scholarly journals Validity of World Health Organisation prescribing indicators in Namibia’s primary healthcare: findings and implications

2018 ◽  
Vol 31 (5) ◽  
pp. 338-345 ◽  
Author(s):  
Q Niaz ◽  
B Godman ◽  
A Massele ◽  
S Campbell ◽  
A Kurdi ◽  
...  
Keyword(s):  
Ambulatory Care ◽  
Treatment Guidelines ◽  
Survey Design ◽  
World Health ◽  
Antibiotic Prescribing ◽  
Medicine Use ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Significant Independent Risk Factor

Abstract Objective World Health Organization/International Network of Rational use of Drugs (WHO/INRUD) indicators are widely used to assess medicine use. However, there is limited evidence on their validity in Namibia’s primary health care (PHC) to assess the quality of prescribing. Consequently, our aim was to address this. Design, setting, participants and interventions An analytical cross-sectional survey design was used to examine and validate WHO/INRUD indicators in out-patient units of two PHC facilities and one hospital in Namibia from 1 February 2015 to 31 July 2015. The validity of the indicators was determined using two-by-two tables against compliance to the Namibian standard treatment guidelines (NSTG). The receiver operator characteristics for the WHO/INRUD indicators were plotted to determine their accuracy as predictors of compliance to agreed standards. A multivariate logistic model was constructed to independently determine the prediction of each indicator. Main outcomes and results Out of 1243 prescriptions; compliance to NSTG prescribing in ambulatory care was sub-optimal (target was >80%). Three of the four WHO/INRUD indicators did not meet Namibian or WHO targets: antibiotic prescribing, average number of medicines per prescription and generic prescribing. The majority of the indicators had low sensitivity and/or specificity. All WHO/INRUD indicators had poor accuracy in predicting rational prescribing. The antibiotic prescribing indicator was the only covariate that was a significant independent risk factor for compliance to NSTGs. Conclusion WHO/INRUD indicators showed poor accuracy in assessing prescribing practices in ambulatory care in Namibia. There is need for appropriate models and/or criteria to optimize medicine use in ambulatory care in the future.

scholarly journals An Evaluation of Antibiotic Prescribing Practices in a Rural Refugee Settlement District in Uganda

Antibiotics ◽  
2021 ◽  
Vol 10 (2) ◽  
pp. 172
Author(s):  
Matua Bonniface ◽  
Winnie Nambatya ◽  
Kalidi Rajab
Keyword(s):  
Treatment Guidelines ◽  
Inappropriate Prescribing ◽  
Antibiotic Use ◽  
Cross Sectional Study ◽  
Health Facilities ◽  
World Health ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
National Treatment ◽  
Cross Sectional

Ensuring access to effective antibiotics and rational prescribing of antibiotics are critical in reducing antibiotic resistance. In this study, we evaluated antibiotic prescribing practices in a rural district in Uganda. It was a cross-sectional study that involved a retrospective review of 500 outpatient prescriptions from five health facilities. The prescriptions were systematically sampled. World Health Organization core medicine use prescribing and facility indicators were used. Percentage of encounters with one or more antibiotics prescribed was 23% (10,402/45,160). The mean number of antibiotics per prescription was 1.3 (669/500). About 27% (133/500) of the diagnoses and 42% (155/367) of the prescriptions were noncompliant with the national treatment guidelines. Prescribing antibiotics for nonbacterial infections such as malaria 32% (50/156) and noninfectious conditions such as dysmenorrhea and lumbago 15% (23/156) and nonspecific diagnosis such as respiratory tract infection 40% (59/133) were considered noncompliant with the guidelines. On average, 68% (51/75) of the antibiotics were available on the day of the visit. Inappropriate prescribing practices included excessive use of antibiotics and failure to diagnose and prescribe in compliance with treatment guidelines. There is a need to strengthen antibiotic use in the health facilities through setting up stewardship programs and interventions to promote adherence to national treatment guidelines.

scholarly journals Identifying antibiotic prescribing patterns through multi-level latent profile analyses: a cross-sectional survey of primary care physicians in Hubei of China

2020 ◽  
Author(s):  
Dan Wang ◽  
Chaojie Liu ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Broad Spectrum ◽  
Primary Care Physicians ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Latent Profile Analyses ◽  
Broad Spectrum Antibiotics

Abstract Background Overuse of antibiotics significantly fuels the development of AMR, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n=501,072) made by the participants from 1 January to 31 March 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO “Watch and Reserve” list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results On average, each primary care physician issued 909 (ranging from 100 to 11941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD=17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD=15.83%) contained broad-spectrum antibiotics; 71.92% (SD=21.42%) contained parenteral administered antibiotics; 23.52% (SD=19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD=20.98%) contained antibiotics listed in the WHO “Watch and Reserve” list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

scholarly journals Assessment of Rational Antibiotic Prescribing in Public Hospitals in Nasarawa State, Nigeria

2020 ◽  
Vol 1 (4) ◽  
Author(s):  
Rejoice Abimiku Helma ◽  
Yakubu Boyi Ngwai ◽  
Istifanus Haruna Nkene ◽  
Sabiu Adamu
Keyword(s):  
International Development ◽  
Essential Medicine ◽  
Antibiotic Use ◽  
Antimicrobial Treatment ◽  
Public Hospitals ◽  
World Health ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional ◽  
Prescribing Indicators

Antibiotics are the most commonly used medicines in healthcare facilities globally; and they are often misused, especially in developing countries. Periodic assessment of antibiotic prescribing practices is essential to improve prescribing standards and ensure rational use. A cross-sectional, retrospective evaluation of antibiotic prescribing in public secondary and tertiary hospitals in Nasarawa State, Nigeria was carried out. A total of 2800 case sheets of patients who accessed the hospitals under review during the period 2008-2018 were randomly sampled and evaluated. Prescribing indicators of World Health Organization (WHO) and Strengthening Pharmaceutical System/United States Agency for International Development (SPS/USAID) were evaluated and compared with published standards for each of the indicators to identify irrational antibiotic use. Percentage of hospitalization with one or more antimicrobials prescribed was 75.6%. Average number of antimicrobials prescribed per hospitalization in which antibiotics were used was 1.75±0.66. Percentage of antibiotic prescribed consistent with hospital formulary was 100.0%. Average duration of prescribed antimicrobial treatment was 5.57±2.42 days. Percentage of antimicrobials prescribed by generic name was 45.8%. Percentage of injectable antibiotic used was 36.4%. Percentage of antimicrobials prescribed from the national essential medicine list was 85.7%. Average encounter with antibiotic was 0.82±0.2. Many of the prescribing indicators deviated from the WHO or SPS/USAID optimal values; and thus, were predictors of irrational antibiotic prescribing. Continuous education and re-training of prescribers in public hospitals in Nasarawa State to comply with approved standards of prescribing should be emphasized in to ensure rational antibiotic use.

scholarly journals How COVID-19 is Affecting Apprentices

BioMedica ◽  
2020 ◽  
Vol 36 (2S) ◽  
pp. 265-269
Author(s):  
Shamaila Hassnain ◽  
Naureen Omar
Keyword(s):  
Survey Design ◽  
Demographic Data ◽  
Sampling Technique ◽  
World Health ◽  
Snowball Sampling ◽  
Physical And Mental Health ◽  
Cross Sectional Survey ◽  
Online Questionnaire ◽  
Cross Sectional ◽  
The World

<p><strong>Background and Objective:</strong> Coronavirus induced disease (COVID-19) is affecting people all around the world. The rising number of deaths due to COVID-19 is not only harassing people but also causing strong emotions in adults as well as in children due to anxiety, fear and stress. The objective of this study was to assess the fears, anxiety and stress due to COVID-19 pandemic and related issues among the apprentices at various levels in different parts of world. <strong>Methods: </strong>It was a cross sectional survey design to assess the students/trainee&rsquo;s immediate psychological response during COVID-19 outbreak by using an anonymous online questionnaire. A snowball sampling technique was conducted focusing general public all around the world from 3rd April 2020 till 7th April 2020. A total of N=354 participants filled the form completely. The structured questionnaire collected information on demographic data and psychological aspect of this outbreak, including extreme fear and uncertainty. <strong>Results:</strong> A total of N = 354 participants completed the questionnaire; majority were from the age group of 21&ndash;30 years. Approximately 66.4% were females and 33.6% males. Participants from Asia were 83.6% while 9.9%, 3.4%, 2.8% and 1% from America/Canada, Europe, Africa and Australia respectively. Out of n = 354 participants 59.3% were relying on health professionals for authentic source of information regarding COVID-19 while 16.4%, 15% and 5.4% considered social media, television and World Health Organization (WHO) website respectively as their authentic guide. Out of the (n = 354) participants 80.5% were afraid about health status during COVID-19 most predominantly females (66.3%) (P = 0.000). A total of 65.8% participants felt agitated or irritated in this outbreak. <strong>Conclusion:</strong> COVID-19 lockdowns are affecting both physical and mental health of students and apprentices enrolled at different levels of education. Females are more affected and concerned to their loved ones and themselves. Working norms are being maintained and responsibilities are being fulfilled despite this grave situation.</p>

A Study of the Effects of Facility and Service Provision on Physical Activity among Students and Staff at MCAST

2019 ◽  
Vol 3 (2) ◽  
pp. 38-60
Author(s):  
Renzo Kerr Cumbo ◽  
Matthew Muscat Inglott ◽  
Dorianne Caruana Bonnici
Keyword(s):  
Physical Activity ◽  
Survey Design ◽  
Action Plan ◽  
Compulsory Education ◽  
World Health ◽  
Global Risk ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Detailed Model ◽  
International Trends

Physical Inactivity is considered a key global risk factor for non-communicable diseases and premature mortality. In its 2017 global action plan, the World Health Organization (WHO) committed to reducing inactivity by 10% by 2025, representing a call-to-action for researchers worldwide to further explore physical activity (PA) trends in applied real world contexts. While research in Malta has revealed some valuable insights about PA among children and youths in compulsory education settings, less is known about the early adulthood years and the effect of higher education settings on PA habits. A cross-sectional survey design, and mixed methods approach to analysis was therefore developed to investigate PA trends among students and staff at MCAST, in light of various international trends and existing organizational structures at the college, namely, the effects of the provision and organization of facilities and activities on campus. The results show that 44% of students and staff at MCAST achieve WHO recommendations, while controlling for the effects of sports students’ PA levels the rate fell to 31% among the remaining student population, and 36% among staff. The achievement of PA recommendations was generally reflective of international trends in college and university settings, while the data on facility-use and activity-participation among various stratifications of students and staff are presented in the findings as a detailed model for assisting prospective development of more relevant, engaging, and effective PA-related initiatives and policies at MCAST.

scholarly journals The magnitude of prescribing medicines by brand names at Muhimbili National Hospital, Tanzania

2020 ◽  
Vol 4 ◽  
pp. 239920261990014
Author(s):  
Ombeni Kisamo ◽  
Manase Kilonzi ◽  
Wigilya P Mikomangwa ◽  
George M Bwire ◽  
Hamu J Mlyuka ◽  
...  
Keyword(s):  
Treatment Guidelines ◽  
Cross Sectional Study ◽  
Brand Names ◽  
World Health ◽  
P Value ◽  
Muhimbili National Hospital ◽  
Prescribing Practices ◽  
National Hospital ◽  
Chi Square ◽  
Cross Sectional

Background: Tanzania National Treatment Guidelines and National Therapeutic Committee circular of 2012 requires prescribers to prescribe medicines using their generic names as recommended by the World Health Organization. The implementation of the aforementioned recommendations by prescribers is not well documented in our settings. Therefore, this study aimed to explore the compliance on the use of generic names by prescribers at Muhimbili National Hospital. Methods: A descriptive cross-sectional study was conducted at Muhimbili National Hospital from January to May 2019 in both inpatient and outpatient pharmacy units. Data were analyzed using SPSS, version 23. Chi-square test was used to analyze proportions between the different variables of the study. A p-value for significance was <0.05. Results: Of 1001 prescriptions analyzed, 71.6% contained medicines prescribed using brand names. The mean (±standard deviation (SD)) number of medicines per prescription was 2.98 (±1.5). The most frequently prescribed medicines by brand names were a combination of vitamin and mineral supplements (34.4%) followed by antibiotics (26.7%). Medical doctors (25.6%) and medical specialists (21.6%) prescribed ⩾2 medicines using brand names per prescription compared to interns (15.0%) and residents (6.9%) ( p < 0.001). Conclusion: Prescribing medicines using brand names was highly observed in this study. Supplements and antibiotics were among the products that were highly prescribed using their brand names. Qualitative studies to explore reasons for brand name prescribing practices are recommended.

Implementation of additional prescribing authorization among oncology pharmacists in Alberta

2018 ◽  
Vol 25 (3) ◽  
pp. 584-598 ◽  
Author(s):  
Bianca Au ◽  
Deonne Dersch-Mills ◽  
Sunita Ghosh ◽  
Jennifer Jupp ◽  
Carole Chambers ◽  
...  
Keyword(s):  
Ambulatory Care ◽  
Clinical Work ◽  
Median Number ◽  
Prescribing Practices ◽  
Patient Assessment ◽  
Ambulatory Patient ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Self Confidence

Purpose To describe the practice settings and prescribing practices of oncology pharmacists with additional prescribing authorization. Methods A descriptive, cross-sectional survey of all oncology pharmacists in Alberta was conducted using a web-based questionnaire over four weeks between March and April 2016. Pharmacists were identified from the Cancer Services Pharmacy Directory and leadership staff in Alberta Health Services. Descriptive statistics were used to describe the practice setting, prescribing practices, motivators to apply for additional prescribing authorization, and the facilitators and barriers of prescribing. Logistic regression was used to explore factors associated with having additional prescribing authorization. Results The overall response rate was 41% (71 of 175 pharmacists). Oncology pharmacists with additional prescribing authorization made up 38% of respondents. They primarily worked in urban, tertiary cancer centers, and practiced in ambulatory care. The top 3 clinical activities they participated in were medication reconciliation, medication counseling/education, and ambulatory patient assessment. Respondents thought additional prescribing authorization was most useful for ambulatory patient assessment and follow-up. Antiemetics were prescribed the most often. The median number of prescriptions written in an average week of clinical work was 5. Competence, self-confidence, and the potential impact on patient care/perceived impact on work environment were the strongest facilitators of prescribing. The strongest motivators to apply for additional prescribing authorization were relevancy to practice, the potential for increased efficiency, and advancing the profession. Conclusion The current majority of oncology pharmacist prescribing in Alberta occurs in ambulatory care with a large focus on antiemetic prescribing. Pharmacists found additional prescribing authorization most useful for ambulatory patient assessment and follow-up.

scholarly journals Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians

2020 ◽  
Vol 11 ◽  
Author(s):  
Dan Wang ◽  
Chaojie Liu ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Broad Spectrum ◽  
Primary Care Physicians ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Latent Profile Analyses ◽  
Broad Spectrum Antibiotics

Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants.Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO “Watch and Reserve” list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns.Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO “Watch and Reserve” list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers.Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

scholarly journals Opportunities and challenges to improving antibiotic prescribing practices through a One Health approach: results of a comparative survey of doctors, dentists and veterinarians in Australia

BMJ Open ◽  
2018 ◽  
Vol 8 (3) ◽  
pp. e020439 ◽  
Author(s):  
Annie Zhuo ◽  
Maurizio Labbate ◽  
Jacqueline M Norris ◽  
Gwendolyn L Gilbert ◽  
Michael P Ward ◽  
...  
Keyword(s):  
Policy Development ◽  
One Health ◽  
Tertiary Care ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Appropriate Prescribing ◽  
Context Specific

ObjectivesTo explore and compare the knowledge, attitudes and experiences of doctors, dentists and veterinarians (as prescribers) in relation to antibiotic use and antibiotic resistance (AbR), and to consider the implications of these for policy-making that support a One Health approach.DesignA cross-sectional survey conducted online.SettingDoctors, dentists and veterinarians practising in primary, secondary or tertiary care in Australia.Participants547 doctors, 380 dentists and 403 veterinarians completed the survey.Main outcome measuresPrescribers’ knowledge, attitudes and perceptions of AbR, the extent to which a range of factors are perceived as barriers to appropriate prescribing practices, and perceived helpfulness of potential strategies to improve antibiotic prescribing in practice.ResultsThere was substantial agreement across prescriber groups that action on AbR is required by multiple sectors and stakeholders. However, prescribers externalised responsibility to some extent by seeing the roles of others as more important than their own in relation to AbR. There were common and context-specific barriers to optimal prescribing across the prescriber groups. Prescriber groups generally perceived restrictive policies as unhelpful to supporting appropriate prescribing in their practice.ConclusionsThe results have implications for implementing a One Health approach that involves doctors, dentists and veterinarians as key players to tackling the crisis of AbR. The findings are that (1) prescribers understand and are likely receptive to a One Health policy approach to AbR, (2) policy development should be sensitive to barriers that are specific to individual prescriber groups and (3) the development and introduction of interventions that might be perceived as reducing prescriber autonomy will need to be carefully designed and implemented.

scholarly journals Identifying antibiotic prescribing patterns through multi-level latent profile analyses: a cross-sectional survey of primary care physicians in Hubei of China

2020 ◽  
Author(s):  
Dan Wang ◽  
Chaojie Liu ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Broad Spectrum ◽  
Primary Care Physicians ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Latent Profile Analyses ◽  
Broad Spectrum Antibiotics

Abstract Background Overuse of antibiotics significantly fuels the development of AMR, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n=501,072) made by the participants from 1 January to 31 March 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO “Watch and Reserve” list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results On average, each primary care physician issued 909 (ranging from 100 to 11941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD=17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD=15.83%) contained broad-spectrum antibiotics; 71.92% (SD=21.42%) contained parenteral administered antibiotics; 23.52% (SD=19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD=20.98%) contained antibiotics listed in the WHO “Watch and Reserve” list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.

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