Hypertoni är en riskfaktor för allvarliga kardiovaskulära sjukdomar. Olika läkemedelsklasser används vid behandling av hypertoni. Dessa inkluderar angiotensin omvandlade enzymhämmare, angiotensin II-receptorblockerare, kalciumkanalblockerare och tiaziddiuretika. Även om nuvarande läkemedelsterapier kan vara effektiva, är det få som kan uppnå målblodtryck. De flesta patienter med hypertoni kräver minst två antihypertensiva läkemedel för att uppnå sitt målblodtryck. Detta ledde till komplicerade behandlingsmetoder som i sin tur har blivit en stor bidragande faktor till dålig patientföljsamhet. Även om ett stort antal läkemedel finns tillgängliga för behandling, är kontrollen av blodtryck dålig på grund av patienternas dåliga följsamhet till medicinering som vanligtvis är en kombination av flera substanser. Följsamheten minskar med antalet tabletter som en patient behöver ta vilket leder till en komplicerad behandlingsstrategi.  Syftet med detta examensarbete var att undersöka blodtryckssänkande effekt med en enkel tablettform Single-Pill Combination (SPC) som innehåller en kombination av flera antihypertensiva läkemedelsklasser och att undersöka patienternas följsamhet till (SPC) behandling.  Metod det här arbetet är en litteraturstudie utförd i PubMed. Olika sökord användes” single-pill combination in hypertension”, “Fixed dose combination in hypertension “, “Adherence to single-pill combination in hypertension”. Sökningen filtrerades till “Randomized controlled trial”. Nya studier valdes ut som undersökte effekten av SPC och följsamhet till behandling. Resultat Studier 1,2,3 och 4 som undersökte effekten gav positiva resultat som gynnade SPC framför standardmonoterapi och placebo. SPC kunde minska blodtrycket statiskt signifikant i alla studierna. I studie 1 blev den genomsnittliga skillnaden i SBT mellan grupperna (–6,9) mm Hg med (p-värde <0,001). I studie 2 blev skillnaden i genomsnittlig 24-timmars SBT mellan SPC- och placeboperioder (–18,7) mm Hg med p-värde <0,0001. I studie 3 blev SBT-förändringar på klinik -16,5 ± (15,5) mm Hg (p <0,001) med amlodipin/valsartan FDC och -6,9 ± (11,4) mm Hg (p = 0,012) med valsartan monoterapi medan motsvarande förändringar i DBP i Office var -9,8 ± (7,7) mm Hg (p <0,001) respektive -2,5 ± (6,6) mm Hg (p = 0,095). Resultat av studie 4 visade att andelen deltagare som uppnådde målblodtryck efter 6 månader (SBT <140, DBT <90 mm Hg) blev 69% i SPC gruppen och 55,3% i monoterapi gruppen. I studie 5 kunde ingen signifikant skillnad i följsamheten observeras mellan SPC gruppen och FEC gruppen. Följsamhetsgraden var 98% i båda grupperna. Studie 6 rapporterade signifikant resultat där PDT blev 95,1 % i SPC gruppen och 92,1% i kontrollgruppen p-värde <0,05.  Slutsats Alla resultat i studierna 1,2,3 och 4 gynnade signifikant SPC när det gäller effekten. Studie 6 visade att patienternas följsamhet till behandling var bättre i SPC gruppen än kontrollgrupp. Studie 5 kunde inte ge signifikanta resultat avseende följsamheten till SPC jämfört med FEC. Fler RCT studier behövs för att undersöka om SPC kan leda till bättre följsamhet hos hypertonipatienter / Background Hypertension is a risk factor for serious cardiovascular diseases. Different drug classes are used in the treatment of hypertension. These include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, and thiazide diuretics. Although current drug therapies can be effective, few are able to achieve target blood pressure therefore it has become well-known that most hypertensive patients require at least two antihypertensive drugs to reach their target blood pressure. This led to complicated treatment methods, which in turn has become a significant contributing factor to poor patient compliance. When two or more drug classes are combined, this contributes to improved efficacy, as different mechanisms of action work together to block different pathways to high blood pressure. This leads to lower doses of the individual components being used, which results in a reduced likelihood of side effects. Although a large number of drugs are available for treatment, there is still poor control of blood pressure due to patients' poor adherence to medication, which is usually a combination of several substances. Adherence decreases with the number of tablets a patient needs to take, leading to a complicated treatment strategy. Lower levels of adherence are associated with poorer blood pressure control. Aim The aim of the work is to investigate the blood pressure-lowering effect with a simple tablet form "Single-Pill Combination" (SPC) that contains a combination of several antihypertensive drug classes and to investigate the patients' adherence to this form of treatment (SPC). Method This work is a literature study carried out in Pubmed. Different search terms were used: "single-pill combination for the treatment of hypertension", "Fixed dose combination in hypertension", and "Adherence to single-pill combination for hypertension". The search was filtered to "Randomized controlled trial". New studies were selected that investigated the effect of single-pill combination and blood pressure control and adherence to treatment. Results Studies 1, 2, 3, and 4 investigating the efficacy produced positive results favoring SPC over standard monotherapy and placebo. SPC was able to reduce blood pressure statically significantly in all studies. In Study 1, the primary outcome variable was the mean difference in SBT between groups (–6.9) mm Hg with (p-value <0.001). In Study 2, the difference in mean 24-hour SBT between SPC and placebo periods was (–18.7) mm Hg with a p-value <0.0001. Whereas in Study 3, in-clinic SBT changes were -16.5 ± (15.5) mm Hg (p < 0.001) with amlodipine/valsartan FDC and -6.9 ± (11.4) mm Hg (p = 0.012) with valsartan monotherapy while the corresponding changes in DBP in Office were -9.8 ± (7.7) mm Hg (p <0.001) and -2.5 ± (6.6) mm Hg (p = 0.095), respectively. The results of study 4 were that the percentage of participants who achieved target blood pressure after 6 months (SBT <140, DBT <90 mm Hg) was 69% in the SPC group and 55.3% in the monotherapy group. In study 5, no significant difference in compliance could be observed between the SPC group and the FEC group. The compliance rate was 98% in both groups. While study 6 reported significant results where PDT was 95.1% in the SPC group and 92.1% in the control group p-value <0.05. Conclusion All results in studies 1,2,3and 4 significantly favored SPC in terms of efficacy. Study 6 showed that patients’ adherence to treatment was better in the SPC group than in the control group. While study 5 which was the first RCT study in this area could not provide positive and significant results regarding the adherence to SPC compared to FEC. More RCT studies are needed to investigate whether SPC can lead to better adherence in hypertensive patients.

Introduktion: Tidigare forskning visar att det finns flera olika faktorer som bidrar till följsamhet vid läkemedelsbehandling av psykisk sjukdom, både möjligheter och svårigheter. En viktig uppgift som psykiatrisjuksköterskan har i mötet med patienter som lider av psykisk sjukdom är att psykiatrisjuksköterskan ska motivera patienten till att ta emot rekommenderad läkemedelsbehandling. Det är av värde att göra en översikt gällande aktuell forskning kring omvårdnadsmetoder och åtgärder som kan vidtas av psykiatrisjuksköterskan för att motivera patienter med psykisk sjukdom till följsamhet vid läkemedelsbehandling. Syfte: Syfte med denna studie är att undersöka hur sjuksköterskor inom psykiatrisk vård kan motivera personer med psykisk sjukdom till följsamhet vid läkemedelsbehandling. Metod: Metoden för detta examensarbete var litteraturöversikt bestående av 21 vetenskapliga artiklar, varav 14 kvantitativa, 5 kvalitativa och två med mixad metod. Vid litteratursökningenanvändes databaserna Pubmed och CINAHL. Resultat: Analysen av data resulterade i fyra kategorier (figur 3) vilket beskriver hur en sjuksköterska inom psykiatrisk vård kan motivera patienter med psykisk sjukdom tillföljsamhet vid läkemedelsbehandling. Dom fyra kategorierna blev: Den terapeutiska relationen och stöd från anhöriga vid följsamhet till läkemedelsbehandling, Psykoedukation för följsamhet till läkemedelsbehandling, Följsamhetsterapi för läkemedelsbehandling och Andra interventioner för att motivera till följsamhet vid läkemedelsbehandling. Slutsats: Det finns flera olika omvårdnadsinterventioner som specialistsjuksköterskan i psykiatrisk vård kan använda sig av för att motivera patienten att ta emot läkemedel och följa rekommenderad läkemedelsbehandling. Dessa omvårdnadsinterventioner överensstämmer med Roys anpassningsteori där Roy beskriver sjuksköterskans roll i patientens anpassningsförmåga och hur sjuksköterskan hjälper individer att hitta strategier för att hantera olika situationer samt ger individer möjligheter och stöd om behovet finns / Introduction: Previous research has shown that there are several different factors that contributes to adherence to drug treatment of mental illness, both opportunities and difficulties. An important task that the psychiatric nurse has in the meeting with patients suffering from mental illness is that the psychiatric nurse should motivate the patient to accept recommended drug treatment. It is of value to make an overview of current research on the different methods and measures that can be used by the psychiatric nurse to motivate patients with mental illness to adherence to drug treatment. Aim: The aim of this study is to investigate on how nurses in psychiatric care can motivate people with mental illness to adherence to drug treatment. Method: The method for this thesis was a literature review consisting of 21 scientific articles, of which 14 quantitative, 5 Qualitative and two with mixed method. The databases Pubmed and CINAHL were used in the literature search. Results: The analysis of the data resulted in four categories (figure 3), which describes how a nurse in psychiatric care can motivate patients with mental illness to adherence to drug treatment. The four categories were: The therapeutic relationship and support from relatives to motivate adherence to drugtreatment, Psychoeducation for adherence to drug treatment, Adherence therapy for drug treatment and Other interventions to motivate adherence to drug treatment. Conclusion: There are several different nursing interventions that the specialist nurse in psychiatric care can use to motivate a patient to receive medication and follow recommended drug treatment. These nursing interventions are consistent with Roy's adaptation theory where Roy describes the nurse's role in the patient's adaptation capability and how the nurse helps individuals find strategies to handle different situations and gives individuals opportunities and support if needed.

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Submitted by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-10-09T16:06:50Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação Patricia Costa.pdf: 1100032 bytes, checksum: eb4ab925fc60980c9f75450c5ed034b7 (MD5) / Approved for entry into archive by Ana Lúcia Torres (bfmhuap@gmail.com) on 2017-10-10T11:33:15Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação Patricia Costa.pdf: 1100032 bytes, checksum: eb4ab925fc60980c9f75450c5ed034b7 (MD5) / Made available in DSpace on 2017-10-10T11:33:15Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertação Patricia Costa.pdf: 1100032 bytes, checksum: eb4ab925fc60980c9f75450c5ed034b7 (MD5) Previous issue date: 2015 / Instituto Estadual de Doenças do Tórax Ary Pareiras / Adesão ao tratamento e o consequente aumento das taxas de cura resultam da interação de fatores relacionados aos serviços de saúde, aos pacientes, à sociedade e à gestão pública. Foi realizado um estudo de caso em uma unidade ambulatorial de referência terciária (UART) para o tratamento da TBMDR no município de Niterói/RJ, utilizando a abordagem quantitativa e qualitativa com o objetivo de conhecer os fatores relacionados à adesão, na perspectiva dos usuários, profissionais e gestores. Foram utilizadas diferentes fontes de evidência na busca de pontos comuns e divergentes e a análise de conteúdo possibilitou a identificação de fatores favoráveis ou não à adesão a partir das categorias adesão, acesso, acolhimento, vínculo, responsabilização. A maioria dos pacientes em tratamento relatou dificuldade de acesso aos benefícios sociais. A ausência de alguns profissionais na equipe comprometeu a abordagem de importantes questões relativas ao perfil dos pacientes, principalmente a vulnerabilidade social, o consumo de álcool e de outras drogas, além do isolamento e preconceito. A oferta gratuita de mediação, a realização de exames na própria UART, a flexibilidade nos agendamentos, a busca de faltosos e o vínculo com a equipe de saúde foram descritos como fatores importantes para a adesão. O conhecimento sobre a doença atual e seu tratamento e seu tratamento associados à vontade do paciente de curar-se foram relatados como aspectos importantes para superar as barreiras encontradas para a realização do tratamento. Os resultados apresentados sugerem que, apesar da existência de fatores desfavoráveis à adesão, as ações de acolhimento, vínculo e responsabilização desenvolvidas pelo serviço foram suficientes para promover a adesão no grupo estudado. Entretanto, recomenda-se a melhoria do acesso aos benefícios assistenciais, a implementação de novas formas de comunicação sobre as formas graves de tuberculose e a articulação com outros segmentos públicos e da sociedade para o enfrentamento da TBMDR

Lévaluation économique en santé a pour objectif dévaluer la rentabilité relative dactions de santé en comparant leurs implications en termes de coûts et leurs résultats. Cette discipline occupe une place croissante dans la prise de décisions de santé publique et est essentielle pour maintenir un système de soins de santé de qualité et accessible à tous. Son rôle devrait se renforcer dans le futur en raison des progrès constants de la médecine, de la limitation des budgets de santé publique et de la régulation accrue du secteur de la santé. Ces dernières années, lostéoporose est devenue un véritable problème de santé publique. Cette maladie chronique se caractérise par une diminution de la masse osseuse et une détérioration de la micro-architecture du tissu osseux, conduisant à une fragilité osseuse accrue et à une augmentation du risque de fracture. Les fractures liées à lostéoporose sont responsables dune morbidité élevée, dun excès de mortalité et elles imposent un poids financier considérable à la société. Les dépenses de santé dévolues à cette maladie sont consacrées principalement à la prévention, au diagnostic et au traitement de lostéoporose et de ses conséquences. Dans un souci de rationaliser les décisions de santé publique, il est indispensable dallouer efficacement les ressources disponibles. Dans cette perspective, lévaluation économique de stratégies de prise en charge de lostéoporose savère un outil de première importance pour aider les preneurs de décisions à optimiser leurs choix. Tel est lobjet de la présente thèse qui se décompose en quatre parties. La première partie se consacre au développement et à la validation dun modèle innovant de microsimulation de Markov. Cette technique de modélisation permet de représenter la complexité de lostéoporose avec un niveau élevé de précision, de manière à garantir la fiabilité des résultats. La deuxième partie a pour objectif dévaluer la rentabilité économique de stratégies de dépistage de lostéoporose et de fournir un ensemble de recommandations pour accroître leur efficience. La troisième partie sintéresse à lévaluation économique de nouveaux traitements de lostéoporose (le ranélate de strontium et le dénosumab). Il est important dévaluer si les améliorations de santé, générées par ces traitements, sont obtenues à un coût raisonnable. La quatrième partie étudie spécifiquement les implications cliniques et économiques de la faible adhérence des patients aux traitements actuels contre lostéoporose. Les informations contenues dans cette thèse ont pour objectif daider les preneurs de décisions à allouer efficacement les ressources financières consacrées à lostéoporose. Elles peuvent également savérer utiles pour sensibiliser la population générale, le corps médical et les autorités de santé publique à limportance du dépistage de lostéoporose et dun suivi adéquat ainsi quaux rôles et aux enjeux de lévaluation économique dans le processus décisionnel dans le secteur de la santé. Health economic evaluation is a method for evaluating the value for money of medical technologies by comparing alternative options in terms of their costs and consequences. This method is frequently used to inform decision makers about how to allocate scarce resources. Economic evaluation has become increasingly important nowadays, with the increasing health care expenditures, the rapid introduction of new medical technologies, and the extending role of economic evaluations in health care decision making. Osteoporosis becomes an increasingly major health problem around the world. It is a disease characterized by low bone mass with microarchitectural disruption and increased skeletal fragility, leading to increased fracture risk. Osteoporotic fractures result in significant morbidity and mortality, and impose a huge financial burden on health care systems. Financial resources are used to prevent, diagnose and treat osteoporosis. These resources must be allocated in an efficient manner. The general purpose of this thesis is therefore to contribute to the economic evaluation of osteoporosis management. More specifically, this thesis is divided into four parts. The first part is devoted to the development and the validation of a new Markov microsimulation model. This modelling approach accurately encompasses the complexity of osteoporosis, increasing the reliability of the results. The second part estimates the cost-effectiveness of osteoporosis screening strategies and provides recommendations for their implementation. The third part estimates the cost-effectiveness of new anti-osteoporotic therapies (strontium ranelate and denosumab). It is important to assess whether new drugs represent a good value for money compared to the relevant alternatives. Finally, the last part of the thesis investigates the clinical and economic implications of non-adherence to osteoporosis medications. This thesis provides new information on the cost-effectiveness of osteoporosis management, which may be useful to inform decisions makers about resources allocation for patients with osteoporosis. The results may also be used to raise awareness among public health authorities, the medical profession and the general population regarding the burden of osteoporosis, the importance of screening and adequate follow-up, as well as to the role of economic evaluation in health care decision making.

Pharmaceutical drugs are one of the most socially important health care products. They are part of many individuals' everyday lives, from the eradicating of diseases at birth to treating patients at the end of life. However, for many patients access is prevented due to expensive cost. This study explored cost-related non-adherence (CRN) and researched if reimportation of pharmaceutical drugs from other countries could increase patient drug adherence. The perceptions of 10 patients and 10 providers in Maine were assessed. Maine is the only state that allowed its citizens to purchase prescription drugs from abroad. The research questions addressed (a) how reimportation drugs could contribute to drug adherence, (b) the perceptions of patients, and (c) the perceptions of key providers of reimportation. This study was guided by a theoretical framework utilizing Kurt Lewin's theory of organizational change. Participants answered 15 open-ended questions. The study utilized a qualitative grounded theory approach; data were analyzed inductively. The research demonstrated that patients and health care providers had positive perceptions for a reimportation policy. Future research of other regions for this topic should prevail. Member checking was used to validate the emerging theories of increased long term drug adherence incentivized by affordable drug cost, which contributes to perception of competence, better management of current disease, and decreased safety concerns. Positive social change implications can be achieved through savings to the health-care industry by creating a pathway to affordable drugs that will bring more drugs to market and create a competitive structure that can drive down pricing.

Pharmaceutical drugs are one of the most socially important health care products. They are part of many individualsâ?? everyday lives, from the eradicating of diseases at birth to treating patients at the end of life. However, for many patients access is prevented due to expensive cost. This study explored cost-related non-adherence (CRN) and researched if reimportation of pharmaceutical drugs from other countries could increase patient drug adherence. The perceptions of 10 patients and 10 providers in Maine were assessed. Maine is the only state that allowed its citizens to purchase prescription drugs from abroad. The research questions addressed (a) how reimportation drugs could contribute to drug adherence, (b) the perceptions of patients, and (c) the perceptions of key providers of reimportation. This study was guided by a theoretical framework utilizing Kurt Lewinâ??s theory of organizational change. Participants answered 15 open-ended questions. The study utilized a qualitative grounded theory approach; data were analyzed inductively. The research demonstrated that patients and health care providers had positive perceptions for a reimportation policy. Future research of other regions for this topic should prevail. Member checking was used to validate the emerging theories of increased long term drug adherence incentivized by affordable drug cost, which contributes to perception of competence, better management of current disease, and decreased safety concerns. Positive social change implications can be achieved through savings to the health-care industry by creating a pathway to affordable drugs that will bring more drugs to market and create a competitive structure that can drive down pricing.

The purpose of this study was to explore factors related to poor adherence to TB treatment in Keetmanshoop municipal area in Namibia. A qualitative, exploratory design was used to explore basic information about the study. Participants were using purposive sampling technique. The researcher-implemented triangulation, based on three different categories of participants, namely Field Promoters (preferred). DOT supporters (more preferred), and TB patients (most preferred). Participants were chosen in a ratio of preference. 1:2:3 respectively. The transcripts and audio tapes from interviews were analysed using the thematic content analysis. Five main themes emerged. In order of descending prominence, these themes included: factors leading to lack of adherence to TB treatment, support to enhance adherence to treatment, existing behaviours determining adherence, suggestions to promote adherence to treatment and practices to promote adherence to treatment. / Health Studies / M.A. (Public Health)

Background: Injecting drug users (IDUs) represent considerable group of patients infected with hepatitis C virus (HCV). HCV treatment is an effective tool for reduction of HCV transmissions among IDUs. Nevertheless treatment rate among IDUs is rather insufficient. Treatment uptake, provision and adherence as well as its efficacy in IDUs are determined by number of specific factors. Aims: Mapping an extent of the provision of HCV treatment to IDUs in the Czech Republic, rules and practices for the admission of IDUs into HCV treatment and its provision, describing relevant factors related to drug use. Material and methods: From January to March 2011, a questionnaire survey among centres for treatment of viral hepatitis in the Czech Republic was conducted. 76 identified centres were addressed, of which 45 (59%) responded, and 40 (53%) filled in an online questionnaire. Results: Estimated number of centres treated HCV with combination of pegylated interferon α and ribavirin in the Czech Republic in 2010 was 61, 39 of them treated IDUs. Estimated 780 persons were treated, of whom 370 were (mostly ex-) IDUs. Reported treatment uptake in IDUs was 60% on average (range 0-90%). Treatment is completed by 80% of IDUs on average (0-100%) according to clinicians. Most clinicians reported no difference in the treatment...

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18165号 / 医博第3885号 / 新制||医||1003(附属図書館) / 31023 / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 髙折 晃史, 教授 中原 俊隆 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM