when developing interventions to improve safe motherhood and childbirth outcomes. As part of a qualitative study, we conducted 25 in-depth interviews with mothers (13) and healthcare staff (12) and held 10 focus group discussions with traditional birth attendants (6) and female relatives (4) in Busia, rural Kenya. Our findings show that mothers prefer facility delivery; however, the choice is not theirs alone but involves both their family and the community. Furthermore, facility delivery poses a risk of being viewed as disloyal to tradition and not 'a real woman', which causes a strained relationship between healthcare staff, family and the community. Our interpretation of the findings is that mothers feel trapped between loyalty to sociocultural norms and awareness of the benefits of facility delivery. Also, we believe healthcare staff's disinclination to recognise certain traditional birth attendant services as a potential asset poses a barrier to increased facility deliveries. Interventions to link traditional birth attendants with formal healthcare combined with sociocultural sensitivity training for healthcare staff may increase facility delivery and PMTCT.

The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya.

OBJECTIVE: The objective of this study was to explore the influence of traditional medicine and religion on discontinuation of antiretroviral therapy (ART) in one of Africa's largest informal urban settlement, Kibera, in Nairobi, Kenya. METHODS: Semi-structured face-to-face interviews were conducted with 20 patients discontinuing the African Medical and Research Foundation (AMREF) ART program in Kibera due to issues related to traditional medicine and religion. RESULTS: Traditional medicine and religion remain important in many people's lives after ART initiation, but these issues are rarely addressed in a positive way during ART counseling. Many patients found traditional medicine and their religious beliefs to be in conflict with clinic treatment advice. Patients described a decisional process, prior to the actual drop-out from the ART program that involved a trigger event, usually a specific religious event, or a meeting with someone using traditional medicine that influenced them to take the decision to stop ART. CONCLUSION: Discontinuation of ART could be reduced if ART providers acknowledged and addressed the importance of religious issues and traditional medicine in the lives of patients, especially in similar resource-poor settings. Telling patients not to mix ART and traditional medicine appeared counter-productive in this setting. Introducing an open discussion around religious beliefs and the pros and cons of traditional medicine as part of standard counseling, may prevent drop-out from ART when side effects or opportunistic infections occur.

Long-term adherence to antiretroviral treatment and program drop-out in a high-risk urban setting in sub-Saharan Africa: a prospective cohort study.

BACKGROUND: Seventy percent of urban populations in sub-Saharan Africa live in slums. Sustaining HIV patients in these high-risk and highly mobile settings is a major future challenge. This study seeks to assess program retention and to find determinants for low adherence to antiretroviral treatment (ART) and drop-out from an established HIV/ART program in Kibera, Nairobi, one of Africa's largest informal urban settlements. METHODS AND FINDINGS: A prospective open cohort study of 800 patients was performed at the African Medical Research Foundation (AMREF) clinic in the Kibera slum. Adherence to ART and drop-out from the ART program were independent outcomes. Two different adherence measures were used: (1) "dose adherence" (the proportion of a prescribed dose taken over the past 4 days) and (2) "adherence index" (based on three adherence questions covering dosing, timing and special instructions). Drop-out from the program was calculated based on clinic appointment dates and number of prescribed doses, and a patient was defined as being lost to follow-up if over 90 days had expired since the last prescribed dose. More than one third of patients were non-adherent when all three aspects of adherence--dosing, timing and special instructions--were taken into account. Multivariate logistic regression revealed that not disclosing HIV status, having a low level of education, living below the poverty limit (US$ 2/day) and not having a treatment buddy were significant predictors for non-adherence. Additionally, one quarter of patients dropped out for more than 90 days after the last prescribed ART dose. Not having a treatment buddy was associated with increased risk for drop-out (hazard ratio 1.4, 95% CI = 1.0-1.9). CONCLUSION: These findings point to the dilemma of trying to sustain a growing number of people on life-long ART in conditions where prevailing stigma, poverty and food shortages threatens the long-term success of HIV treatment.

Challenges for scaling up ART in a resource-limited setting: a retrospective study in Kibera, Kenya.

OBJECTIVE: To determine levels of dropout and adherence in an antiretroviral treatment (ART) program in sub-Saharan Africa's largest urban informal settlement, Kibera, in Nairobi, Kenya. METHOD: Retrospective cohort study. RESULTS: : Of 830 patients that started ART between January 2005 and September 2007, 29% dropped out of the program for more than 90 days at least once after the last prescribed dose. The dropout rate was 23 per 100 person-years, and the probability of retention in the program at 6, 12, and 24 months was 0.83, 0.74, and 0.65, respectively. Twenty-seven percent of patients had an overall mean adherence below 95%. Being a resident of Kibera was significantly associated with 11 times higher risk of dropout. CONCLUSION: Despite free drugs and low associated costs, dropout probabilities in this study are higher and adherence to ART is lower compared with other studies from sub-Saharan Africa. Our results illustrate that ART programs in resource-limited settings, such as Kibera, risk low adherence and retention rates when expanding services. Specific and intensified patient support is needed to minimize the risk of dropout and nonadherence causing future significant health threats not only to individuals but also to public health.

Adherence to treatment: what is done in Sweden? Practice, education and research

Objective: The objective of this review was to identify the practice, education and research of pharmacists in Sweden in regard to adherence to treatment. Methods: Medline was searched up to the end of February 2008. In addition to the Medline search performed, other available sources were also used to identify relevant articles. Results: No adherence-specific programs have been implemented in Swedish pharmacies. No adherence-specific courses are provided in Swedish Universities educating pharmacists. The adherence-related research has so far mainly focused on refill non-adherence, primary non-adherence and patient reported non-adherence and readiness to treatment. Conclusions: Adherence-related practice and education of pharmacists will probably change due to the deregulation of the pharmacy market that will take place in the near future in Sweden. Research on adherence will need to be strengthened in the sense that it has so far not been guided by adherence-related theoretical frameworks, despite the fact that there are several theories to hand that try to explain adherence (AU)

Objetivo: El objetivo de esta revisión fue identificar la práctica, educación e investigación de los farmacéuticos en Suecia en relación a la adherencia al tratamiento. Métodos: Se buscó en Medline a finales de febrero de 2008. Además de la búsqueda en Medline, se utilizaron otras fuentes disponibles para identificar artículos relevantes. Resultados: No se han implantado programas específicos de adherencia en las farmacias suecas. No se han proporcionado cursos específicos en las universidades suecas para educar a los farmacéuticos. La investigación relacionada con adherencia ha estado fundamentalmente centrada en no cumplimiento de las repeticiones de medicamentos, no cumplimiento primario y incumplimiento comunicado por el paciente y disponibilidad al tratamiento. Conclusiones: La práctica y la educación de farmacéuticos relacionadas con la adherencia probablemente cambien debido a la desregulación del mercado farmacéutico que tendrá lugar en Suecia en un futuro cercano. La investigación en adherencia necesitará ser reforzada ya que no se ha basado en marcos teóricos de adherencia cumplimiento, a pesar de que existen varias las teorías que intentan explicar el incumplimiento (AU)

Adherence to treatment: what is done in Sweden? Practice, education and research.

OBJECTIVE: The objective of this review was to identify the practice, education and research of pharmacists in Sweden in regard to adherence to treatment. METHODS: Medline was searched up to the end of February 2008. In addition to the Medline search performed, other available sources were also used to identify relevant articles. RESULTS: No adherence-specific programs have been implemented in Swedish pharmacies. No adherence-specific courses are provided in Swedish Universities educating pharmacists. The adherence-related research has so far mainly focused on refill non-adherence, primary non-adherence and patient reported non-adherence and readiness to treatment. CONCLUSIONS: Adherence-related practice and education of pharmacists will probably change due to the deregulation of the pharmacy market that will take place in the near future in Sweden. Research on adherence will need to be strengthened in the sense that it has so far not been guided by adherence-related theoretical frameworks, despite the fact that there are several theories to hand that try to explain adherence.

A structural equation modeling approach to the concepts of adherence and readiness in antiretroviral treatment.

OBJECTIVE: The objective of this secondary analysis of data from a cross-sectional, nation-wide survey, was to test a hypothesized model with two latent concepts (readiness and adherence), based on the theory of trigger events. A secondary objective was to compare this model with two simpler models, without the concept of readiness. METHODS: Data consisted of a consecutive sample of 828 HIV patients > or = 18 years on antiretroviral treatment at 30 out of 32 HIV Clinics in Sweden (response rate 97.5%). Structural equation modeling (SEM) was used to test the models against the empirical data. Chi2 test was used to compare fit between models. RESULTS: The hypothesized model, with two latent concepts (readiness and adherence), fitted the data best (chi(2)=223.508, d.f.=129, p-value<0.0001, GFI=0.970, CFI=0.913, RMSEA=0.030), and significantly better than the models with adherence as the only latent concept. CONCLUSION: Although the SEM technique could not rule out that other models might also fit the data equally well, the hypothesized model, where readiness and adherence were two separate latent concepts, fitted data the best. This supports readiness as a distinct factor that influences adherence and hence treatment outcome. Increased attention should therefore be attached to interventions that focus on the individual' readiness for behavioural change, i.e. factors amendable to change and that can be addressed by the patients themselves. PRACTICE IMPLICATIONS: Based on these results it seems necessary to shift focus from adherence to readiness, especially in conditions where treatment can be postponed such as antiretroviral treatment.

Differences in adherence and motivation to HIV therapy--two independent assessments in 1998 and 2002.

OBJECTIVE: The aim of this study was to compare the level of adherence and motivation in two independent cross-sectional samples of HIV-infected patients conducted in 1998 and 2002, and to investigate the relationship between adherence and motivation. METHOD: Consecutive HIV-infected patients on treatment at a Swedish clinic were asked to complete an anonymous questionnaire. In 1998, 60 patients participated and in 2002, 53 participated. In 2002, the 9-item Morisky Medication Adherence Scale (MMAS) was added to the questionnaire set. MAIN OUTCOME MEASURE: Self-reported adherence and motivation. RESULTS: In 1998, 28.1% of the respondents were considered adherent, while the corresponding proportion was 57.4% in 2002 (P = 0.002). The mean summary score for MMAS was 10.7 in 2002 (13 = perfect adherence). The proportion considered motivated were 22.4% in the 1998 survey and 41.3% in 2002 (P = 0.038). Of the respondents considered motivated in the 2002 survey, 46.7% scored the maximum summary score on the MMAS, while 8.7% of the non-motivated respondents did so (P = 0.016). CONCLUSION: The respondents in 2002 were more adherent and motivated than the respondents in 1998 and a relationship between motivation and adherence was found. The difference in adherence and motivation might be due to a new treatment model at the clinic.

Assessing and achieving readiness to initiate HIV medication.

OBJECTIVE: To summarise published HIV-specific research on readiness theories, factors influencing readiness, instruments to measure readiness and interventions to increase readiness for treatment. METHODS: Medline and PsychInfo were searched until August 2004. RESULTS: Two HIV-specific readiness theories were identified. Fear of side effects, emotions emerging from the diagnosis and lack of trust in the physician were some barriers to overcome in order to reach readiness. Of the three measurement instruments found, the index of readiness showed the most promise. Multi-step intervention programs to increase readiness for HIV treatment had been investigated. CONCLUSION: Readiness instruments may be useful tools in clinical practice but the predictive validity of the instruments needs to be further established in the HIV-infected population. PRACTICE IMPLICATIONS: Readiness instruments and practice placebo trials may serve as complements to routine care, since health care providers currently have no better than chance probability in identifying those patients who are ready to adhere.

A qualitative study of health-care personnel's experience of a satellite pharmacy at a HIV clinic.

OBJECTIVE: The aim of the study was to investigate how health-care personnel at a HIV clinic perceived conventional pharmacies in Sweden and whether the decentralization of pharmaceutical services to the HIV clinic had led to an improved collaboration between other health-care professionals and pharmacists. METHODS: Doctors and nurses who had regular contacts with HIV patients and the satellite pharmacy were interviewed. The interviews were semi-structured, using open questions and was analysed according to the phenomenographic approach. RESULTS: The respondents perceived the existing co-work between conventional pharmacies and other health care professionals as limited. The availability of the satellite pharmacy enabled the health care professionals to understand the pharmacys' way of working, and to increase trust in the pharmacy staff. Collaboration was hence developed between the professions, leading to a consistent way of informing the patients about their HIV drugs, thereby avoiding contradictory information. The pharmacist also became involved in adherence promoting activities at the clinic. The perceived benefits for the patients were considered to be convenience and preservation of privacy as well as a better basis for safe and appropriate drug utilisation. CONCLUSION: Conventional pharmacies were shown to have several disadvantages in serving the HIV infected population. The health care professionals found the novel approach of dispensing HIV drugs at the clinic valuable. The approach led to increased communication and trust between the health care professions, and enhanced teamwork in medication management.