Evaluation of the Factors Associated with Prescribed and Non-Prescribed Medicine: A Population-Based Study.

OBJECTIVES: Several factors influence medication patterns. The purpose of this study was to look into the role of social determinants in the use of prescribed and non-prescribed medications in a population-based setting of people over 18 in a southern metropolis of Iran (Shiraz) for 2 years. STUDY DESIGN: Prospective population-based cross-sectional. METHODS: This descriptive and cross-sectional survey was done in 2018-2020. A total of 1016 participants were randomly selected based on their postal codes and recruited to the study. The demographic characteristics (age, sex, and education), social profiles (insurance, supplementary insurance, health status, and daily exercise plan), and outpatient visits (family/general physician or specialist/ subspecialist) were recorded by gathering sheets. Descriptive analyses and multinomial logistic analyses were carried out using SPSS software. RESULTS: The medication use pattern was classified into three categories: non-prescribed type I, non-prescribed type II, and prescribed. The mean age of participants was 45.54 ± 15.82 years. The results indicated that most of them took their medication without a prescription (non-prescribed type II). However, people who had insurance and referred to a family physician commonly used the prescribed medications. This study also found that patients who visited a family doctor or a general practitioner used fewer prescribed drugs than those who visited a specialist. CONCLUSION: This study describes social determinants as additional effective factors in health services that influence the use of prescribed and non-prescribed medications in Shiraz. These evidence- based findings can help policymakers to plan the best programs.

Affordability of Medication Therapy in Diabetic Patients: A Scenario-Based Assessment in Iran's Health System Context.

BACKGROUND: Diabetes imposes an enormous burden on patients, families, societies, and healthcare systems. Determining the affordability of medications is an important complicated and vague task, especially in low- and middle-income countries (LMICs). This study aimed to assess the affordability of diabetes medication therapy in Iran's health system. METHODS: This paper presents a scenario-based assessment of the affordability of all registered anti-diabetes medications in Iran in 2017. To this end, 4 medication therapy scenarios were defined as mono, dual, triple, and insulin therapy in accordance with the existing guidelines and clinicians' opinions. Then the affordability ratio of each treatment scenario was determined for type 1 and type 2 diabetes drawing on the World Health Organization (WHO)/Health Action International (HAI) Methodology. If the affordability ratio for treatment schedules was more than 1, the patients' out-of-pocket (OOP) expenses exceeded the lowest-paid unskilled government worker (LPGW)' wage per day, and the treatment was labelled as non-affordable. RESULTS: The results revealed that the mono, dual, and triple (non-insulin) medication therapies in type 2 diabetes were affordable, despite an increase in the dosage or a switch from the monotherapy to the combination therapy of oral medications. However, some treatment scenarios in the triple therapy, including oral plus insulin and some insulin only therapies, were proved to be non-affordable. In type 1 diabetes, only insulin glulisine, detemir, and lispro were non-affordable in monotherapy. Regarding the combination therapy, only isophane insulin with aspart or regular insulin were affordable treatments. CONCLUSION: Although oral medication therapies were documented to be affordable, insulin therapy, with current coverage conditions, for patients with lowest paid wages and those receiving even less is unaffordable and a major barrier to treatment; hence, policy-maker should consider targeting and more financial protection policies to improve the affordability of insulin therapies among this group of patients.

Factors Facilitating and Hindering Development of a Medication Use Review Service in Eastern Europe and Iran-Cross-Sectional Exploratory Study.

Polypharmacy is a common issue in patients with chronic diseases. Eastern-European countries and Iran are exploring possibilities for implementing the Medication Use Review (MUR) as a measure for optimizing medication use and ensuring medication safety in polypharmacy patients. The aim of this study was to gain insights into the development of the community pharmacy sector and map facilitators and barriers of MUR in Eastern Europe and Iran. The representatives of the framework countries received a questionnaire on community pharmacy sector indicators, current and future developments of pharmacies, and factors encouraging and hindering MUR. To answer the questionnaire, all representatives performed document analysis, literature review, and qualitative interviews with key stakeholders. The socio-ecological model was used for inductive thematic analysis of the identified factors. Current community pharmacist competencies in framework countries were more related to traditional pharmacy services. Main facilitators of MUR were increase in polypharmacy and pharmaceutical waste, and access to patients' electronic list of medications by pharmacists. Main barriers included the service being unfamiliar, lack of funding and private consultation areas. Pharmacists in the framework countries are well-placed to provide MUR, however, the service needs more introduction and barriers mostly on organizational and public policy levels must be addressed.

Assessing the Performance of Community Pharmacies in Iran by Measuring Responsiveness to Non-Medical Needs: An Application of WHO Responsiveness Framework.

OBJECTIVE: Despite growing debates about the health systems' nonmedical performance, there has not been any empirical research on nonmedical performance and patients' rights consideration as a driver of human rights in the pharmaceutical sector. This study's main objective was to assess the nonmedical performance of community pharmacies of Shiraz, Iran. METHODS: A cross-sectional study was conducted using two self-administrated Likert-based questionnaires based on the World Health Organization (WHO) responsiveness framework and the legal charter communicated by the Ministry of Health and Medical Education of Iran. The population was patients older than 18 years who took a prescription from community pharmacies located in Shiraz and willing to answer the questions voluntarily, from 2018 to 2019. Considering the weights of subdimensions of responsiveness provided by the WHO framework, the total score of responsiveness was calculated ranging from 0 to 100. FINDINGS: The response rate was 80.5%. The mean (standard deviation) overall score of responsiveness was 57.18 (21.61), with a median of 56.71. The mean score of client orientation was lower in respondents with a high education level than those with a diploma and under diploma (P = 0.028). CONCLUSION: Nonmedical pharmacy performance was considered either medium or high in more than half of the cases based on the participants' views. Regarding client, orientation was seen less often in patients with high education level compared to those with a lower education level.

The Pattern of Medication Usage in the Southern Region of Iran: A population-based Pharmacoepidemiological Study.

OBJECTIVE: The purpose of this study was to document the demographic data, to assess the proportion of consumed medicines and the amounts and types of drugs available to households, and to to estimate the probable prevalence of certain diseases in the southern region of Iran. METHODS: In this cross-sectional population-based study carried out in Shiraz (the central city in the Southern part of Iran), we documented and evaluated the drug usage details in a random sample of 1000 households during 2018-2020. We analyzed the usage of drug categories based on the anatomical therapeutic chemical classification, which the World Health Organization recommends. FINDINGS: In the studied population, the average age (± standard deviation) was 45.54 ± 15.82, ranged 18-91 years. More than 90% had medical insurance coverage. About 81.8% of the participants had individual family medicine practitioners, and most of them (93.8%) received medications with a physician's prescription. The most frequently used medications were cough and cold preparations (12.9%), nervous system drugs (12.6%), and cardiovascular system drugs (11.6%). CONCLUSION: Despite the easy access to medications for most participants, few individuals (about 6%) received their medications without a prescription. The most frequently prescribed medicines were the common cold, acetaminophen, and metformin. Common cold, gastrointestinal (GI) disorder, and diabetes were the most commonly used medication classes. Furthermore, we have found a probably higher than average prevalence of cardiovascular, GI, and endocrine disorders. This information could be used by the local policymakers as a basis for the estimation and allotment of health-care resources.

A Population-Based Study on Patients Complaining Regarding Community Pharmacies Services.

OBJECTIVE: Patients' complain regarding pharmaceutical services at community pharmacies is a fundamental issue as it can directly affect people's service utilization. For the first time in Iran, this survey aimed to investigate the experience of people regarding declare a complaint against the pharmacy sectors as a community-based study. METHODS: In this cross-sectional study, over 100 samples based on postal codes were randomly selected from the city of Shiraz in 2017-2018. The data collection instrument was designed in two parts (demographic and social profile which record the complaint experiences against pharmacists, pharmacy services, etc.). The data were analyzed by SPSS. FINDINGS: All 1035 eligible participants had a mean age of 45.54 ± 15.82 years (ranged from 14 to 91). Nearly 70% of the participants were female. Around 81.8% had a family physician coverage, whereas 7.4% of them had no medical insurance coverage. The frequency of complaints from the pharmacies was 35.6%. Nearly 55% of the complaints were related to governmental pharmacies. Homemakers were 1.36 times more likely to have experienced complaints in comparison with their employed female counterparts. Health status had an inverse association with complaints. Those participants who had received prescription medication were about two times more likely to have filed a complaint in comparison with those who received medication without a prescription. In addition, females aged 40-59 and above 60 and unemployed participants were more satisfied with respect to complaint follow-up process. CONCLUSION: Low level of satisfaction with respect to the complaint process is a concerning issue; hence, strategies are warranted to improve the quality of services provided in the pharmacies.

The Effect of Octreotide in Acute Nonvariceal Upper Gastrointestinal Bleeding: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: Nonvariceal upper gastrointestinal bleeding (NUGIB) is a common cause of hospitalization and is associated with considerable mortality and morbidity. Octreotide has been shown to be an effective treatment in the control of variceal UGIB. Theoretically, octreotide could be effective in the treatment of other types of bleeding ulcers. METHODS: This randomized, double-blind, placebo-controlled trial was carried out on patients with NVUGIB who had been admitted to two referral centers in Shiraz, Iran. Patients were randomized to two groups: Group A (n = 58) received octreotide and Group B (n = 58) received a placebo. Patients in both groups received pantoprazole 40 mg as an initial dose, then 40 mg every 12 h intravenously. In addition to the pantoprazole, patients in Group A received 100 µg octreotide subcutaneously every 8 h for 72 h or until they were discharged. Patients in Group B received pantoprazole and a placebo at the same dose schedule. FINDINGS: There were no statistically significant differences between Groups A and B in terms of mortality (0 vs. 5.17%; P = 0.21,) rebleeding rate (5.17% vs. 1.72%; P = 0.5), blood transfusion requirement (1.65 ± 0.47 units vs. 1.70 ± 0.45 units; P = 0.45), length of hospital stay (1.96 ± 1.00 days vs. 1.65 ± 0.84 days; P = 0.44), and need for surgery (1.72% vs. 1.72%; P = 0.7). CONCLUSION: The results showed that use of subcutaneous octreotide as an adjuvant treatment did not have a beneficial effect on the treatment of NVUGIB.

Knowledge and Attitude regarding COVID-19 among Pregnant Women in Southwestern Iran in the Early Period of its Outbreak: A Cross-Sectional Study.

Both knowledge and attitude can play key roles in the prevention of novel COVID-19. This cross-sectional study was conducted on a statistical sample of pregnant women in southwestern Iran between March and April 2020 to evaluate their knowledge and attitude toward this condition. So, pregnant mothers registered in antenatal clinics affiliated to Shiraz University of Medical Sciences were called and asked to fill in a three-part online questionnaire including sociodemographic characteristics, obstetric/medical history, and knowledge/attitude toward COVID-19. P-values < 0.05 were considered statistically significant. The mean score of knowledge among 540 respondents was 34 (±4.1) out of 43. Also, 44.3% answered more than 80% of the items correctly. Higher knowledge scores were accordingly associated with marriage duration, area of residence, health insurance coverage, socioeconomic status (SES), and self-rated health status. However, a strong relationship was found between knowledge, SES, and health insurance coverage with reference to multivariate analysis results. Moreover, majority of the pregnant women and their households expressed their concern about using preventive measures against COVID-19. Although most respondents were moderately worried about becoming infected with COVID-19, 264 (48.9%) cases reported that they were very much anxious about their newborns being infected with COVID-19 and 388 (71.9%) individuals asserted that they were worried about their mortality due to this infection. Besides, most mothers maintained that they had some degrees of rumination, which could interfere with their routine daily chores. Hence, health policy-makers should pay much focus on educating pregnant mothers to help them prevent mental exhaustion.

Evaluating Pharmacist's Patient Care Process in Shiraz, using a newly-validated questionnaire: The First Report from Iran.

BACKGROUND: The Pharmacists' Patient Care Process (PPCP) as one of many inter-related foundations for the delivery of evidence-based and outcomes-focused patient care has a positive trend in academic literatures in the world. Unfortunately, PPCP has not been establish well in community pharmacies in Iran, yet. This study was performed to explore the current status of the provision and perception toward patient care services and finally evaluate professional competency of pharmacists about PPCP implementation, in both patients and pharmacist's perspectives. METHODS: A cross-sectional study was conducted using two self-administrated Likert-based questionnaires_ one for pharmacists and another one for patients. In total, 121 pharmacists and 479 patients participated to the study. Questionnaires were distributed and collected in the Shiraz during the Oct 2017 till Jun 2018. Obtained data were analyzed through the statistical package for social sciences (SPSS) version 25. In addition, the competency to PPCP implementation was classified to three groups _good, moderate, and weak _ based on achieving ≥75%, 50%-75%, and <50% of the dimensions' total score, respectively. RESULTS: The pharmacist's age range was 23-76 years (mean age: 40.61±12.85 years). Their Competency to PPCP implementation was good (43.8%), moderate (52%), and just 4% weak. Patient's response to PPCP was 11.2% good, 50.7% moderate and 35.6% weak. CONCLUSION: Besides promotion of public awareness about PPCP, improvement of pharmacists' motivation toward these services seems necessary. In addition, the introduced instrument may be useful for practice of pharmacists, but it should be used cautiously until it is tested among clients of pharmacies known to provide all levels of pharmacy care within pharmacy stores.

Knowledge, attitudes, risk perceptions, and practices of adults toward COVID-19: a population and field-based study from Iran.

OBJECTIVES: To determine peoples' knowledge, attitudes, risk perceptions, and practices to provide policymakers pieces of field-based evidence and help them in the management of the COVID-19 epidemic. METHODS: This population-based survey was conducted using multi-stage stratified and cluster sampling in Shiraz, Iran. A total of 1331 persons were interviewed. The questionnaires were completed by face-to-face interviews. Univariable and multivariable (linear regression) data analyses were done using SPSS. RESULTS: The participants answered 63% of questions regarding knowledge, and 78% of questions regarding practice correctly. Only, 4.8% knew about common symptoms of COVID-19 and 7.3% about warning signs that require referral to hospitals. Males, lower educated people, and elders had a lower level of knowledge and poorer practices. Knowledge was also lower in the marginalized (socially deprived) people. Knowledge and practices' correlation was 37%. Overall, 43.6% considered themselves at high risk of COVID-19, and 50% considered it as a severe disease. This disease had negative effects on most participants' routine activities (69.1%). The participants preferred to follow the news from the national TV/Radio, social networks, and foreign satellite channels, respectively. CONCLUSIONS: Encouragement of people to observe preventive measures and decreasing social stress, especially among males, lower educated people, elders, and marginalized groups, are highly recommended.

A preliminary report on the use of Midodrine in treating refractory gastroesophageal disease: Randomized Double-Blind Controlled Trial.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disease with various clinical presentations. Acid suppression with proton pump inhibitors and lifestyle modification may not lead to satisfactory response in a substantial portion of patients. We investigated the possible effect of midodrine in patients with refractory GERD. METHODS: Patients suffering from GERD and were refractory to one-month course of pantoprazole 40mg twice daily entered the study. This was a pilot, randomized, double-blind, and placebo-controlled study. After randomization, one group received Midodrine 5mg before meals for one month, and the other group received placebo for the same period. Meanwhile, pantoprazole was continued 40mg twice daily in both arms. The severity of symptoms was evaluated by the visual scoring system. Quality of life (QoL) in both groups was measured using a standardized version of Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). RESULTS: A total of twenty patients were enrolled in this study. There was a significant interaction between the groups and time on all measured scores based on QOLRAD questionnaire. All the markers in the Midodrine group had significant improvement over time, but the placebo group did not show any significant improvement. Both visual severity score and total QoL score in Midodrine arm showed a U shape change during  6 weeks. CONCLUSIONS: Midodrine before a meal could be useful in alleviating symptoms and improving QoL in the patients with refractory gastroesophageal disease.

Network Clustering and Bibliometrics of Pharmacology and Pharmacy Research Outputs Published by Iranian Authors.

OBJECTIVE: Evidence-based practice in medical sciences needs to publish confidential evidence that strongly depends on the research publications. This bibliometrics and network analytic study aims to evaluate the research publications of Iranian authors in pharmacology and pharmacy. METHODS: Through the pharmacology and pharmacy category of Web of Science (WOS), all published articles affiliated with an Iranian researcher as an author were retrieved. Full records of retrieved articles in the WOS, including author name and affiliation, journal name, citation number, cited references, and keywords, were exported to a plain text file. Network analysis through VOSviewer was used for mapping the characteristics of the retrieved articles. All statistical analyses were done using the Microsoft Excel and SPSS version 25. FINDINGS: The total number of Iran's publications (citations) rose from 1557 articles (10,085 citations) in 2000-2009 years to 6271 articles (77791 citations) in 2010-2018 years. Tehran University of Medical Sciences was the most productive university. The total number of RCTs rose from 82 publications in 2000-2009 to 278 publications in 2010-2018. The same numbers for systematic reviews and meta-analyses were four publications in 2000-2009 and 169 publications in 2010-2018. The five major topics of researches in pharmacology and pharmacy were drug delivery, basic pharmacology, oxidative stress, animal study, and molecular aspect of pharmacy. CONCLUSION: This study showed a marked increasing rate of publications and received citations by Iranians in pharmacology and pharmacy. After 2010, the rate of articles in the high-impact journals had growth. Furthermore, research articles in the highest level of evidence were more published by Iranians.

Enhanced Intestinal Permeation of Doxorubicin Using Chitosan Nanoparticles.

Purpose: Due to limited oral bioavailability of doxorubicin (Dox) many efforts during the last decades focused on the development of novel delivery systems to overcome these limitations. In the present study, Dox encapsulated chitosan nanoparticles were prepared to evaluate the intestinal permeation of Dox via oral administration. Methods: Nanoparticles were fabricated based on ionic gelation method using tripolyphosphate. Some physicochemical properties, such as nanoparticle size and morphology, loading efficiency and in vitro drug release in 3 different pH values (5.0, 6.8 & 7.4) were evaluated. Intestinal permeations of free Dox and Dox loaded in nanoparticles were assessed using rat intestinal sac model. Results: The nanoparticles were spherical shape with average size of 150 ± 10 nm. The entrapment and loading efficiency of Dox were up to 40% and 23%, respectively. According to the release profiles, up to 30% of loaded drug was released within 6hrs and the remaining amount of Dox was released more gradually, but this pattern was related to pH of the medium. The amount of drug released at acidic condition (pH 5.0) was greater than other pHs. The intestinal permeation of Dox increased nearly up to 90% by loading in chitosan nanoparticles. Conclusion: Using chitosan nanoparticles presents a potential safe drug delivery system for oral administration of Dox. In vivo studies and the determined pharmacokinetic and pharmacodynamic of Dox loaded chitosan nanoparticles after oral administration are planned for future studies.