Adherence to antiretroviral therapy in children in Zimbabwe: a randomized control trial to validate a new self-reported adherence monitoring tool
- Authors: Mugore, Linnetie
- Date: 2014
- Language: English
- Type: text , Thesis , Doctoral , PhD
- Identifier: http://hdl.handle.net/10962/54734 , vital:26607
- Description: Background: Among children taking antiretroviral therapy (ART), self-reports have been widely reported to over-estimate adherence levels. Pill count adherence levels are often lower than self-reported levels, with unannounced home pill count adherence being lower than facility based pill count adherence. There is often poor agreement between pill count adherence levels and those measured using other objective adherence measuring methods such as Medication Event Monitoring Systems (MEMS®), which is widely viewed as the gold standard for adherence measurement. Objectives: The aim of this study was to design and evaluate a new self-reported paediatric adherence monitoring tool, assess the feasibility of using pill count methods in monitoring adherence and identify challenges to reporting adherence among children on ART in rural and urban Zimbabwe. Methods A dual centre, superiority, parallel design RCT was conducted to evaluate the newly-developed visually- and verbally-cued „past 10 days‟ tool for the assessment of adherence in children on ART at two sites in Zimbabwe; Harare Central Children‟s Hospital in an urban setting, and Murambinda Mission Hospital, a rural site. Child-caregiver pairs presenting to one of these facilities for the child‟s review of ART and refill of the medication were recruited, signed informed consent obtained, and were randomised for self-reported adherence monitoring into either the experimental group („new 10-day tool‟) or the control group („PACTG-style‟ self-report tool). Data (demographic, socioeconomic, and reported adherence) were collected in individual interviews with child-caregiver pairs. Additional adherence monitoring methods used for both groups included the Morisky-8-Item Medication Adherence Scale (MMAS-8) and a facility based pill count. FGDs were held with groups of caregivers and groups of children ≥13 years of age to understand reasons for non-adherence as well as issues around reporting non-adherence. Superiority testing was conducted by comparing adherent proportions and their confidence intervals (95% CI). Further concurrent validity test was done using the Mann-Whitney U test to evaluate the relationship between the new tool and the MMAS-8 scores. Agreement between the child and caregiver reports of adherence was used as a test of reliability of the new tool using the kappa statistic. Socio-demographic, clinical and care-related factors associated with adherence were identified using reported adherence in both child and caregiver groups in a logistic regression model. Two pill count methods were assessed for feasibility using the proportions of children with complete data for calculating adherence levels, and their CI and a comparison of the two methods, a routinely-used method and one that incorporated the reported residual quantity (RRQ) of medication at last refill. Results : Analysis included 245 child-caregiver pairs, 123 in the experimental group and 122 in the control group. The median age for children was 9 years. In the experimental group, adherence by caregiver and child reports ranged from 94.3% - 98.4% and 78.4% - 96.1%, and those in the control group ranged from 89.2% - 97.5% and 71.2% - 98.1%, respectively. There was no significant difference between adherence levels in the two groups. Adherence levels measured by both the experimental and control tools were found to be associated with MMAS-8 adherence levels (p <0.05). Agreement between child- and caregiver-reported adherence was moderate though significant (kappa; 0.407, p <0.05). Only about half of the children had adequate data to compute pill counts. Proportions adherent at 95% cut-off were 39% by the „routine pill count‟ and 58% by the „Pill count RRQ‟. Being an orphan was associated with child reported-adherence whereas use of non-human reminders, having a maternal relative as a primary caregiver and knowledge of dose frequency, were all associated with caregiver-reported adherence. Major causes of non-adherence mentioned during the FGDs included interference of medication administration times with scheduling of routine socio-economic activities and lack of support from some non-biological caregivers. Reporting of non-adherence appeared to be hampered by perceptions of negative reactions by healthcare workers to these reports and by caregivers being unaware that the child missed some doses. Conclusions: The „new 10-day tool‟ was not shown to be superior to the „PACTG-style tool‟ in detecting non-adherence, however this new tool was found to be a valid and reliable adherence monitoring tool that included a moderately long recall period of 10 days, can be applied without the need for the respondent to remember names of individual medicines in the
- Full Text:
- Date Issued: 2014
- Authors: Mugore, Linnetie
- Date: 2014
- Language: English
- Type: text , Thesis , Doctoral , PhD
- Identifier: http://hdl.handle.net/10962/54734 , vital:26607
- Description: Background: Among children taking antiretroviral therapy (ART), self-reports have been widely reported to over-estimate adherence levels. Pill count adherence levels are often lower than self-reported levels, with unannounced home pill count adherence being lower than facility based pill count adherence. There is often poor agreement between pill count adherence levels and those measured using other objective adherence measuring methods such as Medication Event Monitoring Systems (MEMS®), which is widely viewed as the gold standard for adherence measurement. Objectives: The aim of this study was to design and evaluate a new self-reported paediatric adherence monitoring tool, assess the feasibility of using pill count methods in monitoring adherence and identify challenges to reporting adherence among children on ART in rural and urban Zimbabwe. Methods A dual centre, superiority, parallel design RCT was conducted to evaluate the newly-developed visually- and verbally-cued „past 10 days‟ tool for the assessment of adherence in children on ART at two sites in Zimbabwe; Harare Central Children‟s Hospital in an urban setting, and Murambinda Mission Hospital, a rural site. Child-caregiver pairs presenting to one of these facilities for the child‟s review of ART and refill of the medication were recruited, signed informed consent obtained, and were randomised for self-reported adherence monitoring into either the experimental group („new 10-day tool‟) or the control group („PACTG-style‟ self-report tool). Data (demographic, socioeconomic, and reported adherence) were collected in individual interviews with child-caregiver pairs. Additional adherence monitoring methods used for both groups included the Morisky-8-Item Medication Adherence Scale (MMAS-8) and a facility based pill count. FGDs were held with groups of caregivers and groups of children ≥13 years of age to understand reasons for non-adherence as well as issues around reporting non-adherence. Superiority testing was conducted by comparing adherent proportions and their confidence intervals (95% CI). Further concurrent validity test was done using the Mann-Whitney U test to evaluate the relationship between the new tool and the MMAS-8 scores. Agreement between the child and caregiver reports of adherence was used as a test of reliability of the new tool using the kappa statistic. Socio-demographic, clinical and care-related factors associated with adherence were identified using reported adherence in both child and caregiver groups in a logistic regression model. Two pill count methods were assessed for feasibility using the proportions of children with complete data for calculating adherence levels, and their CI and a comparison of the two methods, a routinely-used method and one that incorporated the reported residual quantity (RRQ) of medication at last refill. Results : Analysis included 245 child-caregiver pairs, 123 in the experimental group and 122 in the control group. The median age for children was 9 years. In the experimental group, adherence by caregiver and child reports ranged from 94.3% - 98.4% and 78.4% - 96.1%, and those in the control group ranged from 89.2% - 97.5% and 71.2% - 98.1%, respectively. There was no significant difference between adherence levels in the two groups. Adherence levels measured by both the experimental and control tools were found to be associated with MMAS-8 adherence levels (p <0.05). Agreement between child- and caregiver-reported adherence was moderate though significant (kappa; 0.407, p <0.05). Only about half of the children had adequate data to compute pill counts. Proportions adherent at 95% cut-off were 39% by the „routine pill count‟ and 58% by the „Pill count RRQ‟. Being an orphan was associated with child reported-adherence whereas use of non-human reminders, having a maternal relative as a primary caregiver and knowledge of dose frequency, were all associated with caregiver-reported adherence. Major causes of non-adherence mentioned during the FGDs included interference of medication administration times with scheduling of routine socio-economic activities and lack of support from some non-biological caregivers. Reporting of non-adherence appeared to be hampered by perceptions of negative reactions by healthcare workers to these reports and by caregivers being unaware that the child missed some doses. Conclusions: The „new 10-day tool‟ was not shown to be superior to the „PACTG-style tool‟ in detecting non-adherence, however this new tool was found to be a valid and reliable adherence monitoring tool that included a moderately long recall period of 10 days, can be applied without the need for the respondent to remember names of individual medicines in the
- Full Text:
- Date Issued: 2014
Establishing a formulation design space for a generic clobetasol 17- propionate cream using the principles of quality by design
- Fauzee, Ayeshah Fateemah Beebee
- Authors: Fauzee, Ayeshah Fateemah Beebee
- Date: 2014
- Language: English
- Type: Thesis , Doctoral , PhD
- Identifier: vital:20983 , http://hdl.handle.net/10962/5868
- Description: The pharmaceutical industry is global, is highly regulated and is able to achieve reasonable product quality but at high cost with maximum effort. Numerous challenges face the pharmaceutical industry and include a shrinking research pipeline, less innovation, outsourcing, investments, increasing research and development costs, long approval times, growth of the generic industry, failure to understand or analyze manufacturing failure and wastage as high at fifty percent for some pharmaceutical products. An efficient and flexible pharmaceutical sector should be able to consistently produce high quality pharmaceutical products at a reduced cost with minimal waste. As a result, Food and Drug Administration (FDA) and other agencies such as the International Conference on Harmonization (ICH) have embraced a “Quality by Design” (QbD) paradigm and this has become the “desired state” so as to shift manufacturing from being empirical to a science, engineering, and risk based approach. QbD is a systematic approach for the development of high quality pharmaceutical dosage forms that begins with predefined objectives based on the premise that quality must be built into and not tested into a product. QbD together with the establishment of a design space for dosage forms is a fairly new concept and there is limited published data on QbD concepts that report the entire process of identifying Critical Quality Attributes (CQA), design of a formulation and manufacturing process to meet product CQA, understanding the impact of material attributes and process parameters on product CQA, identification and controlling sources of variability in materials and processes that affect the CQA of a product and finally establishing, evaluating and testing a design space using both in vitro and in vivo approaches to assure that a product of consistent quality can always be produced. The objective of these studies was to implement a QbD approach to establish a design space for the development and manufacture of a safe, effective, stable generic formulation containing 0.05% w/w clobetasol 17-propionate (CP) that had similar in vitro and in vivo characteristics to an innovator product, Dermovate® (Sekpharma® Pty Ltd, Sandton, Gauteng, RSA). Such a product would pose a minimal risk of failure when treating severe skin disorders such as seborrhoeic dermatitis, extreme photodermatitis and/or severe psoriasis in HIV/AIDS patients in Southern Africa.
- Full Text:
- Date Issued: 2014
- Authors: Fauzee, Ayeshah Fateemah Beebee
- Date: 2014
- Language: English
- Type: Thesis , Doctoral , PhD
- Identifier: vital:20983 , http://hdl.handle.net/10962/5868
- Description: The pharmaceutical industry is global, is highly regulated and is able to achieve reasonable product quality but at high cost with maximum effort. Numerous challenges face the pharmaceutical industry and include a shrinking research pipeline, less innovation, outsourcing, investments, increasing research and development costs, long approval times, growth of the generic industry, failure to understand or analyze manufacturing failure and wastage as high at fifty percent for some pharmaceutical products. An efficient and flexible pharmaceutical sector should be able to consistently produce high quality pharmaceutical products at a reduced cost with minimal waste. As a result, Food and Drug Administration (FDA) and other agencies such as the International Conference on Harmonization (ICH) have embraced a “Quality by Design” (QbD) paradigm and this has become the “desired state” so as to shift manufacturing from being empirical to a science, engineering, and risk based approach. QbD is a systematic approach for the development of high quality pharmaceutical dosage forms that begins with predefined objectives based on the premise that quality must be built into and not tested into a product. QbD together with the establishment of a design space for dosage forms is a fairly new concept and there is limited published data on QbD concepts that report the entire process of identifying Critical Quality Attributes (CQA), design of a formulation and manufacturing process to meet product CQA, understanding the impact of material attributes and process parameters on product CQA, identification and controlling sources of variability in materials and processes that affect the CQA of a product and finally establishing, evaluating and testing a design space using both in vitro and in vivo approaches to assure that a product of consistent quality can always be produced. The objective of these studies was to implement a QbD approach to establish a design space for the development and manufacture of a safe, effective, stable generic formulation containing 0.05% w/w clobetasol 17-propionate (CP) that had similar in vitro and in vivo characteristics to an innovator product, Dermovate® (Sekpharma® Pty Ltd, Sandton, Gauteng, RSA). Such a product would pose a minimal risk of failure when treating severe skin disorders such as seborrhoeic dermatitis, extreme photodermatitis and/or severe psoriasis in HIV/AIDS patients in Southern Africa.
- Full Text:
- Date Issued: 2014
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