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Objective: To assess barriers and attitudes related to emergency contraception access among women seeking emergency contraceptive pills by using the Internet., Methods: We conducted quantitative surveys and qualitative interviews of 200 women seeking emergency contraceptive pills from The Emergency Contraceptive Website (http://ec.princeton.edu). Main outcome measures included barriers to and attitudes toward emergency contraception access., Results: Participants were predominately white, college-educated, urban residents. Women most frequently cited structural barriers to obtaining emergency contraceptive pills, such as inconvenient office hours. Although women supported advanced prescription of emergency contraceptive pills, there was less enthusiasm for nonprescription access because of concerns that others (but not they) would engage in risky sexual behavior. Women valued the consultation with a health professional; 42% stated they would still speak with a clinician even if nonprescription access was available., Conclusion: The Internet as a resource for emergency contraception appears limited to women of high socioeconomic status in our sample. There is a need to address beliefs that increased access to emergency contraception promotes risky sexual behavior because current evidence refutes this concern. Clinicians should still be prepared to discuss emergency contraception with patients, despite the fact that emergency contraceptive pills are now available to most (but not all) women without a prescription.

Aim: To investigate whether involvement in research can have a positive effect on the education and management of disease of children and young people with diabetes., Method: Children's and young people's experiences of exposure to intensified intervention during a clinical trial were examined by a questionnaire given to 44 young patients with type 1 diabetes from the UK and Ireland. The young people had participated in a trial comparing specific insulin regimes. Most patients were obliged to increase injection frequency, clinic attendance, glucose monitoring and diary entries., Findings: Of the 44 patients, 36 completed the questionnaire. Most, including the younger children, did not regard basal-bolus therapy, additional injections or intensified self-monitoring as barriers to self-management. They also believed that the management of their diabetes was further supported as a result of increased contact and intensive insulin management. Many of the children participating in this study felt they had learned something about their diabetes, and, furthermore, almost all opted to remain on an intensive treatment regimen., Conclusion: These results suggest that trial involvement benefits the young person's approach to self-management of diabetes.

Objective: Patients with low health literacy have difficulty understanding prescription drug labels and other medication instructions. This article describes the development, implementation, and preliminary evaluation of an illustrated medication schedule (a "pill card") that depicts a patient's daily medication regimen using pill images and icons., Methods: Participants in a randomized controlled trial who were assigned to receive the pill card intervention described their use of the card and its perceived effectiveness. Responses were analyzed by level of patient literacy and other characteristics., Results: Among the 209 respondents, 173 (83%) reported using the pill card when they initially received it, though use declined to 60% approximately 3 months later. Patients with inadequate or marginal literacy skills, less than high school education, or cognitive impairment were most likely to refer to the card on a regular basis initially and at 3 months (p<0.05). Most pill card users (92%) rated the tool as very easy to understand, and 94% found it helpful for remembering important medication information, such as the name, purpose, or time of administration., Conclusion: Nearly all patients considered an illustrated medication schedule to be a useful and easily understood tool to assist with medication management. Patients with limited literacy skills, educational attainment, or cognitive function referred to the aid with greater frequency., Practice Implications: Picture-based instructions promote better understanding of prescription medications, particularly among patients with limited literacy skills or cognitive impairment, and should be used more widely in practice.

Rationale: It has long been hypothesized that human as well as animal cocaine users titrate their intake to maintain a specific level of cocaine reward. This hypothesis predicts that the dose-injection function of each subject individually should be a decreasing function, with no initial, gradual ascending limb., Objectives: The present study was designed to test this specific prediction., Methods: Rats were trained to self-administer cocaine under a continuous reinforcement schedule. After stabilization of cocaine self-administration, all rats were tested with a wide range of i.v. cocaine doses (0.0078-1 mg). To accurately measure the threshold dose of each individual, the pharmacological resolution was set at 0.0078 mg at the four lowest doses., Results: As predicted, individual dose-behavior curves are discontinuous at a threshold dose, with a descending limb but no gradual, ascending limb. Below the threshold, there is no evidence for cocaine self-administration; at and above the threshold, the rate of injections spikes to its maximum and then decreases lawfully with the dose, a decrease that reflects cocaine titration. In all individuals, this critical transition occurred over a dose interval of less than 0.008 mg., Conclusions: This study suggests that the cumulative effects of cocaine maintained during self-administration are all-or-nothing-a conclusion that confirms the regulation hypothesis of cocaine reward. The neurobehavioral consequences of this specific level of cocaine reward remain to be elucidated.

Previous studies have shown that withdrawal from psychostimulant drugs such as d-amphetamine or methamphetamine decreases motivation to work for a natural reinforcement, which is thought to be associated with the withdrawal-induced depressive state and hypofunction of the mesolimbic dopamine system. However, to our knowledge, studies exploring the effect of morphine withdrawal on motivation for a natural reinforcement are lacking. The purpose of the present study was to examine whether motivation to work for a natural reinforcement changes during morphine withdrawal. Three groups of male Sprague-Dawley rats were trained to respond on a nose poke for a 4% sucrose solution under a progressive ratio schedule and were subsequently administered a 10-day regimen of injection of high or low dose of morphine or saline. Their duration of break point and withdrawal symptoms were assessed. The finding showed that break points were significantly reduced on day 1 and persisted to at least day 10 of withdrawal without change in locomotor activity. There were hardly any differences bear mentioning when comparing the magnitude of the decrease between the high- and the low-dose group, whereas the withdrawal scales were significant greater in the high-dose group than in the low-dose group. The results suggest that the morphine withdrawal resulted in decreased motivation to obtain the natural reinforcement. The progressive ratio procedure may be a useful technique for evaluation of changes in motivation for natural reinforcing stimuli following withdrawal from opiates.

Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.

Rationale: Previous studies have shown that environmental context can powerfully modulate the induction of psychomotor sensitization to cocaine in the rat. Rats that receive repeated administrations of cocaine in association with environmental novelty exhibit greater psychomotor sensitization than animals that receive the same treatments in their home cages., Objectives: The goal of the present study was to investigate whether environmental context can exert its modulatory influence also on cocaine self-administration., Materials and Methods: Independent groups of rats with intravenous catheters were given the possibility to self-administer different doses of cocaine (0.0, 0.2, 0.4, and 0.8 mg/kg per infusion) under two environmental conditions. Some animals were housed in the self-administration cages (home groups), whereas other rats were transported to the self-administration cages only for the test sessions (novelty groups)., Results: Environmental "novelty" facilitated the acquisition of cocaine self-administration at the doses of 0.2 and 0.4 mg/kg per infusion. When rats were given access to a higher dose of cocaine (0.8 mg/kg per infusion), there were no significant group differences in drug taking. Environmental context had no effect on the self-administration of the vehicle. Thus, it appears that environmental "novelty" produced a shift to the left in the dose-effect curve for cocaine self-administration. Furthermore, "novelty" enhanced the motivation of the rats to work for cocaine, as indicated by the results of a progressive ratio procedure., Conclusions: The present findings demonstrate for the first time that the environment surrounding drug taking can alter both the intake of and motivation for cocaine.

Opiate addiction is a chronic relapsing disorder characterized by high rates of relapse. The gamma-aminobutyric acid GABA(B) receptor agonist baclofen is known to affect the reinforcing effects of several drugs of abuse, including heroin, as well as to decrease cue-maintained responding for heroin, cocaine and nicotine and suppress alcohol deprivation effect in rats. Here we studied the effect of baclofen on the reinstatement of extinguished heroin-seeking behavior triggered by a priming injection of heroin in abstinent rats trained to stably self-administer heroin (30 microg/kg per infusion) under a continuous reinforcement schedule. Following extinction, the effect of non-contingent non-reinforced primings with heroin, baclofen or heroin/baclofen combination on the resumption of responding was evaluated. Results indicate that heroin priming (0.25mg/kg) promptly reinitiated heroin-seeking behavior, an effect dose-dependently reduced by baclofen at doses (0.625 and 1.25mg/kg) not affecting responding per sè. Importantly, baclofen did not affect locomotion either alone or in combination with heroin, dispelling any doubt as to the eliciting of possible non-specific (motor) effects. The present results show that GABA(B) receptor activation may reduce the propensity to resume drug-induced heroin-seeking behavior thus offering a possible approach in maintaining opiate abstinence.

Studies from our laboratory indicated that local perfusion of the ventral tegmental area (VTA) with a serotonin-3 (5-HT(3)) receptor agonist increased dopamine (DA) neuronal activity and that the self-infusion of ethanol (EtOH) and cocaine into the posterior VTA could be inhibited with coadministration of a 5-HT(3) receptor antagonist. The study tested the hypothesis that activating 5-HT(3) receptors within the VTA produces reinforcing effects. The study also examined whether there were differences between Wistar rats and a line of rats selectively bred for high alcohol consumption with regard to the self-infusion of a 5-HT(3) receptor agonist within the VTA. Adult female alcohol-preferring (P) and Wistar rats were allowed to self-infuse the 5-HT(3) receptor agonist 1-(m-chlorophenyl)-biguanide (CPBG) into the posterior or anterior VTA. Furthermore, experiments examined the effects of coinfusion of the 5-HT(3) antagonist ICS 205,930 (ICS), and the DA D(2,3) agonist quinpirole on the self-infusion of CPBG. Both Wistar and P rats readily self-administered CPBG into the posterior, but not anterior, VTA. P rats self-infused lower concentrations of CPBG (0.10 microM) than did Wistar rats (1.0 microM). Coinfusion of either ICS or quinpirole reduced CPBG self-infusion into the posterior VTA. The results of this study suggest that activation of 5-HT(3) receptors within the posterior VTA produces reinforcing effects and that these reinforcing effects are mediated through activation of DA neurons. Furthermore, the data suggest that selective breeding for alcohol-preference results in the posterior VTA being more sensitive to the reinforcing effects of CPBG.

Background: There have been many studies of underadherence to antipsychotics, but antipsychotic overadherence, or medication oversupply, in which patients receive more prescription medications than are needed, has been overlooked. Both underadherence and oversupply can have an important impact on clinical outcomes., Objectives: This study examined adherence (based on the medication possession ratio [MPR]) among patients treated with antipsychotics in the Central Texas Veterans Health Care System (CTVHCS) and investigated factors associated with their adherence status., Methods: Data from September 1995 to October 2002 were extracted from the computerized patient record system of the CTVHCS for continuously enrolled adult outpatients receiving antipsychotic monotherapy and filling at least 2 prescriptions within a year of the index date. Patients' prescription records were tracked for up to 12 months. Underadherence was defined as an MPR <0.8, good adherence as an MPR from 0.8 to 1.2, and oversupply as an MPR >1.2., Results: Of 3268 eligible patients, 49.9% had good adherence, 42.6% were underadherent, and 7.6% had medication oversupply. The overall mean (SD) MPR was 0.83 (0.33). Multinomial logistic regression analysis revealed that compared with patients with good adherence, underadherent patients were significantly more likely to be nonwhite (P < 0.001), younger (P < 0.01), and receiving chlorpromazine therapy (P < 0.05), and were less likely to be receiving fluphenazine (P < 0.01), olanzapine (P < 0.05), or risperidone (P < 0.05). Patients with medication oversupply were significantly more likely to be receiving olanzapine (P < 0.001), quetiapine (P < 0.01), or risperidone (P < 0.05) than those with good adherence., Conclusions: Although half of adult outpatients receiving antipsychotic monotherapy in the CTVHCS were adherent to their treatment regimens, a large proportion were underadherent, and a small proportion had medication oversupply. Patients receiving second-generation antipsychotics were more likely to be adherent and were more likely to have medication oversupply than patients receiving first-generation antipsychotics.

Ulcerative colitis is a lifelong disease causing inflammation and ulceration of the colon. Symptoms of ulcerative colitis include abdominal pain, bloody diarrhea, bloating, and fecal urgency. The current standard therapy for mild to moderate ulcerative colitis is the use of 5-aminosalicylates, with patients requiring continuous treatment to maintain remission. A substantial proportion of patients, however, are nonadherent to prescribed 5-aminosalicylate treatment regimens, resulting in a greater chance of disease relapse with severe associated symptoms. There are many reasons why a patient with ulcerative colitis may be nonadherent including the patient's perception of the condition or a lack of understanding about the disease or treatment. Multiple daily dosing or rectal administration of 5-aminosalicylate medications also can adversely affect adherence rates. Because gastrointestinal nurses often are the primary points of contact for patients with ulcerative colitis, they are in a unique position to take simple steps that will improve adherence rates and thus increase the efficacy of prescribed therapy. This article highlights important aspects of education and patient care for patients with ulcerative colitis.

Objective: We wished to identify potential factors associated with medication administration hassles, daily irritants, among informal caregivers who provide long-term medication assistance to persons aged 55 or older., Methods: A sample of 156 informal caregivers were recruited from seven states and several types of settings. The dependent variable was scores on the Family Caregiver Medication Administration Hassles Scale (FCMAHS). Independent variables included in the analyses were medication complexity; caregiver's gender, ethnicity, relationship to recipient, length of time in caregiving, education, and employment outside the home; care recipient's physical capacity and mental capacity; and whether the caregiver and care recipient live together. After preliminary analysis to reduce the number of independent variables, the remaining variables were included in a linear model (GLM procedure). Possible interactions and residuals were considered., Results: Whites and Hispanics experience greater medication administration hassles than other groups, and perceived hassle intensity increases with medication complexity. Medication administration hassle scores increase with increasing education levels up to a high school degree, after which they remain consistently high. Caregivers whose care recipients have moderate levels of cognitive functioning have higher medication administration hassles scores than those whose care recipients have very high or very low cognitive functioning., Conclusion: The preliminary set of significant variables can be used to identify caregivers who may be at risk of experiencing medication administration hassles, increased stress, and potentially harmful events for their care recipients., Practice Implications: Family caregivers are accepting complex caregiving responsibility for family members while receiving little or no support or assistance with caregiving hassles associated with this duty. The FCMAHS offers the means to monitor how caregivers are handling the daily irritants involved with medication administration so that educational interventions can be provided before hassles lead to more serious stress and strain.

Objective: To examine medication-related problems from the perspective of patients with a chronic condition and to identify how they may be supported in managing their medication., Methods: Patients prescribed medication for cardiovascular disease were recruited through five general medical surgeries and four community pharmacies in south London. Data were collected in 98 face-to-face interviews in participants' own homes. Interviews were designed to enable a detailed and holistic exploration of medication-related problems from participants' perspectives. Data were audio-recorded and transcribed verbatim to allow qualitative analysis., Results: Five broad categories of medication-related problem emerged which were examined in the context of patients' perspectives on, and experiences of, the use of medicines and health services. These were concerns about and management of side effects; differing views regarding the use of medicines; cognitive, practical and sensory problems; lack of information or understanding; and problems with access to, and organisation of, services., Conclusion: All categories of problem had potential implications for the success of therapy in that they created barriers to adherence, access to medication or informed decision-making. The study demonstrated how patients actively engage in decision-making about their medicines in the home, if not in the consultation., Practice Implications: The five categories of problem provide a focus for interventions by health professionals to support patients in achieving optimal theory outcomes. They demonstrate the need for a comprehensive approach, spanning patient education to the systems of delivery of care. Within the NHS in Britain, policy and practice initiatives are being designed to achieve this end. Further research should focus on the evaluation of professional practices and service developments in supporting patients in the self-management of their medicines.

Histamine H1 receptor antagonists have some behavioral effects that predict abuse liability. In the present study, diphenhydramine and cocaine each maintained i.v. self-administration under a progressive-ratio schedule in rhesus monkeys. When cocaine and DPH were combined in a 1:1 ratio of the ED50s, the combination was super-additive in all monkeys. The data predict that the combination of cocaine and histamine H1 receptor antagonists would have enhanced potential for abuse relative to either drug alone.

In a previous report, we found that a 5-min. delay in alcohol access increases ethanol intake in rats trained to self-administer 5% ethanol. To assess the effects of this delay on the motivation to self-administer ethanol, Wistar rats were trained on a progressive ratio schedule of reinforcement and presented with the 5-min. delay. There was no change in break point (6 presses/delivery), active (125 presses/30 min.) or inactive (10 presses/30 min.) lever presses after the 5-min. delay compared to baseline. However, response cessation occurred 10 min. earlier in this delay session compared to baseline indicating that consumption was accelerated by delayed access to alcohol.

Background: Uganda was the first country to scale up Home Based Management of Fever/Malaria (HBM) in 2002. Under HBM pre-packaged unit doses with a combination Sulphadoxine/Pyrimethamin (SP) and Chloroquine (CQ) called "HOMAPAK" are administered to all febrile children by community selected voluntary drug distributors (DDs). In this study, community perceptions, health worker and drug provider opinions about the community based distribution of HOMAPAK and its effect on the use of other antimalarials were assessed., Methods: In 2004, four focus group discussions with mothers and 11 key informant interviews with drug sellers, drug distributors and health workers were conducted in Kasese district, western Uganda. This was complemented by three months of field observations., Results: Caretakers concurred that they were benefiting from the programme. However, according to the information from the DDs and health workers, many caretakers perceived HOMAPAK as a drug of lower quality only meant for first aid. Caretakers also expressed need for other drugs to treat other childhood diseases. The introduction of HOMAPAKs was said not to affect the sale of other allopathic antimalarial drugs in the community. DDs expressed concerns about lack of incentives and facilitation such as torches, gumboots and diagnostic equipment to improve their performance., Conclusion: HBM is well appreciated by the community. However, more efforts are needed to improve uptake of the strategy through systematic community sensitization and community dialogue. This study highlights the potential of community based volunteers if well trained, facilitated and integrated into a functioning local health system.

Objective: To explore the unique experiences, challenges, and coping strategies of pregnant women diagnosed with thrombophilia and who are on daily heparin injections., Design: A qualitative, descriptive approach with semistructured interviews was used., Participants and Setting: Nine women from the thrombosis clinic of a large university-affiliated hospital in Montreal, Canada, participated in the study., Data Analysis: Thematic analysis was used throughout the processes of interviewing, transcribing, and reviewing the data., Results: Findings indicate that past pregnancy experiences influenced the meaning of diagnosis and treatment as well as the participants' experience of uncertainty. Participants expressed a need for increased professional support in health care decision making as well as increased information around injection technique. In facing these challenges, participants coped by taking control and maintaining perspective., Conclusions: Coping with thrombophilia in pregnancy can be a stressful experience. However, the ensuing challenges are perceived as manageable discomforts in light of the outcome of a healthy baby.

Sublingual nitroglycerin (SLN) is front-line therapy for the treatment of episodic stable angina discomfort. Anecdotal evidence gathered by advanced practice nurses in a cardiac pre-assessment clinic suggested that SLN was often overlooked by health care professionals as an integral component of angina self-management. A brief questionnaire exploring patients' knowledge and use of SLN was subsequently administered to 300 patients. Information gathered from the questionnaire indicated that patients are not consistently prescribed SLN for suspected or confirmed coronary artery disease. Knowledge deficits were evident concerning the proper dosage and administration of SLN, even in patients with a longstanding history of angina. Many were unaware of SLN prophylaxis and the concomitant use of topical nitrates. This paper will discuss practice implications for optimizing SLN therapy in angina self-management.

Medication nonadherence remains a significant obstacle to achieving improved health outcomes in patients with chronic disease. Self-efficacy, the confidence in one's ability to perform a given task such as taking one's medications, is an important determinant of medication adherence, indicating the need for reliable and valid tools for measuring this construct. This study sought to develop a self-efficacy scale for medication adherence in chronic disease management that can be used in patients with a broad range of literacy skills. The Self-efficacy for Appropriate Medication Use (SEAMS) was developed by a multidisciplinary team with expertise in medication adherence and health literacy. Its psychometric properties were evaluated among 436 patients with coronary heart disease and other comorbid conditions. Reliability was evaluated by measuring internal consistency and test-retest reliability. Principal component factor analysis was performed to evaluate the validity of the SEAMS. Reliability and validity analyses were also performed separately among patients with low and higher literacy levels. The final 13-item scale had good internal consistency reliability (Cronbach's alpha = 0.89). A two-factor solution was found, explaining 52.3% of the scale's variance. The scale performed similarly across literacy levels. The SEAMS is a reliable and valid instrument that may provide a valuable assessment of medication self-efficacy in chronic disease management, and appears appropriate for use in patients with low literacy skills.

Background: Upon discharge from the hospital, patients are significantly deficient in their knowledge of their medications. Provision of information has been shown to have an effect on health measures such as compliance to medication therapy, quality of life, and utilization of hospitalization services., Aims: To assess patients' knowledge about their long term medication therapy and to measure the association between knowledge and health service utilization in the community., Methods: A prospective study was performed, with home telephone interviews conducted 1 week and 1 month after discharge. The study population included 130 patients discharged to the community with new prescriptions for long term medications., Results and Conclusions: About 60% of the patients reported receiving no counseling regarding their new medication. About 30% utilized 3 or more types of service (family physician, specialist, nurse, etc.). Eighteen percent (18%) visited the ER during the month after discharge, of whom 35% visited twice or more. Higher levels of patient knowledge predicted higher levels of health services utilization (OR=4.76 95% CI: 1.74-13.06). The younger patients tended to utilize a larger variety of health services compared to the older patients (OR 0.32 95% CI: 0.13-0.79). The results of this study provide that patients with higher levels of knowledge utilized the health care system more often, perhaps indicating greater awareness and self care.

Objectives: (1) To help identify patients with poor adherence and (2) to identify potential reasons that impede or facilitate adherence., Methods: Seventeen patients who used antihypertensive drugs participated in semi-standardized interviews. Interviews were recorded and reviewed by two investigators. Forty-four items were selected. An exploratory factor analysis was performed. Convergent validity was assessed by evaluating the association between sum scores on the identified subscales and three other adherence measures: (1) the Brief Medication Questionnaire (BMQ), (2) pharmacy refill records and (3) electronic monitoring. Regression analysis was used to evaluate the magnitude of associations., Results: Two hundred and fifty-five (90%) patients completed the questionnaire. Factor analysis resulted in a four-factor solution, explaining 30% of cumulative variance among respondents. The factors (scales) were labeled: positive attitude towards health care and medication (I), lack of discipline (II), aversion towards medication (III) and active coping with health problems (IV). Chronbach's alpha coefficient was 0.75, 0.80, 0.63 and 0.76 for scales I, II, III and IV, respectively. Convergent validity was partly supported by statistically significant associations that were found between sum scores of subscales 1 and II and the BMQ and electronic monitoring, respectively., Conclusion: The MUAH-questionnaire has excellent psychometric properties and may be useful to identify factors that impede or facilitate adherence. However, it is not clear to what extent the questionnaire measures actual adherence., Practice Implications: Validation of the MUAH-questionnaire in other studies is needed.

This article assesses the suitability of inhaler devices for patients with asthma according to their individual needs. Three main types of inhalers are discussed: pressurised metered dose inhalers, breath-actuated inhalers and dry powder inhalers. The advantages and disadvantages of these devices are discussed in relation to lifestyle, ability and suitability for individuals.

The Center for Adherence Support Evaluation (CASE) Adherence Index, a simple composite measure of self-reported antiretroviral therapy (ART) adherence, was compared to a standard three-day self-reported adherence measure among participants in a longitudinal, prospective cross-site evaluation of 12 adherence programs throughout the United States. The CASE Adherence Index, consisting of three unique adherence questions developed for the cross-site study, along with a three-day adherence self-report were administered by interviews every three months over a one-year period. Data from the three cross-site adherence questions (individually and in combination) were compared to three -day self-report data and HIV RNA and CD4 outcomes in cross-sectional analyses. The CASE Adherence Index correlated strongly with the three-day self-reported adherence data (p < 0.001) and was more strongly associated with HIV outcomes, including a 1-log decline in HIV RNA level (maximum OR = 2.34; p < 0.05), HIV RNA < 400 copies/ml (maximum OR = 2.33; p < 0.05) and performed as well as the three-day self-report when predicting CD4 count status. Participants with a CASE Index score >10 achieved a 98 cell mean increase in CD4 count over 12 months, compared to a 41 cell increase for those with scores < or =10 (p < 0.05). The CASE Adherence Index is an easy to administer instrument that provides an alternative method for assessing ART adherence in clinical settings.

Background: The purpose of this study was to assess low molecular weight heparin auto-injection skills of self-supporting patients, taught by a nurse through a rapid demonstration in an emergency department., Methods: The study was a prospective, multicentre study, carried out in emergency departments. It included all ambulatory attending patients over 18 years of age, who were given a lower limb cast in an emergency ward and provided with limited orthopaedic treatment. Eligible patients who accepted self-injection training were given a quick demonstration by the nurse in the emergency ward. A questionnaire about the perception of the patient was completed at the beginning of the treatment and at the end of the treatment. A surveillance chart for recording injections and side effects was also given to the patient, and platelet counts were performed twice weekly., Findings: Two hundred and fourteen patients have been assessed. Forty-four patients (20.5%) were judged inappropriate for training (n=19) or refused it (n=25). Primary perception of the self-injection method showed absence of fear of injections among patients in 43.7% of cases. Training was successful in 88% of cases. Twenty-one patients out of 170 (12%) gave up after completing the training. Questionnaires given at the end of the treatment found a generally favourable opinion on self-injections among 73.26% of patients (n=86). Compliance was good - 95.5% of patients completed all their injections. Platelet counts were considered appropriate only in 52.5% of cases., Interpretation: It seems possible to extend the practice of self-injection to other types of injections prescribed after discharge from the emergency department, such as preventive low molecular weight heparin for surgical or medical purposes and curative ambulatory low molecular weight heparin treatment for deep vein thrombosis.

Youth homelessness is a growing Australian and international concern associated with considerable health disadvantage, including serious mental health problems. This paper reports findings of a qualitative study that explored young homeless people's experiences of mental health and well-being through in-depth interviews. Thematic analysis identified medication use and management as a central issue for the young people. Reasons identified for medication non-adherence included unwanted side-effects, issues of access and storage, and lack of support from health and social agencies. These problems were compounded by everyday stresses of homelessness. Medication adherence was facilitated by social support, consistent contact with supportive health services, and regular medication supply, often resulting in improved mental health and well-being. For these young people, prioritizing management of medication helped stabilize one aspect of their lives. Health professionals can play an important role in helping them achieving this goal.

Aims and Objectives: The purpose of this study was to evaluate the effectiveness of a self-medication programme (SMP) for inpatients of the Nursing Convalescent Unit, a 26-bed unit with medical and surgical patients., Background: Self-medication is an important part of self-management of chronic illness. Self-medication is a way of allowing patients to give themselves their medications in hospital after receiving education instead of the usual practice of medications administered by a Registered Nurse (RN)., Design: The pilot study was undertaken over a six-month period to examine the relationship between a programme of self-medication and patient knowledge and adherence to medication regimens, number of medication errors, efficiency in relation to the number of nursing hours associated with the SMP, patient and nursing satisfaction., Methods: A total of 220 patients participated in the study. The SMP included three levels of patient self-administration of medications: level one, medications administered by a RN; level two, self-medication directly supervised by a RN and level three, self-medication indirectly supervised by a RN. Outcome measures included staff and patient satisfaction, number of medication errors, time taken by nurses to undertake activities related to the SMP and the number of patients who achieved levels two and three., Results: Study findings showed that 45% of patients remained on level one, 26% achieved level two and 29% achieved level three. There were no patient initiated medication errors during the study period. Efficiencies were identified in staff workload associated with patient discharge procedures. Overall, nurses perceived that the SMP increased their knowledge of medications and contributed to effective patient education., Conclusions: In selected patients, the SMP was an effective aid for improving adherence to medication regimens. Collaboration between nurses, medical staff, pharmacists, patients and carers is integral to the success of in hospital SMP.

To improve elderly patients' understanding and safe usage of their medications. English-speaking hospital inpatients aged > or =65 years were recruited. They were self-medicating at home with at least 1 regular medication and had a Mini-Mental State Examination (MMSE) score of at least 20 out of 30. The patients were taught medication details on 3 consecutive days. The patients' medication knowledge was recorded before education and again at a home visit after discharge from hospital. Patient medication knowledge before education showed that participants knew 50% of brand names, dosage and times, 55% of medication purpose, and 15% of major side effects. At follow-up home visits, the relevant figures improved significantly to 90%, 85%, and 25%, respectively (P < or = .05). Similar improvement occurred in the 2 patient groups with an MMSE score of 20 to 24 and 25 to 30 (P = .03). This simple, practical, nursing-staff-conducted program worked well in a hospital setting and resulted in improved medication knowledge, even in patients with mild cognitive impairment.

Medication regimens for older adults are often complex and costly. Designing, implementing, and maintaining an appropriate treatment regimen is challenging. The AIDES method is built on the principles of completing a comprehensive medication Assessment; partnering with patients to ensure Individualization of the regimen; choosing appropriate Documentation; providing accurate and ongoing Education tailored to the age group and needs of the individual; and continuing Supervision after initiation.

Previous research has shown that patients are not able to learn to use self-administered inhaler devices if they have impaired general cognition, executive (frontal lobe) dysfunction or dyspraxia. These impairments are most frequently encountered in frail elderly people. Some of the tests required to detect such impairments are time-consuming and are therefore not easily adopted in routine clinical practice, particularly in an outpatient setting. We performed a study of 50 elderly inhaler-naïve patients to explore the use of a simple quick drawing test (copying overlapping pentagons) to determine whether that test was able to identify patients who were unable to learn to use a Turbohaler. Patients who were not able to perform the pentagon copying test were found to be unable to learn to use a Turbohaler with a specificity of 93% and positive predictive value of 87%. This was at least as discriminating as the Abbreviated Mental Test and the Mini Mental State Examination. The overlapping pentagon drawing test is useful in clinical practice to identify patients who will probably not use a self-administered inhaler correctly, and who will require an alternative approach to the treatment of their airways disease. This finding might have implications for other self-administered treatment, such as insulin pens and complex drug regimens.

Objective: This prospective study tested whether implementation intentions increased adherence to short-term antibiotics in a patient sample. Implementation intentions specify exactly when and where an individual will undertake an activity. They may help people achieve health behaviours, such as taking medicines., Methods: A total of 220 patients with an antibiotics prescription were randomly assigned to four groups (control, Theory of Planned Behaviour (TPB) questionnaire, TPB questionnaire+formed own implementation intention for taking the medicine, TPB questionnaire+researcher formed implementation intention). Participants were telephoned at the end of the course to record adherence. Two hundred and seven participants completed the study., Results: At follow-up, adherence was high (75.8% reported no tablets left). Analysis revealed no significant difference in adherence between groups., Conclusion: High adherence to antibiotics was achieved, but not improved by implementation intentions., Practice Implications: Providing information and telephone follow-up may have been the unintended effective intervention in this study.

The authors used the sucrose-substitution procedure to train operant self-administration of a 10% alcohol solution in 8 Long-Evans rats. After they established stable responding, they began a 10-session baseline. A 10-session experimental phase followed the baseline phase. During the experimental phase, the authors placed a large glass marble in the center of the experimental chambers before self-administration sessions. The presence of the marble decreased the rats' responding and alcohol intake significantly. The authors discussed the results in terms of distraction and the effects of concurrently available reinforcers on alcohol self-administration.

Medication compliance is essential to treating the symptoms of schizophrenia effectively. This study utilized a virtual reality (VR) apartment paradigm to assess medication compliance behaviors in 25 patients with schizophrenia and in 16 healthy control subjects. Participants were assigned a prescription consisting of three medications and were asked to self-administer this regimen in 15 min. Results demonstrate that patients had considerably more difficulty in complying with the medication regimen than did controls. They manifested significantly more quantitative errors, and were much less accurate in consuming the medications at the assigned time. Significant differences in performance between these groups were also evidenced by a variety of validated neuropsychological measures. Correlations between the data may suggest a convergent validity for this new VR task. Future research will investigate the validity of this task in predicting additional measures of psychosocial functioning.

Background: Non-concordance with medication remains a major public health problem that imposes a considerable financial burden on the health care system, and there is still a need for studies on correlates of non-concordance. Our first aim is to analyse whether any of the individual characteristics age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary non-concordance with medication. Our second aim is to investigate whether people living in the same area have similar probability of primary non-concordance with medication, that relates to area social participation., Methods: We analysed cross sectional data from 9,070 women and 6,795 men aged 18 to 79 years, living in 78 areas in central Sweden, who participated in the Life & Health year 2000 survey, with multilevel logistic regression (individuals at the first level and areas at the second level)., Results: Younger age, financial strain, low self-rated health, and low trust in the health care system were associated with primary non-concordance with medication. However, area social participation was not related to primary non-concordance, and the variation in primary non-concordance between the areas was small., Conclusion: Our results indicate that people in central Sweden with younger age, financial difficulties, low self-rated health, and low trust in the health care system may have a higher probability of primary non-concordance with medication. However, the area of residence--as defined by administrative boundaries--seems to play a minor role for primary non-concordance.

Considering that adolescence is associated with an increased motivation to seek out new stimuli and with low anxiety levels in exploring novel environments, and that both behavioral traits may be associated with substance abuse, we investigated whether the behavioral response to a novel environment can predict subsequent oral nicotine self-administration in adolescent C57BL/6 mice. On postnatal day 30 (PN30), the novelty-seeking behavior and anxiety levels were assessed in a hole board activity box. The total number of head-dips (DIP) was used to classify animals either into the high novelty (HN; DIP above median) or low novelty (LN; DIP below median) groups. The percentage of center squares crossed (CEN) was used to classify animals either into the high anxiety (HA; CEN below median) or low anxiety (LA; CEN above median) groups. From PN31 to PN41, all animals were given a free choice between tap water or a nicotine solution (10 microg/ml). LN mice did not change nicotine intake throughout the free choice procedure, however, HN mice presented a marked increase in consumption. There were no differences in consumption between HA and LA mice. Our results indicated that mice that presented a more intense novelty-seeking behavior increased their preference for nicotine during the free choice experiment but that anxiety levels did not predict nicotine consumption. These results suggest that higher motivation to seek out new experiences is a significant contributor to drug use in adolescents and that anxiety is probably not a major factor that determines differential nicotine consumption during adolescence.

This study examined the relationship between patients' cognitive status, deficit awareness, medication management skills, and actual medication adherence. Twenty-seven persons with Alzheimer's disease and 20 healthy controls were evaluated for their predicted and objective performance on tasks related to medication management. Caregivers were also evaluated for their prediction of the care recipient's management abilities. A pill count was taken at the initial interview and 30 days later. MMSE and deficit awareness were related to amount of help received from a family member, suggesting that caregivers tend to accurately assess their relatives' medication management abilities. Adherence rates were acceptable, but some intervention strategies selected by caregivers were not effective in assuring adequate adherence. Additional study is needed to determine the effectiveness of various strategies adopted by informal caregivers.

Benzodiazepine (BZD) drug use among community-dwelling seniors is a significant health issue. Although long-term use of BZDs by seniors is a recognized problem, little is known about the mental health of the consumers. Better knowledge of their mental health would help nurses in identifying the psychological needs of this population. The goals of this longitudinal study1 (n = 138) were to describe the mental health status of long-term users of BZDs and to compare it with the mental health of seniors who have either begun or stopped consuming BZDs over a 1-year period (from Phase 1 to Phase 2). Results showed that one third of long-term users of BZDs do not present any mental health problem. Furthermore, no differences were observed between the mental health statuses of new users of BZDs, individuals who stopped using BZDs, and long-term users of BZDs. In conclusion, at least one third of long-term users of BZDs should stop using these drugs, and nurses should play a leading role in helping these seniors withdraw from BZD consumption.

This study examines college students' beliefs about health, prescriptions, doctors, and the influence those beliefs have on adherence to prescribed medication regimens. After a brief review of attitudinal factors that influence adherence to prescription medicine directions, the authors discuss measurement issues and explain the reasons for their approach to studying adherence issues. The results of the exploratory study indicate that college students' adherence to a prescribed medication regimen is more strongly associated with beliefs about health, prescription drugs, and a self-cure orientation than students' satisfaction with their physicians. In the sample of students, forgetfulness appears to be the dominant reason for nonadherence. One implication from these results is that adherence issues may be more appropriately addressed in campus promotions than in the medical clinic. The authors also offer suggestions for further research.

This study used performance tests to assess the cognitive, visual and physical abilities related to taking medicines in the elderly population. The study population consisted of the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD II), a nationally representative interview survey. SWEOLD II is a random sample of all community-based and institutionalized persons aged 77+ in Sweden. Five tests related to medication management were administered in the direct interviews (n=492): hand function (opening bottle), vision (reading label), and medication competence (comprehension and calculation). Results showed that 9.4% could not read instructions on a medicine container and 14.6% had difficulty opening a plastic flip-top medicine bottle. The three cognitive tests related to taking medicine resulted in 30.7, 47.4 and 20.1% errors. Combining all the tests revealed that 66.3% of the sample had at least one limitation of capacity related to taking medicine. There were no significant gender differences. Among those people who did not pass all the tests, 31.8% lived alone with no home-help. Taking medicines is a complex task and a large proportion of the Swedish elderly population has cognitive, visual or physical limitations that may hinder their ability to take medicines accurately. Awareness of these limitations is essential to concordance.

Accumulating evidence suggests that the endogenous cannabinoid system is involved in the reinforcing effects of heroin. In rats intravenously self-administering heroin, we investigated effects of cannabinoid CB1 receptor agonists and compounds that block transport or metabolism of the endogenous cannabinoid anandamide. The natural cannnabinoid CB1 receptor agonist delta-9-tetrahydrocannabinol (THC, 0.3-3 mg/kg i.p.) did not alter self-administration of heroin under a fixed-ratio one (FR1) schedule, except at a high 3 mg/kg dose which decreased heroin self-administration. Under a progressive-ratio schedule, however, THC dose-dependently increased the number of 50 mug/kg heroin injections self-administered per session and the maximal ratio completed (break-point), with peak increases at 1 mg/kg THC. In addition, 1 mg/kg THC increased break-points and injections self-administered over a wide range of heroin injection doses (25-100 microg/kg), indicating an increase in heroin's reinforcing efficacy and not its potency. The synthetic cannabinoid CB1 receptor agonist WIN55,212-2 (0.3-3 mg/kg i.p.) had effects similar to THC under the progressive-ratio schedule. In contrast, AM-404 (1-10 mg/kg i.p.), an inhibitor of transport of anandamide, and URB-597 (0.01-0.3 mg/kg i.p.), an inhibitor of the enzyme fatty acid amide hydrolase (FAAH) that degrades anandamide, or their combination, did not increase reinforcing efficacy of heroin at any dose tested. Thus, activation of cannabinoid CB1 receptors facilitates the reinforcing efficacy of heroin and this appears to be mediated by interactions between cannabinoid CB1 receptors and mu-opioid receptors and their signaling pathways, rather than by an opioid-induced release of endogenous cannabinoids.

The aim of this study was to investigate how factors in the workplace and personal factors are related to the frequency with which people with diabetes perform self-management activities and the degree to which they do or do not experience the performing of self-management activities as a burden. Two hundred and ninety-two employees with insulin-treated diabetes completed questionnaires on socio-demographic and illness-related background variables, work experience, diabetes self-efficacy, social support outside of work, coping styles and self-management activities. The results indicate that employees who reported a high workload were more likely to perceive injecting insulin as a burden. The level of social support was positively related to the frequency of dietary self-management in type 2 diabetes and negatively related to the sense of being burdened by dietary self-management in type 1 diabetes. With respect to personal factors, we found that a diabetes avoidance coping style was associated particularly with infrequent blood glucose monitoring and a high sense of being burdened by blood glucose monitoring. Individuals with a low level of self-efficacy were more likely to perceive all types of self-management activities as a burden. These results may guide health professionals when counseling individuals with diabetes.

Australians' use of the English language is influenced by a British educational curriculum, exposure to international television programmes and cultural backgrounds. Hence, adapting research instruments for use with Australian populations can be challenging. This study adapted the United Kingdom's version of the 20-item Diabetes Management Self-Efficacy Scale and tested it psychometrically with Australians. Face validity of the adapted instrument was established through consultation with diabetes educators and people with type 2 diabetes. Data from a convenience sample of 88 people with type 2 diabetes were analysed to determine the psychometric properties of the adapted instrument. The results indicate that the Australian/English version of the instrument is internally consistent, stable over time and it measures self-efficacy. However, there was evidence to show that there might be some redundant items in the scale. Further psychometric testing is warranted with a larger sample to determine whether the scale requires refinement.

Objective: To apply human error theory to explain non-adherence and examine how well it fits., Method: Patients who were taking chronic medication were telephoned and asked whether they had been adhering to their medicine, and if not the reasons were explored and analysed according to a human error theory., Results: Of 105 patients, 87 were contacted by telephone and they took part in the study. Forty-two recalled being non-adherent, 17 of them in the last 7 days; 11 of the 42 were intentionally non-adherent. The errors could be described by human error theory, and it explained unintentional non-adherence well, however, the application of 'rules' was difficult when considering mistakes. The consideration of error producing conditions and latent failures also revealed useful contributing factors., Conclusion: Human error theory offers a new and valuable way of understanding non-adherence, and could inform interventions. However, the theory needs further development to explain intentional non-adherence.