Scale validation for the identification of falsified hand sanitizer: public and regulatory authorities perspectives from United Arab Emirates

Background: Since the time of declaration of global pandemic of COVID-19 by World Health Organization (WHO), falsified hand sanitizers surfaced regularly in markets, posing possible harm to public due to unlisted inclusion of methanol. The current research is an attempt to develop and validate a tool to document falsified hand sanitizer in the UAE community. Method: A descriptive cross-sectional community-based study was conducted among 1280 randomly selected participants. Respondents were sent a web-based electronic link to the survey via email. Content validity, factor analyses and known group validity were used to develop and validate a new scale to identify falsified hand sanitizer. Test-retest reliability, internal consistency, item internal consistency (IIC), and intraclass correlation coefficients (ICCs) were used to assess the reliability of the scale. SPSS version 24 was used to conduct data analysis. Results: A total of 1280 participants were enrolled in the study. The content validity index (CVI) was 0.83 with the final scale of 12 items. The Kaiser-Meyer-Olkin (KMO) value was 0.788, with the Bartlett test of sphericity achieving statistical significance (p < 0.001). Our factor analysis revealed a 3-component model. The 3-factor solution was confirmed by PCFA analysis and had associations with good fit values. The PCFA for NFI was 0.970, CFI 0.978, and TLI 0.967. All values were in excess of 0.95, with RMSEA values below 0.06 at 0.03; all of these values indicated a good model fit. The Cronbach’s alpha was good overall (0.867). All factors had a Cronbach’s alpha value in excess of 0.70. The instrument demonstrated that every item met the IIC correlation standard ≥0.40. The scale displayed good overall ICC statistics of 0.867 (95% CI 0.856–0.877) with statistical significance (p < 0.001). The scale’s test-retest reliability was assessed through correlation of the falsified hand sanitizer identification score of respondents at the two time points. The test-retest correlation coefficient was 0.770 (p value < 0.01). Participants with post-graduate education were more likely to identify the falsified hand sanitizer compared to those with high school education. (p < 0.001

Essential medicines in universal health coverage : a scoping review of public health law interventions and how they are measured in five middle-income countries

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated

Development and validation of a tool to improve community pharmacists' surveillance role in the safe dispensing of herbal supplements

Background: There has been an appreciable increase in the use of herbal supplements, including immune boosters, during the current COVID-19 pandemic. However, there are concerns with falsified herbal supplements Objectives Developed a new questionnaire that can potentially help community pharmacists with identifying the extent of falsified herbal supplements. Methods: A cross sectional study conducted over nine months among 500 community pharmacies in the UAE. Face-to-face interviews were undertaken using a structured questionnaire, which was subjected to face and content validity, with the content validity index (CVI) computed. Construct validity was tested using an exploratory factor analysis (EFA) via principally component analysis (PCA). The model was then confirmed through Partial confirmatory factor analysis (PCFA). Reliability was assessed via test-retest reliability, internal consistency, item internal consistency (IIC), and intraclass correlation coefficients (ICCs). Results: An instrument compromised of five domains with a 24-item scale was developed with CVI of 0.843. The KMO measure of sampling adequacy was 0.891, and Bartlett’s test of sphericity indicated significance (p-value < 0.001). Confirmation of the subsequent 5-domains was achieved through PCFA using MLA with oblimin rotation. The PCFA obtained values of 0.962 for NFI, 0.977 for CFI, and 0.987 for TLI; all values were greater than 0.95, and the RMSEA value was 0.03 (i.e., less than 0.06). Consequently, the model had a good fit. All domains demonstrated Cronbach’s alpha coefficients above 0.70, with 0.940 for the full instrument. Meanwhile, all items met the IIC correlation standard of ≥ 0.40. The instrument presented good ICC statistics of 0.940 (0.928 – 0.950) as well as statistical significance (p < 0.001). Those participants who had more than 10 experience years more likely to identify falsified herbal supplements compared to those who have 1 to 10 experience years (p < 0.001). Conclusions: This study developed and validated a new instrument to identify safe herbal supplements products, which will help enhance the role of the community pharmacists in safe and effective treatment of suitable patients with herbal supplements

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions. Funding: Bill & Melinda Gates Foundation

A cost evaluation analysis to identify solutions for affordable medicines in Jordan: a comparative study with the UK

Background: Health is a core human right. The right of health care includes access to affordable medicines. Affordability of medicines by individual patients in low-income countries is a significant factor influencing access to care and treatment. However, drug prices in low income countries are found to be higher than those in high-income countries. Although the health care system in Jordan is quite advanced in comparison to neighbouring countries, the access to affordable medicines remains problematic. It was reported that almost 80% of the public in Jordan pay for their medications through out-of-pocket payments. High medicine prices are of a great concern to patients and their finances, which can result in poor compliance. Moreover, non-compliance can lead to reduced productivity and increased medical costs. In fact, several studies found that the high out of pocket-costs can be a significant obstacle to medical adherence with prescription medication regimens. Aims: The aim of this thesis is to research medicine prices and policies in Jordan, in order to recommend feasible solutions to make these affordable. To measure the affordability of medicines in Jordan and to assess the extent by which the cost of medicines is high, prices and factors affecting them were compared with the United Kingdom (UK), a high income developed country. Methods: A mixed-method approach was used in this thesis to research medicine prices and policies. The thesis reviewed the relevant literature, followed by reviewing the health care and pharmaceutical systems in both countries and their impact on medicine prices. Quantitative studies to measure the affordability of medicines in Jordan were conducted to assess the extent by which the cost of medicines is high in comparison to the UK and the factors that may affect medicine prices. This was followed by a qualitative study on how and why high unaffordable prices occur in Jordan. Finally, a quantitative survey exploring patients', pharmacists' and prescribing physicians' opinions towards measures that could be used to achieve greater clinical effectiveness and economic efficiency from drug prescribing was conducted. All the findings from the thesis were synthesised to form policy recommendations, designed to ensure affordable medicines for the Jordanian population. Results and discussion: Factors that influence prices of medicines over time were identified. These included; competition, marketing strategies, time in the market, regulations and pricing policy, change of clinical guidelines, epidemiology of disease, change in therapeutic use/value and exchange rate. Although the income per capita is much lower in Jordan (almost 7 fold less) than the one the UK, the studies conducted within this thesis demonstrated that medicine prices were significantly higher in Jordan compared to the UK. Generic medicines are three fold more expensive than the equivalent prices of the same drugs in the UK. However, the difference in prices for many drugs was significantly higher than the 3 fold difference. For example, the average price of pravastatin and amlodipine generics was more than eight fold higher than the UK price. Moreover, the average price of omeprazole, citalopram and fluoxetine generics were around 10 fold higher than the comparable UK price. Additionally, originator brand medicines prices were also found to be 1.5-fold more expensive in Jordan compared to the UK. Many originators were extremely higher than this average. For example, the Jordanian price of misoprostol originator tablets was around 19 times the comparable UK price. The price of ranitidine originator in Jordan was more than seven times the UK price and lansoprasole originator was around 6 times more than the price in the UK. The current pricing policy and its application are believed to be the root causes for the high prices of medicines in Jordan, as revealed by the qualitative interviews. The expected patients' saving by using generic medicines instead of originators in Jordan ranged from 32% up to 74%. The median saving in Jordan was -30.65% compared to - 71.43% in UK. The average savings were 32.68% and 43.54% in both Jordan and UK respectively. This increased to 54.96% in the UK when one outlier was removed. However, the saving calculated in both countries would have been higher if the lowest priced generic was used. An extra saving of 6.86% was identified in Jordan if the lowest priced generics were used for cardiovascular diseases (the calculated saving increased from 32.71% when using the average generic price compared to 39.57% when using the lowest priced generic). The findings also showed a positive attitude of all stakeholders (patients, pharmacists and prescribing physicians) towards generic medications and their willingness and acceptance of strategies that encourage generic utilisation in Jordan such as generic substitution, lnternational. Non-proprietary Name (INN) prescribing and Electronic Prescribing (EP). Such measures will help reduce the high expenditure on drugs in Jordan which accounts for around one-third of the national health care budget. Conclusion: A range of policy measures and changes are required to improve access to medicines in Jordan. Recommendations made included amendments to pharmaceutical policies, better enforcement of the current regulations, encouraging the use of generic medicines by introducing measures such as generic prescribing, generic substitution and public awareness education programs. These changes should result in more affordable medicines in Jordan

Exploring the factors impacting physicians’ attitudes toward health information exchange with patients in Jordanian hospitals

Abstract Background The uniqueness of the physician–patient relationship and the latter's lack of medical experience and knowledge necessitate providing patients with accurate and timely information necessary to engage them in treatment decision-making. Without detailed information from their physicians, patients cannot understand their medical condition, assess treatment options, and participate meaningfully in their care. Objectives The present research determines the main factors influencing physicians' attitudes toward health information exchange with patients in Jordanian hospitals. The fundamental question addressed by this paper is why Jordanian physicians are reluctant to provide their patients with detailed health information about the potential risks, complications, and benefits of proposed treatments and other recognised alternative therapies. Method This study is qualitative in nature, adopting face-to-face interviews as the key instrument of data collection in two hospitals in Jordan. The chief consideration of the sampling process was to select direct informants whose input would generate accurate results that might be generalised or translated to other contexts or settings. Thematic analysis was then used, and all participants’ opinions, answers, and interactions were transcribed and then reduced into themes and patterns for research, as per similarities and relationships, through coding and representing the data. Key findings The findings show that most patients in government hospitals, especially those elderly, poorly educated, or inexperienced, choose practitioners based solely on medical service fees and costs rather than quality and convenience. On the other hand, the large number of patients attending public hospitals and the insufficiency of physicians' financial incentives in such hospitals may discourage physicians from providing patients with detailed health information. Matters, however, take a different turn in private hospitals, in which many physicians improve the patient experience to keep him and attract others by sharing information with patients about their health and treatment. However, it was noted that some physicians at such hospitals still rely heavily on their relations with health insurance companies to attract patients rather than on meaningful communication with their patients. Finally, the present findings reveal that the absence of a clear legal duty of medical disclosure negatively influences the amount of information received during the clinic visit. Conclusions The fact that the level of communication in Jordanian healthcare settings has not been determined in detail opens the door to unnecessary healthcare expenditure and creates uncertainty concerning the amount of information that patients need to know in order to be involved in their treatment decision-making. The lack of proper control and quality monitoring may also negatively affect the interests of patients and their rights to receive adequate information about their health status

Physicians' perception of generic and electronic prescribing: a descriptive study from Jordan.

Jordanian physicians have a positive attitude towards generic medications and high willingness and acceptance of strategies that encourage generic utilisation such as EP, INN prescribing and generic substitution. All these strategies would help reduce the high expenditure on medicines in Jordan. These findings would provide baseline data to policy makers to develop a robust generic policy to achieve greater clinical effectiveness and economic efficiency from medicines prescribing