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ObjectiveThis study aims to assess the relative importance of attitude and subjective norms as well as physicians' characteristics and practice-setting factors in predicting the outcome of physicians' interactions with MRs.MethodsA cross-sectional survey was conducted among a convenience sample of 602 physicians in Sana'a, Yemen. The data were analysed using descriptive and inferential analyses. The t-test/Mann–Whitney test and ANOVA/Kruskal–Wallis test with post hoc analysis, principal component analysis, correlation analysis and regression analysis were applied at an a priori significance level of 0.05.Key findingsThe response rate was 76.5%. Results showed that physicians who see a greater number of MRs per week or have academic affiliations were significantly more likely to have received high/low-value promotional items than were those who saw fewer MRs or have no academic affiliations (P values < 0.001 and 0.021, respectively). Also male physicians and physicians who have private clinics were significantly more likely to have received high-value promotional items (P value < 0.001). Three out of five hypotheses were supported (physicians' belief in the appropriateness of accepting high/low-value pharmaceutical companies' promotional techniques relate positively and significantly to their behaviour of interactions with MRs, and physicians' attitudes towards pharmaceutical companies relates positively and significantly to their interactions with MRs).ConclusionPhysicians in Yemen consider most of the promotional techniques as normal practice. The article provides empirical evidence for policymakers in developing countries in general, and Yemen specifically, to develop suitable policies and regulations for drug promotion.

Background: To authors’ knowledge, in Saudi Arabia, information regarding patients’ knowledge about their medications is lacking. Objectives: This study aimed to fill this literature gap by assessing patients’ knowledge and perceptions about their medications. Design: To achieve the objective of the study, a cross-sectional survey was conducted outside community pharmacies in Qassim region through an exit interview with patients after getting their prescriptions filled or refilled. Methods: A convenient sample of patients was chosen based on acceptance to participate. A form was prepared based on the core and complementary medicines use indicators for evaluation of medicines use in healthcare settings developed by the World Health Organization (WHO). Results: Four hundred forty-three forms were completed. A total of 70% of the indicators of patients’ knowledge about their medications were found to be satisfactory, and a total of 89% of the patients were found to have positive perceptions about safety and effectiveness of their medications. Conclusion: Overall, patients’ knowledge about their medications was found to be reasonable with exception of the area “information about precautions and possible side effects” which had shown poor patients’ knowledge.

Background: Dispensing of antibiotics without a prescription (DAwP) has been widely practised among community pharmacies in Saudi Arabia despite being illegal. However, in May 2018, the law and regulations were enforced alongside fines. Consequently, we wanted to evaluate the impact of these changes. Methods: A study was conducted among 116 community pharmacies in two phases. A pre-law enforcement phase between December 2017 and March 2018 and a post-law enforcement phase one year later. Each phase consisted of a cross-sectional questionnaire-based survey and a simulated client method (SCM) approach. In the SCM, clients presented with either pharyngitis or urinary tract infections (UTI). In SCM, for each phase, all 116 pharmacies were visited with one of the scenarios. Results: Before the law enforcement, 70.7% of community pharmacists reported that DAwP was common with 96.6% and 87.7% of participating pharmacies dispensed antibiotics without a prescription for pharyngitis and UTI respectively. After the law enforcement, only 12.9% reported that DAwP is still a common practice, with only 12.1% and 5.2% dispensing antibiotics without prescriptions for pharyngitis and UTI respectively. Conclusion: law enforcement was effective. However, there is still further scope for improvement. This could include further educational activities with pharmacists, physicians and the public.

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

BACKGROUND: Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa. METHODOLOGY: Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa. RESULTS: Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care. CONCLUSION: There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

BackgroundChronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in low- and middle-income countries (LMICs) such as India. Medicine costs are a key issue in LMICs, with typically high patient co-payments. In addition, pharmacists are underutilised in LMICs, including India. However, pharmacist-led educational interventions may improve the care of patients with COPD, as well as reduce medicine costs. Consequently, the objective of this study was to assess the effectiveness of a pharmacist-led intervention in reducing medicine costs.MethodologyWe assessed the impact of a pharmacist intervention on direct medicine costs in COPD patients (medicine costs and pharmacist time) in a randomised controlled study involving an intervention and control group, conducted at a tertiary care teaching hospital in India.ResultsThe 6-monthly cost of medicines at baseline increased with disease severity, from a maximum of US$29.46 for those with mild COPD to US$63.28 for those with very severe COPD. Substantial savings in medical costs were achieved with the pharmacist-led programme, to a maximum of US$20.49 over 6 months for very severe patients. This equates to a reduction of 30.6% in medicine costs (p ConclusionThere could be a key role for pharmacists as educators for COPD patients in LMICs, to improve care and reduce costs, including patient co-payments.

Introduction Pharmacists have a unique opportunity to promote good health through assuring the quality use of medicines. One of the most important tools to achieve this is medication counseling. Counseling plays an important role in enhancing medication adherence and optimizing medication therapy. Therefore, for improving the quality of services delivered by community pharmacists, it is essential to assess the current situation of counseling services delivered to patients. Aims and objectives To date, there is a paucity of data regarding the quality of counseling services delivered to patients in community pharmacies in Saudi Arabia. This study aims to fill this gap through evaluating the counseling skills and counseling content delivered by pharmacists in a sample of community pharmacies in Qassim region, Saudi Arabia. Methods The study was conducted at eleven community pharmacies in Qassim region. A convenient sample of community pharmacies was chosen based on their willingness to participate. To gather information, a form was prepared based on the core and complementary drug use indicators for evaluation of drug use in healthcare settings developed by the WHO. The study was conducted through observing the counseling services performed by the community pharmacists who participated in the study. Results Two hundred and thirty-five forms were completed in eleven community pharmacies. A total of 44.4% of the counseling skills was found to be performed adequately, while only 20.1% of the counseling contents were performed adequately. Conclusions The overall standard of medication counseling services provided to patients to improve usage of their medications, and consequently, their well-being was poor.

Objective: Interaction between physicians and medical representatives (MR) is an area of controversy, which discussed heavily in the literature. However, the perspectives of physicians on the extent and composition of pharmaceutical promotion techniques have been neglected especially in developing countries. Therefore, this study aims to bridge this gap through investigating physicians' perceptions, beliefs and attitudes towards interactions with medical representatives with special emphasis on their perception about the appropriateness of accepting drug company promotions and their either positive or negative attitudes towards drug promotion activities. Methods: This is a descriptive cross-sectional study that investigates physicians' perceptions about interactions with medical representatives. Data were collected through an anonymous survey questionnaire circulated to 610 physicians. Key findings: Majority (85.3%) of participated physicians has positive attitudes towards interactions with medical representatives, and they disagree with the idea of banning medical representatives' visits. Also perception of the majority (60.8%) of physicians is that most promotional techniques do not pose ethical problem, and it is appropriate to accept most promotional items. Conclusion: Majority of the physicians have positive attitudes towards interactions with MRs. Most of the physicians believe that most promotional techniques do not pose ethical problem, and it is acceptable to accept promotional items. 1 2017 Royal Pharmaceutical Society This work was supported by Yemeni Ministry of Health and Population. Scopus

Background This study was conducted in Sudan, which is a sub-Saharan Africa country with similar problems regarding infertility, to explore the perspectives of currently married infertile Sudanese women on complementray medicine seeking behaviour with more emphasis on traditional self-management strategies. Methods A cross-sectional survey involving 203 infertile women in Khartoum, Sudan, using a convenient sampling method at the women’s visits of infertility treatment clinics. A validated questionnaire was used for data collection. Results Findings of the study revealed that 43.3% of participated women had rich experience with infertility self-management strategies, and 65.0% of them used these strategies to treat infertility. Also 59.1% of the participants mentioned unaffordability of modern treatment as a main factor for trying self-management strategies. 45.3% of the participating women believe that the best strategy for self-management of infertility is Qura’an and Sunna treatment provided by Shaikh. Only 42.9% of the participants agreed with the statement that their ‘cognitive knowledge about self-management of infertility does not encourage its use’. Conclusion The study revealed women’s rich experience and wide use of different types of self-management strategies together with formal infertility health care services either simultaneously or subsequently. Also, unaffordability of formal treatment services was reported as one of the most encouraging factors towards seeking traditional treatment options. Therefore, most important literature gap this study hoped to fill is its focus on traditional treatment strategies of infertility, and thereby, can help policy makers and public health activists tailor more efficient plans to handle this complicated problem.

Purpose This study aims to investigate relationship between attitude and belief of physicians towards drug promotion and their characteristics and practice-setting factors in Sana'a, Yemen. Methods A survey method approach was used in this study. To test the relationship between attitude and belief of physicians towards drug promotion and their characteristics and practice-setting factors in Sana'a, Yemen, data were analysed using descriptive and inferential analysis. The hypotheses were tested using independent t-test and one-way ANOVA. Results Findings revealed that only possession of private clinic makes significant difference (P-value 0.003) among physician in attitude towards pharmaceutical companies, and only occupational commitment makes significant difference (P-value 0.020) in attitude towards ethical pharmaceutical promotion, while only gender and possession of private clinic make significant difference (P-value 0.001 and 0.009 respectively) in physicians’ belief in the appropriateness of accepting high-value promotions. ANOVA showed significant difference in physicians’ attitude towards pharmaceutical companies (P-value 0.003) and medical representatives (MRs; P-value 0-048) only when the number of MRs seen per week is more than six. Conclusion Only gender, possession or nonpossession of private clinic, occupational commitment and number of MRs the physician see per week can be considered as possible predictors of the relationship between physicians’ belief and attitude towards drug promotional activities. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors acknowledge Dr Michael Steinman, Assistant Professor of Medicine in Geriatrics, San Francisco VA Medical Center and UCSF and Dr Douglas Ball, Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, for providing background support in terms of developing the questionnaire. We also thank all the physicians for their involvement in and cooperation during the study. Scopus

Introduction: One major contributing factor to the prevalence of counterfeit medicines in a country is the lack of knowledge and awareness of the society. Information on general public and healthcare professionals awareness and vulnerability towards counterfeit medicines in developing countries is limited. Aim: To assess how the general public and pharmacists perceive counterfeit and substandard medicines and to evaluate their vulnerability level toward counterfeit medicines. Materials and Methods: A cross-sectional study was conducted in Qatar where a prevalidated questionnaire was used to collect information about: a) demographic characteristics, b) attitude, c) subjective norm, d) motivation, and e) behavioural intentions of pharmacists and public regarding counterfeit medicines on a Likert-scale. A total of 190 questionnaires were distributed conveniently to the public and community pharmacists. Chi-square and independent t-tests were used at p-value of 0.05. Results: One hundred ninety questionnaires were distributed to both community pharmacists and public, however, only 167 (87.8%) were collected which resulted in response rate. Most of the results of the survey (41 items) were not significant (p-value>0.05). Only questions about awareness towards counterfeit medicines, its societal consequences, the effect of price affordability and the effect of pressure exerted by relatives and friends on purchase intent of counterfeit medicines gave significant difference between public and pharmacists (p-value 0.05). Conclusion: Overall findings suggested that there is no significant difference between pharmacists and public in the way they perceive counterfeit and substandard medicines. Both of them have the same susceptibility level toward counterfeit medicines. Both pharmacists and public have low-level of knowledge and moderate level of vulnerability to counterfeit and low-quality medicines. This work was supported by the Qatar University Student Grant [grant numbers: QUST-CPH-Fall-14/15-11]. Scopus

Pharmaceutical care can be given in all settings: The community, hospitals, long-term care, and the clinic. However, published literature indicates that there is a substantial barrier to implementing pharmaceutical care programs in community pharmacies. This review was conducted to discover gaps and limitations in pharmaceutical care services in community pharmacies in the Kingdom of Saudi Arabia (KSA). We searched PubMed and other available scientific website databases using the following key words to retrieve the relevant articles: Community Pharmacy, Healthcare System, Pharmaceutical Care, KSA. Two authors independently screened the titles and abstracts of promising articles. They discarded irrelevant studies and retained studies, and reviews that held the promise of relevant data or information. The review revealed that only one out of the four studies conducted in KSA retrieved by the authors reported pharmaceutical care service other than dispensing. The same results were reported in other studies conducted in some developing countries. All pharmaceutical care services were reported in studies conducted in Europe. The authors came to the conclusion that in KSA, dispensing of medicines is the dominant service provided by community pharmacists and that there was very limited if not a total absence of other pharmaceutical care services.ملخص البحث : يمكن تطبيق برنامج الرعاية الصيدلانية في جميع المنشآت الصحية كصيدليات المجتمع، والمراكز الصحية. تشير البحوث المنشورة بوجود عوائق حقيقية تحول دون تنفيذ برامج الرعاية الصيدلانية في صيدليات المجتمع. وتبين هذه المقالة أن هناك قصورا في خدمات الرعاية الصيدلانية في صيدليات المجتمع بالمملكة العربية السعودية، وأن عمليات صرف الدواء هي الخدمة المهيمنة بالصيدليات مع هامش لا يكاد يذكر لخدمات الرعاية الصيدلانية.

Background The counterfeit drug trade has become widespread and has developed into a substantial threat to both the public's health and the pharmaceutical industry. Objectives The aim of this study was to seek insights into the determining factors of counterfeit drug purchases among health policy makers and community pharmacists in a developing country. Methods In-depth qualitative interviews with Sudanese policy makers and community pharmacists were undertaken in 2 Sudanese states, namely Khartoum and Gadaref. A semistructured interview guide was developed by incorporating information from existing literature. A purposive sample of knowledgeable policy makers and community pharmacists was interviewed. Results Thematic content analysis of the interviews identified 8 major themes: understanding the term “counterfeit drug,” presence of counterfeit drugs in the Sudanese market, vulnerability to counterfeit drugs, price-quality inference, awareness of societal consequences of counterfeit drugs, subjective social norms, difference in vulnerability according to demographic characteristics, and education pertaining to counterfeit drugs. Unaffordability of medicines and desperate need were emphasized by both policy makers and community pharmacists as major influencing factors that increased consumers' vulnerability to counterfeit drugs. Conclusions This study concluded that high prices and the unaffordability of medicines have a major role in increasing vulnerability to counterfeit drugs, in addition to lack of knowledge about counterfeiting and the implications of use of these products. Because very limited studies have been conducted in developing countries to explore perceptions about counterfeit drugs, the present study provides information from which policy makers and key stakeholders in the supply chain can benefit.

Introduction There are limited studies on consumer behaviour toward counterfeit products and the determining factors that motivate willingness to purchase counterfeit items. Aim This study aimed to fill this literature gap through studying differences in individual ethical evaluations of counterfeit drug purchase and whether that ethical evaluation affected by difference in income. It is hypothesized that individuals with lower/higher income make a more/less permissive evaluation of ethical responsibility regarding counterfeit drug purchase. Materials and Methods To empirically test the research assumption, a comparison was made between people who live in the low-income country Sudan and people who live in the high-income country Qatar. The study employed a face-to-face structured interview survey methodology to collect data from 1,170 subjects and the Sudanese and Qatari samples were compared using independent t-test at alpha level of 0.05 employing SPSS version 22.0. Results Sudanese and Qatari individuals were significantly different on all items. Sudanese individuals scored below 3 for all Awareness of Societal Consequences (ASC) items indicating that they make more permissive evaluation of ethical responsibility regarding counterfeit drug purchase. Both groups shared a basic positive moral agreement regarding subjective norm indicating that influence of income is not evident. Conclusion Findings indicate that low-income individuals make more permissive evaluation of ethical responsibility regarding counterfeit drugs purchase when highlighting awareness of societal consequences used as a deterrent tool, while both low and high-income individuals share a basic positive moral agreement when subjective norm dimension is exploited to discourage unethical buying behaviour.

Introduction: Medicine prices are often high and unaffordable not only for the majority of people in low- and middleincome countries, but also for significant number of the population without social protection or insurance in high income countries. As a result, the lack of access to essential medicines due to unaffordability in developing countries is one of the most pressing global health problems. Objective: To provide comparable, evidence-based information for policy makers. Method: A cross sectional descriptive survey study was applied. Results and discussion: It seems that despite of the affordability was shown for many studied conditions, but still affordability of medicines remains a major problem for Sudan. Conclusion: It could be concluded that absence of standard treatment guidelines that are of sound scientific bases and cost-effectiveness resulting in low quality prescribing and dispensing practices which had led to wide variations in the prescribing patterns for the assessed acute and chronic conditions.

Background: Although desperate need and drug counterfeiting are linked in developing countries, little research has been carried out to address this link, and there is a lack of proper tools and methodology. This study addresses the need for a new methodological approach by developing a scale to aid in understanding the demand side of drug counterfeiting in a developing country. Methods. The study presents a quantitative, non-representative survey conducted in Sudan. A face-to-face structured interview survey methodology was employed to collect the data from the general population (people in the street) in two phases: pilot (n = 100) and final survey (n = 1003). Data were analyzed by examining means, variances, squared multiple correlations, item-to-total correlations, and the results of an exploratory factor analysis and a confirmatory factor analysis. Results: As an approach to scale purification, internal consistency was examined and improved. The scale was reduced from 44 to 41 items and Cronbach's alpha improved from 0.818 to 0.862. Finally, scale items were assessed. The result was an eleven-factor solution. Convergent and discriminant validity were demonstrated. Conclusion: The results of this study indicate that the "Consumer Behavior Toward Counterfeit Drugs Scale" is a valid, reliable measure with a solid theoretical base. Ultimately, the study offers public health policymakers a valid measurement tool and, consequently, a new methodological approach with which to build a better understanding of the demand side of counterfeit drugs and to develop more effective strategies to combat the problem. This work was supported by the Federal Ministry of Health Sudan. Scopus

Background: Counterfeiting of medicines in developing countries has been reported as a distressing issue. Moreover, although desperate need and drug counterfeiting are linked, no much study has been carried out to cover this area. Objective: The objective of this study is to assess the impact of demographic variables, including age, annual income, working status, education, and gender with respect to increasing or decreasing vulnerability of consumers to counterfeit drugs. Methods: This article reports on two studies conducted in two Sudanese states, namely Khartoum and Gadaref. In study 1 in-depth qualitative interviews with a purposive sample of knowledgeable policy-makers and community pharmacists were undertaken. Study 2 employed a face-to-face structured interview survey methodology to collect data from 1003 subjects. Descriptive and inferential statistical techniques (ANOVA) were used to evaluate the data. Results: The paper identified demographic groups who are more vulnerable to counterfeit drugs. Thematic content analysis of the interviews identified difference in vulnerability according to demographic characteristics pertaining to counterfeit drugs. Also a significant difference in purchase intention of counterfeit drugs was supported for all demographic groups (annual income F (4,998)=6.255, p

Introduction Availability of counterfeit drugs is increasing, especially in developing countries. This fact makes it critical to develop new measures that can help to combat this problem. Objectives This study was designed to examine the influence of certain factors on consumers' behaviour regarding counterfeit drugs. Specifically, this study investigates consumers' intention to purchase counterfeit drugs based on their attitude towards the purchase of counterfeit drugs, subjective norm and motivation. Method This study was conducted in a resource limited setting context. A face-to-face structured interview survey methodology was employed to collect data from 1003 subjects. Data were analysed by maximum likelihood estimation procedures using structural equation modelling. Key findings Out of a total of 11 proposed hypotheses, only four were significant as expected. All hypotheses related to factors affecting attitude were found to be non-significant and, consequently, attitude towards purchase intention was also found to be non-significant. Conclusion The model, which was based on past research and the authors' theoretical considerations, was confirmed. Moreover, using the theory of planned behaviour provided strong contributions towards explaining the demand for counterfeit drugs. This study is among the few, and may indeed be the first, that examines an African country drugs market and provides information and knowledge highly demanded by marketing managers and public health policymakers. It provides an in-depth understanding of Sudanese consumers that can be used in designing more efficient anti-counterfeiting strategies in developing countries.