Research Doctorate - Doctor of Philosphy (PhD) / A large body of population- and treatment-based evidence exists to indicate depression and alcohol/other drug (AOD) use are highly prevalent on a global scale, and co-occur with considerable frequency. Despite this evidence, significant gaps exist in treatment research and clinical services, as people with co-occurring depression and AOD use problems have typically been excluded from randomised controlled treatment trials, and also face many individual- and service-level barriers to accessing treatment. Consequently, a well-defined and adequately tested treatment strategy does not currently exist for people experiencing the complexities of concurrent depression and AOD use problems. A small body of evidence exists to suggest that co-occurring mental and AOD use disorders (“comorbidity”) leads to poorer treatment outcomes, increased risk of relapse, higher levels of problematic symptomatology, and poorer quality of life. However, little consistent information is currently available to suggest what additional impact comorbid depression and AOD misuse produces relative to the experience of a “single” condition (such as depression or AOD misuse in isolation). Studies 1 and 2 attempted to address this important gap in knowledge by examining the presenting characteristics of 246 people with AOD use problems, according to the presence of comorbid depressive symptoms. One hundred and thirty seven participants were drawn from AOD treatment services, and a further 109 were referred via mental health services and also met criteria for a psychotic disorder. Results indicated that the presence of depression was associated with a significantly higher severity of psychiatric symptoms and personality disorder, significantly decreased social and occupational functioning and significantly reduced quality of life. Current depression was also associated with a significant increase in the experience of cravings and self-reported dependence on amphetamines. These difficulties were over and above the already high rates of disability and distress reported by each sample as a whole. Furthermore, treatment for mental health problems was rare among the AOD treatment participants, as was AOD treatment among the mental health sample. This is despite the presence of moderate to severe levels of depression and AOD use reported by each sample. In particular, Studies 1 and 2 highlight the vulnerabilities for people with comorbid mental health and AOD use problems who present to treatment in the mental health or AOD use settings, and in particular how depression significantly increases the disability and other challenges experienced by these people. These results provide a strong rationale for the development of an appropriate treatment protocol for depression and AOD use comorbidity. No clear treatment model or evidence-based approach exists to suggest how depression and AOD use comorbidity is best managed. When people with this comorbidity do manage to access clinical treatment services, they typically receive treatment targeted at one aspect of their presentation (e.g. depression-focussed or AOD-focussed treatment). Yet, it is not known whether a singular focus of treatment is effective in producing sustainable change in the outcomes of people with comorbid problems, nor whether failure to treat all components of the comorbid presentation confers a worse outcome. Studies 3 and 4 reported on two randomised controlled clinical trials of psychologicaltreatment for AOD use problems among a sample of 246 people with AOD use problems, drawn from AOD treatment services (n=137) or mental health services (n=109). In doing so, these studies provide some of the first available data on these issues. Participants were categorised according to the presence of comorbid depression (as per Studies 1 and 2) and response to treatment was analysed over a six- to 12-month follow-up period. In spite of high levels of current depressive symptoms at entry to the studies, and equally hazardous use thresholds of a range of substance, people enrolled in Studies 3 and 4 reported some gains via their experiences with these single-focussed treatments. Attendance and retention rates were higher than reported in previous research, and the presence of depression did not adversely influence the motivation of project participants to change their current AOD use patterns. A treatment effect was generally not detected among the Study 3 and 4 participants, regardless of the presence of depression, with those receiving an assessment-only control treatment in both studies reporting similar patterns of change in outcome. Regardless of the magnitude of change reported by all study participants, people with depression reported significantly higher levels of depression, poly-drug use, amphetamine dependence, hazardous use of a range of substances, HIV risk taking and criminal activity and lower levels of functioning and self-concept across the follow-up assessment period. These residual symptoms were present at sufficiently high levels of severity to increase the risk of relapse to AOD use and continued morbidity. These results suggested the potential value of targeting depression in the context of comorbid AOD use problems. One previous study has examined the impact of an adjunctive psychological treatment of depression for people hospitalised for alcohol use disorder. Results indicated that people who received the additional depression treatment reported significantly greater improvements on depression- and alcohol-related outcomes over the short-term relative to people receiving a relaxation-only control treatment. These improvements were suggested to be enhanced if treatment had integrated depression- and alcohol-related approaches into the one treatment program. In the first study of its kind, Study 5 developed and evaluated the efficacy of an integrated psychological treatment program for comorbid depression and AOD use problems. Sixty-seven participants received integrated treatment delivered by a therapist, computer-delivered integrated treatment or a brief intervention (control) treatment delivered by a therapist. Depression scores, daily use of alcohol and cannabis, hazardous use of a range of substance and poly-drug use fell significantly over a 12-month follow-up period across the integrated treatments and brief intervention (control) conditions. The small sample size of Study 5 meant that very few treatment effects were detected at a statistically significant level, however important reductions in key outcomes for depression, AOD use, quality of life and general functioning were noted for people in the integrated treatment relative to controls over a 12-month period. The magnitude of change in Study 5 across these domains was comparable with the only other study of psychological treatment of depression and alcohol-use disorders described above. The integrated treatment in Study 5 was associated with higher levels of improvement in depression, alcohol use and cannabis use (where present) than did the AOD-focussed treatment examined in Studies 3 and 4. The results further suggest that a brief intervention targeting both depression and AOD drug use problems is associated with reductions in key outcomes in the short-term, withintegrated, lengthier psychological treatment potentially associated with longer-term changes on the same outcomes. No previous study has directly compared the outcomes for people completing psychological treatment delivered via a computer program with those completing treatment with a ‘live’ clinician over an extended follow-up period of 12-months. Given the barriers people with comorbid depression and AOD use problems face in accessing available treatment services, the consideration of alternative modes of delivery of evidence-based treatment to this group is timely. Study 6 expanded on the Study 5 results by presenting further analysis of the performance of the computer-delivered version of the integrated treatment relative to the clinician-delivered equivalent, matched for content. Given the small sample size of participants, Study 6 devised a four-point criterion which, if satisfied, would suggest that the computer-delivered and clinician-delivered integrated treatments were approximately equal. Based on these criteria, the results indicated that the outcome profiles for people engaged in the computer-delivered treatment were equivalent to those reported by people involved in clinician-delivered therapy over a 12¬month follow-up period. Additionally, computer-delivered integrated treatment was associated with similar rates of improvement as the therapist-equivalent on depression scores, risky drinking patterns, hazardous use of substances, poly-drug use, levels of daily cannabis use, suicidality, treatment retention and therapeutic alliance. This result requires further replication to test these assumptions, however it is promising that a treatment requiring an average of 12-minutes face-to-face of “generic” clinician time per weekproduces a similar pattern of improvement to a treatment requiring an average of 60 minutes of face-to-face specialist psychologist input over the same time period. Studies 1-6 resulted in the development of a menu of treatment options for people with depression and AOD use comorbidity, with each treatment approach providing evidence for at least some benefit among the study participants. While encouraging, these results again raise the issue of how treatment may be incorporated into existing services (mental health, AOD use, primary care, etc.), which typically remain segregated, with little opportunity for collaboration and cross-fertilisation of skills and expertise between service settings. Chapter 7 discusses a new model of treatment for comorbid depression and AOD use problems that incorporates the results of Studies 1-6, and involves a stepped care approach to developing a treatment plan tailored to the specific needs and levels of distress experienced by people with depression and AOD use comorbidity. The stepped care model of treatment could be incorporated into existing service settings and structures, with the potential for computer-based therapy to provide access to specialised treatment for depression and AOD use comorbidity that might otherwise be unavailable. As a result, stepped care treatment could foster earlier engagement with treatment services and encourage motivation and optimism among people with comorbid depression and AOD use problems. These are important issues for service development and delivery of appropriate treatments to this underserved population.

Does Nimbin have a drug problem? This tiny village in north-eastern NSW has an international reputation for its alternative community and its street drug market. Ever since the Aquarius Festival thirty years ago Nimbin has fascinated the media, and recurrent headlines about the village's (undefined) 'drug problem' suggested my research topic. My research aim was to investigate the meaning/s of Nimbin's 'drug problem' in the context of Nimbin's 'alternative' culture. Because the topic of illicit drugs is both ethically challenging and highly sensitive, my research design was strongly participant-focused, with an emphasis on confidentiality balanced by a mixed methodology to cross-validate results. My methods included an anonymous household (door-to-door) survey based on a national household survey; an anonymous mailed-back survey of Nimbin and Lismore drug injectors; taped interviews with health and legal professionals, cannabis activists and drug dealers; semi-structured interviews with 'professional' cannabis crop growers; and participant observation over several years. I found the multi-method research design to be particularly effective for investigating illegal drug marketing and use, and the design provided me with multiple perspectives on a complex issue. Superficially, there appeared to be two drug 'problems' in Nimbin — one was the (largely cannabis) street market, and the other revolved around heroin users, and included complaints about scruffy-looking people hanging around the main street, or overdosing in the public toilet. However, my research suggested that these issues, while immediately comprehensible as 'drug problems', obscured more complex issues. For example, the village's street drug market was intertwined with the local economy and with the alternative community's values and drug use, while close to half of the drug injectors lacked secure housing (which creates problems that are not related to heroin), and all heroin users were blamed for the actions of few. Many factors influence the creation and maintenance of what we might call 'problems', and drugs are frequently blamed for broader social problems. What is Nimbin’s drug problem? The answer depends, in part, on the drug of interest, but more importantly it depends on your definition of a ‘problem’. Some useful and meaningful perspectives on this important social issue include quantified indicators such as death, injury, arrest rates, the economics of black markets, the demographics of drug use, and estimates of ‘social costs’. Qualitative perspectives include people’s opinions about drugs, media-generated moral panics, the effects of social marginalisation, and the role of drug cultures. A number of ‘drug problems’ arise as a direct result of drug illegality. They include black markets, corruption, drug-related violence, theft, stronger forms of the drug, and more dangerous using practices (with the risk drug overdoses and HIV/AIDS), as well as public nuisance issues. Government policy, judicial sentencing and public opinion are moving towards the social reintegration of illicit drug users, but this is almost invariably counter-balanced by a toughening of legal sanctions against supply of the same drug. Most discussions about illicit drugs fail to consider the long-term implications of harsh penalties for, and elaborate and punitive police operations (such as occurred throughout my Nimbin research) against, small-scale independent growers and dealers. The only way to directly engage with drug markets and all the attendant problems, is to legitimise and regulate the supply of recreational drugs. I discuss several examples of the important role of the drug culture in mitigating problems caused by illegality. One example is the influence of Nimbin's alternative community on the style of the drug market. The village drug scene more closely resembles the many north coast village craft markets, than it does Kings Cross, Cabramatta or New York's Bronx. Buyers are north coast locals, along with national and international tourists (the small village is known to cannabis users world-wide, both through media attention and word-of-mouth). Nimbin offers a 'safe' village market ambience and competitive prices to a mainly cannabis using clientele. I suggest that there are two major underlying influences on the experience of a ‘drug problem’, regardless of the drug or the place. They are: 1. Political influences — specifically the effects of government policy on black markets, law enforcement practices, and access to services and resources; 2. Cultural influences — particularly the beneficial effects of norms and functional role models for the safe use of a drug, cultural effects on the drug market, and the role/s of the drug in the day-to-day life of the culture. These influences can operate with, or despite, each other, and can create or ameliorate many ‘drug problems’. In the case of Nimbin’s alternative culture, government policy has created a number of drug problems and the counter-culture has worked to minimise them. In my research into Nimbin’s ‘drug problem’ I have clarified some issues and raised a number of others. I have examined the notion of a ‘drug problem’ from several perspectives using a range of research tools, and discussed some key influences on the problem associated with drug use. Drawing from the Nimbin research and my reading, I suggest legalising the recreational drugs to bring them under the dual controls of supply legislation and social norms. In conclusion, I suggest that we need to be very clear about what ‘drug problem’ it is that we are talking about, and indeed, whether the problem is really about drugs at all.

Does Nimbin have a drug problem? This tiny village in north-eastern NSW has an international reputation for its alternative community and its street drug market. Ever since the Aquarius Festival thirty years ago Nimbin has fascinated the media, and recurrent headlines about the village's (undefined) 'drug problem' suggested my research topic. My research aim was to investigate the meaning/s of Nimbin's 'drug problem' in the context of Nimbin's 'alternative' culture. Because the topic of illicit drugs is both ethically challenging and highly sensitive, my research design was strongly participant-focused, with an emphasis on confidentiality balanced by a mixed methodology to cross-validate results. My methods included an anonymous household (door-to-door) survey based on a national household survey; an anonymous mailed-back survey of Nimbin and Lismore drug injectors; taped interviews with health and legal professionals, cannabis activists and drug dealers; semi-structured interviews with 'professional' cannabis crop growers; and participant observation over several years. I found the multi-method research design to be particularly effective for investigating illegal drug marketing and use, and the design provided me with multiple perspectives on a complex issue. Superficially, there appeared to be two drug 'problems' in Nimbin — one was the (largely cannabis) street market, and the other revolved around heroin users, and included complaints about scruffy-looking people hanging around the main street, or overdosing in the public toilet. However, my research suggested that these issues, while immediately comprehensible as 'drug problems', obscured more complex issues. For example, the village's street drug market was intertwined with the local economy and with the alternative community's values and drug use, while close to half of the drug injectors lacked secure housing (which creates problems that are not related to heroin), and all heroin users were blamed for the actions of few. Many factors influence the creation and maintenance of what we might call 'problems', and drugs are frequently blamed for broader social problems. What is Nimbin’s drug problem? The answer depends, in part, on the drug of interest, but more importantly it depends on your definition of a ‘problem’. Some useful and meaningful perspectives on this important social issue include quantified indicators such as death, injury, arrest rates, the economics of black markets, the demographics of drug use, and estimates of ‘social costs’. Qualitative perspectives include people’s opinions about drugs, media-generated moral panics, the effects of social marginalisation, and the role of drug cultures. A number of ‘drug problems’ arise as a direct result of drug illegality. They include black markets, corruption, drug-related violence, theft, stronger forms of the drug, and more dangerous using practices (with the risk drug overdoses and HIV/AIDS), as well as public nuisance issues. Government policy, judicial sentencing and public opinion are moving towards the social reintegration of illicit drug users, but this is almost invariably counter-balanced by a toughening of legal sanctions against supply of the same drug. Most discussions about illicit drugs fail to consider the long-term implications of harsh penalties for, and elaborate and punitive police operations (such as occurred throughout my Nimbin research) against, small-scale independent growers and dealers. The only way to directly engage with drug markets and all the attendant problems, is to legitimise and regulate the supply of recreational drugs. I discuss several examples of the important role of the drug culture in mitigating problems caused by illegality. One example is the influence of Nimbin's alternative community on the style of the drug market. The village drug scene more closely resembles the many north coast village craft markets, than it does Kings Cross, Cabramatta or New York's Bronx. Buyers are north coast locals, along with national and international tourists (the small village is known to cannabis users world-wide, both through media attention and word-of-mouth). Nimbin offers a 'safe' village market ambience and competitive prices to a mainly cannabis using clientele. I suggest that there are two major underlying influences on the experience of a ‘drug problem’, regardless of the drug or the place. They are: 1. Political influences — specifically the effects of government policy on black markets, law enforcement practices, and access to services and resources; 2. Cultural influences — particularly the beneficial effects of norms and functional role models for the safe use of a drug, cultural effects on the drug market, and the role/s of the drug in the day-to-day life of the culture. These influences can operate with, or despite, each other, and can create or ameliorate many ‘drug problems’. In the case of Nimbin’s alternative culture, government policy has created a number of drug problems and the counter-culture has worked to minimise them. In my research into Nimbin’s ‘drug problem’ I have clarified some issues and raised a number of others. I have examined the notion of a ‘drug problem’ from several perspectives using a range of research tools, and discussed some key influences on the problem associated with drug use. Drawing from the Nimbin research and my reading, I suggest legalising the recreational drugs to bring them under the dual controls of supply legislation and social norms. In conclusion, I suggest that we need to be very clear about what ‘drug problem’ it is that we are talking about, and indeed, whether the problem is really about drugs at all.

The idea of evidence-based policy has gained increasing prominence. Much research exists on the subject, particularly tackling the evidence-based policy turn and, subsequently, its critique. A plethora of studies have identified the shortcomings of the evidence-based policy ideal and challenged its supposed linearity. This project aims to provide an understanding of the way in which evidence is utilized in policy, and contribute to this debate by enacting an innovative research design. I am proposing a 2x2 comparative approach, which looks at the use of evidence across two domains, drug and prostitution policy, across two countries, Australia and the UK. A case-based qualitative comparative approach has the potential to offer a certain depth while at the same time providing the opportunity for analytic generalisation. I argue that evidence can be a prime focus for analysis of the policy process, and that through its lenses one can appraise deeper theoretical and epistemological questions about the state in late modern capitalism, the relationship between knowledge and ideology, science and politics, science and values, reason and emotion. The labelling of prostitution and drug policy as morality policies exposes the nature of these domains as morally and politically antagonistic, whilst providing opportunity to reflect on the role of morality in filtering understandings of evidence and shaping policy positions.

In-depth interviews were conducted with women who use ecstasy for recreation, mainly in the context of the dance event. The aim was to discover the meaning of ecstasy use, and its surrounding culture, for women in the late 1990s. A further endeavour involved disclosing how the body was experienced at the dance event and what this meant to the women. Existential phenomenological analysis led to the following key conclusions. The dance event is experienced as a social space that allows women to be themselves and find a strong sense of belonging. There may be apparent dependence upon the experiences surrounding ecstasy. But, the journey of ecstasy use allows alterations in attitude, and transitions in life, to be experienced, which the women view positively. The women use ecstasy for pleasure, believe themselves to be independent in their use, and do not view their actions as deviant. These findings are important to scholarly literature on female drug users because they redress the gender balance by presenting the specific experiences of women. They also have implications for social policy and health service provision, in the sense that this description of a social world enables understanding, enhances communication and, thus, betters education.

Background: Good parent-child connectedness, general and substance use specific communication are protective against alcohol, tobacco and drug use during adolescence. Previous research also suggests that general communication with foster and other statutory carers is associated with more positive outcomes, including relationships with caregivers and siblings. However, no studies have examined substance use specific communication between looked after young people and their carers. Aims: The aim of this study was to gain an understanding of how carers and looked after young people communicate about alcohol, tobacco and drug use and the factors that shape communication, including the use of digital media. Methods: A qualitative study was conducted, using in-depth interviews with 13 looked after young people in foster and residential care; two social workers; six foster carers and eight residential care workers. Interviews were audio-recorded, transcribed verbatim and the data were analysed thematically. Findings: Relationships between carers and young people were crucial and acted as the antecedent to communication. Carers' role identity influenced their relationships with young people and their approach to and communication about substance use. Shared doing provided a way in which communication about substances could be facilitated in an environment which feels natural. The context in which communication occurred was important, with differences between foster and residential care. Digital media were viewed with caution, as something used to gain information about substances but not as a way of communicating with young people. Conclusions: The findings have implications for foster carers and residential care staff working with looked after young people, in terms of relationships and communication about substance use. Carers should continue to develop positive relationships with young people, whilst considering the potentially negative effects of conflicts in professional role identity. Techniques such as shared doing and encouraging natural conversations about substance use may help.

This research explores the understudied phenomenon of performance and image enhancing drug (PIED) markets by examining the structure and formation of the market for PIEDs in the Netherlands and Belgium. Furthermore, this study aims to understand and analyse the actors that operate in the PIED dealing environment. In particular bodybuilding is adopted as a case study. Finally, this thesis examines how the PIED control system and its application influence these respective markets. Chapter one introduces the global PIED problem, the policy options currently available to deal with it, and its connection to anti-doping and sport. Chapter two begins by reviewing the literature on PIED use and its supply, and reflects on the anti-doping and PIED policies that seek to regulate this market. In chapter three the theoretical contours of this dissertation are developed. Chapter four describes the research methods which form the empirical bases of the findings chapters. Chapter five focuses on the general characteristics of PIED suppliers, and the ways in which the actions of PIED dealers are influenced by the market cultures in which they operate. Chapter six examines the importance of socio-cultural factors in the formation and development of PIED dealing networks within bodybuilding subcultures. Chapter seven analyses and describes the characteristics of the Belgian and Dutch PIED markets, and unravels the complex relationship between the two. Chapter eight explores the illegal production of steroids in the Netherlands and the flourishing Internet trade in Belgium. Chapter nine assesses the harms related to the production and distribution of PIEDs, and accounts for the effects that Belgian and Dutch PIED policies may have on this illicit market. Finally, in chapter ten, the main findings of this dissertation are summarized, future research endeavours are considered and policy implications are drawn from the analysis. This thesis illustrates that social systems of rules and values, and in particular the embeddedness of culture, are important factors in our efforts to comprehend illicit PIED markets. Specifically, ‘the beliefs, norms, ‘tools’, rules and behaviours appropriate to a cultural setting are key factors for understanding the structure of PIED markets and greater attention must be given to the role played by socio-cultural factors in influencing the market behaviour of criminal groups and individuals. Nevertheless, this thesis also demonstrates that it is imperative to examine the production, distribution and use of PIEDs, as embedded within a diverse combination of social, economic and cultural processes. Indeed, the structure and formation of illicit PIED markets are shaped by a variety of factors including the types of PIEDs dealt within them, the characteristics of the users, the social structures which sustain them, the cultural and economic context in which the markets exist, and market forces (e.g. technical innovations, drug policies).

abstract: Mexican American adolescents report high rates of internalizing symptomatology and alcohol use. However, very little research has explored to what extent internalizing distress may contribute to alcohol use among this population. The current study utilized longitudinal data from a community sample of Mexican American adolescents (n=626, 51% female) to test a series of hypotheses about the role of internalizing distress on alcohol use and misuse. Specifically, this study used a bifactor modeling approach to investigate (1) whether different forms of internalizing distress are composed of common and unique components; (2) whether and to what extent such components confer risk for alcohol use; and (3) whether youth cultural orientation plays a role in these associations. Confirmatory factor analyses revealed that a bifactor model with a general factor and three specific factors (depressed mood, general worry, social anxiety) provided good fit to the data. The general distress factor was significantly associated with past month alcohol use but not binge drinking. However, these effects were conditional based on level of acculturation. Differential relations were found between the specific factors of internalizing distress and alcohol use. Depressed mood predicted past month alcohol use among girls; social anxiety negatively predicted past three month binge drinking among boys. Overall, results highlight the multidimensional nature of internalizing distress and suggest that both common and unique components of internalizing distress may be relevant to the etiology of alcohol use among Mexican-American adolescents. Findings underscore the importance of considering cultural orientation as a moderating factor when investigating substance use among Hispanic youth. Implications for future research examining the etiological relevance of the internalizing pathway to alcohol use among Hispanic adolescents are discussed. / Dissertation/Thesis / Doctoral Dissertation Psychology 2018

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Kidneys are vulnerable to chemical agent-induced injuries. Children (neonates and infants) are a particular at risk age group because they have renal functions less developed than that of adults. The exposure of children to medicines considered to be nephrotoxic agents - namely the aminoglycosides, nonsteroidal anti-inflammatory drugs (NSAID) and angiotensin converting enzyme (ACE) inhibitory drugs - should be avoided whenever possible. Hospitalized children are pointed out to be the group at greatest risk of nephrotoxicity due to their high level of exposure to these medicines as well as the frequent and improper use of non standardized medicines in this age range. To determine the prevalence of use of potentially-nephrotoxic drugs (PND) and the frequency of concomitant risk factors in hospitalized children younger than 2 years old in a medical ward in a pediatric hospital in Fortaleza, Brazil. A prospective, observational, follow-up study was developed. All children younger than 2 years old admitted to the general ward were included and followed-up. Sociodemographic data, pathological and pharmacotherapeutic antecedents were recorded, as well as information about the use of drugs and the attendance of risk factors for nephrotoxicity associated with aminoglycosides, NSAID and ACE inhibitors. Also, the occurrence of adverse events was identified. Data was taken from medical records and interviews with the mothers of the children. Statistical analysis involved cumulative frequency, cumulative percentage, central tendency measures, Student âtâ test and ANOVA. During the study period (September/2005 to March/2006), 120 admissions were recorded. Three patients were excluded because of incomplete data. The results represented 117 admissions that affected 103 different children. The prevalence of the use of PND was 96,6%. A total of 1065 drugs were used, 69% with potential intrinsic nephrotoxicity based on available literature. The mean number of PND used was 6,3  4,0 per patient. The PND most frequently used were: metamizole (10,1%), ranitidine (6,2%) and prednisone (5,1%). Around 18% of children used aminoglycosides, 65,8% and 4,3% had taken NSAID and ACE inhibitory drugs respectively. A total of 368 risk factors for nephrotoxicity were detected (3,5Â1,8 risk factors/patient). The most frequent factors were: the use of at least one PND (30,7%), the use of 2 or more PND (28,3%) and the use of NSAID concomitantly with that of potassium-rich salt substitutes(10%).The PND use was considered high when compared with published data from this studied age group. The frequency of risk factors for nephrotoxicity also reached considerable levels. It would be important to know if there exist safer therapeutic alternatives and what preventative measures could be adopted in each case. The contribution of a clinical pharmacist to a safe pharmacotherapy for hospitalized children would be a strategy for reducing PND-associated risk. / Os rins sÃo bastante vulnerÃveis a danos produzidos por agentes quÃmicos. Dentre as substÃncias nefrotÃxicas estÃo os medicamentos, os quais merecem destaque devido à ampla exposiÃÃo aos mesmos. Alguns grupos, como aminoglicosÃdeos, antiinflamatÃrios nÃo-esteroidais (AINE) e inibidores da enzima conversora de angiotensina (IECA) sÃo muito conhecidos pelo seu potencial nefrotÃxico intrÃnseco. As crianÃas menores (neonatos e lactentes) sÃo dignas de atenÃÃo especial no que se refere a essa questÃo, porque freqÃentemente usam medicamentos e, alÃm disso, a capacidade funcional de seus rins à menor do que a dos adultos. A melhor maneira de tratar a questÃo da nefrotoxicidade à prevenindo-a. Determinar a prevalÃncia de uso de medicamentos potencialmente nefrotÃxicos (MPN) e observar a presenÃa de condiÃÃes que favorecem ao desenvolvimento da nefrotoxicidade (fatores de risco) em crianÃas menores de dois anos de idade internadas em enfermaria geral de um hospital pediÃtrico em Fortaleza â Brasil. Estudo observacional, prospectivo, de seguimento de pacientes. Todas as crianÃas menores de dois anos admitidas na enfermaria âEâ foram incluÃdas e monitorizadas. InformaÃÃes sociodemogrÃficas, antecedentes patolÃgicos e farmacolÃgicos foram registrados, bem como informaÃÃes sobre o uso de medicamentos, presenÃa de fatores de risco para nefrotoxicidade associada a aminoglicosÃdeo, AINE e IECA, e ocorrÃncia de eventos adversos. Os dados foram coletados dos prontuÃrios mÃdicos e atravÃs de entrevista com os responsÃveis pelas crianÃas, sendo analisados estatisticamente usando medidas de freqÃÃncia, tendÃncia central e os testes âtâ de Students e Anova. Durante o perÃodo de estudo (setembro/2005 a marÃo/2006), ocorreu um total de 120 admissÃes na enfermaria; trÃs dos pacientes foram excluÃdos do estudo porque tinham dados incompletos. Os resultados se referem a 117 admissÃes correspondentes a 103 crianÃas. A prevalÃncia de uso de MPN foi de 96,6%. Do total de 1065 itens de prescriÃÃo consumidos, 68,6% tinham potencial nefrotÃxico intrÃnseco. O nÃmero mÃdio de MPN utilizados foi 6,3  4,0 por paciente. Dentre os MPN mais usados estavam: dipirona (10,1%), ranitidina (6,2%) e prednisona (5,1%). Dois por cento das crianÃas usaram aminoglicosÃdeos, 7,3% usaram AINE e 0,8% utilizaram IECA. Foram detectados 368 fatores de risco para nefrotoxicidade, com uma mÃdia de 3,15  1,8 fatores de risco/paciente. Os fatores de risco mais freqÃentes foram: uso de, no mÃnimo, um MPN (30,7% do total de fatores); uso de 2 ou mais MPN concomitantemente (28,3%) e o uso de AINE concomitante ao uso de suplementos de potÃssio (10%). O uso de MPN na faixa etÃria estudada foi considerado elevado. A freqÃÃncia de fatores de risco para nefrotoxicidade tambÃm ocorreu em nÃveis preocupantes. Seria importante conhecer se existiam alternativas mais seguras em cada caso e que medidas preventivas poderiam ser adotadas. A inclusÃo do farmacÃutico clÃnico na atenÃÃo a crianÃas hospitalizadas seria uma estratÃgia com grande potencial de impacto na reduÃÃo de riscos associados aos MPN.

Master of Public Health - MPH / Background: Drugs are essential components of the health system and their rational use is vital to delivering quality and efficient healthcare services. However, inappropriate prescribing is a common rational drug use problem globally, particularly in developing countries including Nigeria. Despite measures to address this problem, inappropriate drug use continues to be a major public health problem in Nigeria. Aim: This study assessed rational drug use (RDU), with a focus on rational prescribing and factors affecting it, among primary healthcare providers working in primary healthcare facilities of a LGA in Northwestern Nigeria. Methods: The study was a cross sectional descriptive study and it included retrospective review of patient encounters and interviews with prescribing healthcare providers in sampled health facilities. Stratified random sampling method was used to select 20 public primary healthcare facilities and 30 patient encounters were drawn by systematic random sampling from each facility. One hundred and sixty three prescribing healthcare providers in the health facilities were also included in the study. Adapted WHO's drug use study tools and a structured self-administered questionnaire were used to collect data. Data were analysed using Statistical Package for Social Sciences (SPSS Version 17) software and presented as contingency table with chi square test used to test for relationship between variables with statistical significance taken at p < 0.05. Ethical approval was obtained from the University of the Western Cape Research Ethics Committee and Kaduna State Ministry of Health, and permission from local stakeholders. Confidentiality of individual patients, healthcare providers and health facilities data was maintained. Results: The prescribing staff at the selected facilities were predominantly Nurses/Midwives and community health assistants with SCHEWs constituting the majority (60.8%). More than half (54.4%) of providers did not know about the concept of RDU. Similarly, the computed knowledge score of RDU revealed that the majority (74.4%) had poor knowledge of the concept. Knowledge was significantly associated with duration of service, providers' previous training in rational drug use and professional status (p<0.05), with the CHOs having better knowledge of RDU compared with other professional cadres. High antibiotic use (68.3% in retrospective review and 82.9% in survey) and injection use (9.5% in retrospective review and 12% in survey) were found in the study with significant proportions of providers admitting that all cases of URTI should receive antibiotics (72.3% ) and that patients could be prescribed injections if they requested for it (35.3%). The Standing Order was the main source of information for the majority (50.6%) of providers and it served as the major influence affecting prescribing practices. Conclusion: This study revealed a poor understanding and knowledge of RDU among healthcare providers. High antibiotic and injection use also reflected providers' poor attitude to rational prescribing of these commodities. To improve prescribing practices at the PHC level, adequate staff skill mix, including physicians should be established. Since RDU knowledge was associated with prior training, curriculum development towards RDU and opportunities for in-service training should be provided to build prescribers capacity, in addition to instituting a system of rational drug use monitoring. Further research into rational drug use among different cadres of PHC healthcare providers is also recommended.