In the app stores of mobile platforms, consumers are confronted with an enormous number of mobile apps. Over the past few years, considerable research has been undertaken into to identifying, characterizing, and evaluating apps, be it in health-related or other contexts. However, many of these projects are restricted to specific areas of application and offer little flexibility in adapting the applied criteria.This paper presents an adaptable method for selecting and characterizing mobile apps listed in a mobile App Store (the Apple App Store). The method is based on filtering processes using predefined criteria, through a semiautomated retrospective App Store analysis (SARASA).To illustrate the SARASA process, keyword-based filtering and metadata-based description, review, and ranking steps were applied to a dataset, more specifically, an April 2018 readout of the Medical category of the German App Store, with the aim of obtaining a list of cardiology-related apps.From the original list of 39,427 apps within the “Medical” category of the App Store on April 14, 2018, 34,382 apps with store descriptions in languages other than German were removed. For the remaining 5045 apps, keywords related to cardiology were applied to filter the output, obtaining a final total of 335 subject-specific apps for further analysis and description.SARASA provides an easy to use method for applying filtering processes to identify apps matching predefined, formal criteria from app stores. The criteria can be well adapted to the needs of users. Automatic and manual analyses are easily combined when using SARASA. In the future, additional features, such as algorithmic topic analyses, may supplement the process. Although the area of application is currently limited to Apple’s App Store, expansion to other stores is planned. The method stands or falls with the transparency of the app store providers and the manufacturers to make relevant meta-information available. It is up to them to liberalize information and restrict censorship to provide clients, customers, and users truly fair circumstances finding their way around the app market. Analyses of software repositories predate modern distribution channels for mobile software -3. In thHowever, there is often only limited information about the methodologies used by those performing the analyses. Scientific approaches try to describe and classify apps based on available information -10. For Respective analyses are based on various data sources and data types. For example, metadata about an app can be retrieved directly from the stores, for example, using query interfaces provided by the store operators themselves or Web crawlers. It may not only consist of somewhat unstructured store descriptions but also structured information used for organization and management purposes in the stores. Often, factors such as user ratings , update This paper presents a method for identifying and describing health apps based on formal criteria. To illustrate the process, we present an evaluation of our proposed semiautomated retrospective App Store analysis (SARASA) ,17 appliSARASA describes a multistep procedure, consisting of automated extraction and analysis and manual review and assessment processes, which are described in further detail in the following paragraphs. An example of a viable application of SARASA, as shown in the following sections, is a descriptive evaluation of cardiology-related, German-language apps in the “Medical” category of the German storefront of the App Store.Fundamentally, the SARASA method consists of 7 steps : (1) firDue to the lack of publicly available, comprehensive, and readily accessible app inventory lists, which also provide full access to metadata, such a list was created for Apple's German App Store on April 14, 2018, using specifically developed, R-based scripts  fine-tuning. In the sample run of SARASA as presented here, the definition of cardiology-related keywords was based on a list of terms commonly used in cardiology and cardiology-related areas, established through consensus of the authors. This initial list was extended and validated by means of an iterative procedure. For this purpose, functions of the R-package “wordVectors”  were useThe initial list of search terms was extended on the basis of the existing app description texts. For this purpose, the descriptions of apps with recognized German texts that matched the initial list of search terms were preprocessed. Formatting and punctuation marks, digits not enclosed in a word or acronym, and filling words such as articles, number words, and pronouns were removed, and particularly, frequently combined terms were combined to form so-called N-grams . The app descriptions prepared in this manner were then used to fine tune the keyword lists. It is only during this process that we chose to also include app descriptions assigned to the “Health & Fitness” category of the App Store.This was done to obtain a more comprehensive set of keywords, for example, cardiology-related search terms more commonly used in an amateur context, which would have been more likely to be listed under the store category “Health & Fitness” and could possibly have been overlooked if we had solely restricted ourselves to apps listed in the “Medical” category. For each search term in the initial keyword list, the words most commonly associated with the respective term were recorded. To compile this list, for each occurrence of a keyword, the 10 words or N-grams in its direct proximity (± 5 words) were appended to a list, which was then ordered by the number of occurrences of each word or word combination. For words with an obvious cardiology reference (established through consensus of the authors), again, a list of the 10 most frequently associated terms was compiled. These final word lists were then manually checked by the authors for their potential to extend the keyword list. However, apart from different spellings , there were no significant changes observed for cardiology-related keywords.For the subsequent automated filtering of all apps with German descriptions, the identified search keywords were then converted into regular expressions (in Perl notation) and optimized see .We chose not to use case sensitivity. For example, the partial term “blut[hoc]*druck” thus matched terms “Bluthochdruck” (high blood pressure) and “Blutdruck” (blood pressure) in the filtering process.For the final analysis, only apps with German-language store descriptions, for which at least one of the predefined, cardiology-related keywords matched, were retained. Furthermore, for these apps, “Medical” had to be set as either as the primary or secondary category (assigned by the manufacturer). All apps not meeting these criteria were excluded from further analysis.a[r]{1,2}hythmie[n]* | atrioventrikularklapp|bikuspidalklapp | blut[hoc]*druck | blutgefä[sß]{1,2} | bradykard|cardiol | defibrillat[orin]* | elektrokardiogra[phien]* | erregungsleitungssyst | extrasystol | herzanalys | herzanf[aä]+ll | herzbeschwerd | herz[druck]*massag | herz[er]*krank | herzfehler | herzfit | herzfrequenz | herzfunktion | herzgesund | herzgeweb | herzinfarkt | herzinsuffizien | herzkamm | herzkatheter | herzklapp | herz[kranz]*gefä[sß]* | herz[-]*kreislauf[-]* | herz[minute-]*volum | herz[-]*monitor | herz[-]*patient | herzprobl | herzras | herzrhythmus | herzschl[aä]+g | herzschrittmach | herzschw[aä]+ch | herzspezialist | herzstiftung | herzstillstand | herztagebuch | herztest | herztod | herztransplantation | herzzyklus | hypertens | hyperton | kardial | kardiol | klappenprolaps | koronar | kreislaufforsch | kreislaufstillstand | kreislaufsystem | mitralklapp | myo[ck]+ard | pulmonalarterie | pulmonalklapp | schlagader | systol | trikuspidalklapp | ventrikel | vorhof | diastol | bekg[s]* | bgefä[sß]{1,2}w* | bw*aort[aen]+w*For each app remaining in the analysis process, the readability index according to Flesch, that is, the Flesch Readability Ease  was not employed in a cardiology-related context but as a part of a term related to other anatomical structures , there were no obvious mismatches to terms not used in cardiology-related contexts. Some apps related to cardiology but intended for use in a veterinary environment could have been excluded, and there were also apps trying to influence their users’ heart rate, for example, by means of meditation or other apps with a rather alternative approach to the subject. For cardiologists applying SARASA to identify apps for their specific professional needs, these apps would of course not be acceptable and would be eliminated. However, in our evaluation, these apps were not removed to create a realistic application scenario that can reproduce a manual keyword-based search within the app store, and we chose instead to differentiate them via the manual categorization process described in the following sections.The remaining apps were then classified manually by the authors, according to function types and subject areas.The 22 function types developed in the CHARISMHA  study , which cThe groups of topics used for classifying the apps with respect to their subject areas were developed in a discussion between the authors. In addition to the function types mentioned in the previous step, which allow for a subdivision independent of the app’s application area, a classification method focusing on the respective subject area and its facets, in this case, cardiology, is of advantage. For the example shown here, the apps were manually assigned to a set of defined topic groups . DisputeIn addition to the aforementioned filtering and review procedures, SARASA also provides a ranking mechanism with the intent to support presorting for manual processing. This mechanism presents apps that best match a manually determined and adaptable set of criteria in an order that displays apps that conform better to certain characteristics more prominently. To this end, predefined (and weighted) ranking criteria are used, relying on attributes either directly deducible from the metadata or calculated by various means.The selection of ranking criteria used in the example evaluation  was chosRanking the apps, in this case, based on a score calculated using the attributes and weighting factors defined in As basis for the descriptive statistics presented here, German-language, cardiology-related apps were selected using the aforementioned processes. Originally, there were 39,427 apps listed within the “Medical” category on April 14, 2018. First, 34,382 apps with store descriptions in languages other than German were removed, and for the remaining 5045 apps, the selected keywords were used to further filter the output, obtaining a final total of 335 apps, related to cardiology, for further analysis see .For an initial overview and comparison, descriptive statistics were first calculated for all 39,427 apps of the “Medical” category as well as for the 5045 apps with German-language store descriptions and the 335 apps with matches for the cardiology keywords .German-language apps, as well as those related to cardiology, were on the market slightly longer on average at 32.58 (interquartile range [IQR] 33.35) and 39.25 months (IQR 48.39), respectively, than all apps in the “Medical” category .German-language apps in the “Medical” category  or with a cardiology reference  were updated more than usual, compared with the “Medical” store category .With regard to the file sizes, cardiological apps seem to be somewhat larger in median  than those without restriction of the field of application . It is conceivable that this is influenced by the contents included for apps in the field of cardiology. For example, a higher proportion of reference works with somewhat larger amounts of texts and multimedia content may exert an influence here.With regard to app pricing, a higher proportion of paid apps  is seen in those related to cardiology than in other medical apps . Although only about every sixth app in the medical category requires a purchase, this is necessary for slightly more than every fourth app in cardiology-related apps with a German store description.It is also noteworthy that apps in the “Medical” category  have shorter description texts overall than those in German  and, in particular, cardiology-related apps . Although German-language texts are generally known for being longer compared with, for example, English-language texts, this does not explain the much greater length of descriptions of cardiology-related apps; it is also in this instance that specific cardiology-related peculiarities are speculated as a potential cause.With regard to the app ratings given by users for the most recent versions available through the store, there were only a small number of apps that had received any ratings at all. That being said, there was a much larger proportion of current ratings for German-language apps  and apps found using the cardiology-related keywords  compared with all apps  listed in the “Medical” category. Looking at the ratings given for all versions of the apps, the percentage of apps rated for all medical apps was 6.55%  compared with 33.32% (1681/5045) for German-language apps and 51.6% (173/335) for those relating to cardiology. Median ratings differ only marginally.The vast majority of the vendors of the 335 selected apps are represented with only a single app in the app selection . This caThe extent to which an app can be used depends, among other things, on the technical requirements it demands from the devices on which it should be run. Devices with iOS 9 or 10 are still represented in relevant figures. According to Apple, the (at the time of this writing) current iOS 11 version was installed on 81% of all devices at the end of May 2018. This does, however, mean that approximately one-fifth of the devices in use were not yet equipped for apps requiring this version. Apps that only require iOS 6 or older versions can hardly be expected to have been updated , based on the automatically derived readability scores, only relatively low educational standards were required for potential users: On the basis of the available description texts for the corresponding apps, a maximum of 10 school years was required to comprehend the texts. However, just over half of the apps  required a high school diploma level, and for about one-fifth of the apps , the results of the text complexity analysis according to Flesch ,28 with. It shousupport (n=22) and data acquisition, processing, and evaluation (n=28). Support apps offer functions that go beyond the mere recording and processing of data and strive to achieve an added value for the user. Of these, apps belonging to the field of complementary medicine (n=24) are noteworthy. For example, although not exactly targeting cardiology in a strict sense, these often try to influence parameters such as heart rate or blood pressure with acupressure or mediation and were therefore also included on the basis of hits when employing the corresponding keywords.With regard to function types , and thus include additional text and multimedia content, exceeds the size of apps that only evaluate and process recorded data  or offer management functions .As expected, the size (in megabytes) of apps that provide information  or help guide users to do exercises, for example coaching apps , when compared with the values otherwise usual in the medical category ; the median ratings differ only marginally in comparison.Similarly, differences between the groups with respect to the distribution of prices within the groups are unremarkable. With the exception of a larger proportion of paid cardiology-related apps —compared with all apps in the medical category  and those with German-language descriptions —there are only minor differences in median prices, which can mainly be explained by some particularly expensive “outliers.”In terms of the 19 manually assigned subject areas, apps that use health data in the broadest sense are the most common . Apps for use in emergencies  and those where blood pressure  or complementary medicine  are also seen frequently. Overall, 13.4% (45/335) of the apps could not be assigned to a specific topic .Observing the median, the sample apps originally appeared 4 to 5 years ago, and apps belonging to the field of complementary medicine had been published approximately 6 to 8 month  before the blood pressure apps , metabolic apps , and ECG apps  contained in the sample.Apps are updated relatively frequently . Exceptions are apps for organizing one’s conference participation or apps that provide information about such events after the conference has taken place.Apps from the ECG domain exhibit noticeable differences in terms of pricing. Almost every second app  is subject to a fee. With a median price of €20.99 (IQR 119.85) and a maximum price of €249.99, these apps are also significantly more expensive when compared with the other thematic areas.With respect to the length of provided store descriptions, apps aimed at laymen and patients, in particular, for example, for complementary medicine , metabolism-related apps , or those to be used in conjunction with medication , tend to have more extensive descriptions (represented by the number of characters) than other cardiology apps .Apps for cardiological issues were rated more frequently than other apps in the “Medical” category  and without additional effort. The manual assignment of function types and topics for descriptive purposes is to be understood as an optional step until it can be carried out automatically. The analysis not only takes into account all available metadata, especially app description texts, but also other attributes such as average user ratings. Although others such as Berardi et al , for exaAt the current stage of development, the approach presented is subject to several limitations, the knowledge of which is essential for assessing the method. These are explained in further details below. Much of future work on SARASA will have to take these aspects into account. In the course of this, additional modules may be included into SARASA.The incorporation of various characteristics into analyses on a larger scale is strongly dependent on the willingness of the respective bodies to be transparent. For example, analyzing app installation archives may require the ability to download and analyze installation archives, without actually installing them on a physical device, but this may not be possible for all mobile platforms. In addition, not all app stores provide the same amount of access to desired attributes, for example, regarding required app permissions and numbers of downloads, the willingness of store providers to be transparent is also somewhat limited. For this reason, the analysis according to the SARASA scheme is currently limited to a single App Store (Apple). In our example evaluation, the German-language storefront was used to obtain the data. Evaluating other regional storefronts might have led to larger numbers of apps for which a more time-consuming manual evaluation would have been necessary. Using the ranking methodology, possibly with further adaptations to the attributes and ranking factors used, may be essential to still keep filtered results manageable, for example, by only evaluating a specific proportion of the top-ranked apps .For stores of other platforms, for example the Play Store provided by Google for Android, an adaptation of the readout and—to a lesser extent—the evaluation routines will be necessary. For example, there is no official interface available for Google's Play Store that would allow full capture of the store or individual categories. In addition, some of the attributes provided in the stores differ between platforms, making it difficult to compare results of the SARASA method when applied to apps on different platforms.The method presented in this study, a complete survey of the desired store categories, demonstrates a substantial reduction in, often criticized, sampling bias  in the eRegardless, the SARASA method is prone to underrepresentation of certain apps if the keywords chosen for selecting the apps do not adequately cover the desired subject. It could be argued that the proposed approach may not guarantee the identification of all suitable apps: For example, although nutritional and many other types of apps may also exert influence on cardiological parameters and thus be relevant in cardiology-related use cases, these will not be returned if their descriptions do not match any of the chosen search terms; adding corresponding terms to our search would, however, have been outside the scope of our presented work, as our aim was not to even identify apps for which the manufacturers had failed to specify a corresponding connection or purpose. In this instance, the limitations are comparable with those of a systematic literature search in review articles. Here, a strategy is used, searching for potentially relevant literature in databases; following the initial search, the results of course need to be evaluated manually. These reviews, however, do not commonly aim at determining whether or not there were potential matches that were missed, and which exactly were these; measures such as sensitivity and specificity, which are indispensable in diagnostic studies, are not common in literature searches, and this also holds true for the SARASA method. We believe that the comprehensiveness of the results for both literature and app searches, as they were described in this paper, can be derived from the comprehensive and easily verifiable search strategy, which includes a transparent specification of the search keywords, inclusion and exclusion criteria, and so on.Selecting apps based on our methodology may also be favorable when compared with solely searching for apps based on search APIs or Web interfaces, as they are services provided by the respective app stores. In Apple’s case, for example, there is currently a maximum of 200 search results  for keyword-based searches when using the provided search API , and it Still, a bias may be introduced when applying the methodology to data acquired from other App Stores in the future. Much will depend on whether readout routines for these stores allow access to all apps in the desired store categories, rather than restricting access to so-called top apps. A complete survey of an entire app store’s content, which could, for example, counteract the aforementioned bias of incorrect category allocation on the part of the manufacturers, will not be expedient simply because of the scope. Here, the platform providers’ desire for transparency also plays a decisive role.When selecting storefronts provided for other (language) regions , a significant variation of the results is to be expected. For example, if English-language apps are included in the evaluation, the number of apps selected increases many times over. As the purpose of the study was purely to illustrate the filtering and classification of apps using SARASA, we decided to confine ourselves to the described restrictions in database acquisition. In the future, the processes for other app stores or linguistic and geographical regions will have to be adapted so that universal statements beyond geographical or language borders can be made. In addition, changing the language or adding additional languages to SARASA-based evaluations will require adjustments that go beyond simply translating the search terms. For example, although the German language is known for the use of, often rather lengthy, compound terms, N-grams will be more relevant in other languages. Aspects such as these must then be taken into account within the search.At present, the assignment to define function types and subject areas was done manually to classify prefiltered apps based on language and keywords. For topics or inquiries that lead to a number of hits that significantly exceed the number demonstrated here, an automation of these assignments would be desirable. In an initial attempt to achieve this by means of keyword-based assignment, only little correlation with the manually defined assignments was observed. This is why the strategy was not pursued further in the context of the work presented here.In spite of advantages, a more efficient procedure, for example, via a machine learning–based assignment, would have initially increased the work required . Nevertheless, it is planned to implement natural language processing (NLP)-based methods  in the future to enable at least a basic assignment. This idea seems particularly promising for the manual definition and assignment of subject areas. These would otherwise have to be redefined and discussed when using SARASA if the selected area of application changes. A topic analysis that would be an automatic definition of certain thematic subareas from the initially filtered apps and the ability to reliably assign the apps to these subareas would be helpful and should therefore be a goal of future developments of SARASA. The extent to which a successful assignment to the function types, known from the study by Albrecht et al , by meanThe ranking is strongly dependent on the analyst-defined values and factors used. Depending on the desired filtering objective or target group, it may make sense to adjust the ranking factors and/or to include the score calculated for the ranking as an additional filter criterion in the SARASA process. This could exclude apps that fall below a minimum score, defined from the outset. For example, Berardi et al  also useThe automated text complexity analysis, outlined only briefly in this paper, is subject to certain limitations as well, especially for nonstandard texts. Only in a few cases do the authors of the description texts follow the conventions commonly used for continuous texts in scientific or journalistic fields. Algorithms for determining text complexity, however, are usually specially standardized for such texts, expecting, among other things, a certain minimum length. Particularly with regard to punctuation and formatting, but also addressing texts that are (too) short in length, peculiarities or deviations are to be noted in app descriptions, which can have a negative influence on the automated analysis. Our analysis tried to eliminate the most common problems relating to punctuation and so on. Nevertheless, it cannot be ruled out that, for example, missing sentence points or formatting characters recognized as punctuation elements may cause the results to be skewed because the (recognized) sentence length  plays an essential role in the calculation of many readability formulas. It is, however, not possible to counteract the widespread problem of texts being too short. In the future, it may therefore make sense to additionally resort to other measures such as lexical diversity  in addition to a pure text complexity analysis, if corresponding statements on text complexity or comprehensibility that can be derived from the texts are to remain part of SARASA.For the future, it is planned to evolve the filtering process. At present, filtering can only be adjusted by parameterization in the R-based scripts. The aim would be to create a shiny frontend , that isSARASA is a method for filtering app store data according to formal criteria and accompanying description of the extract using common statistical measures. The filter results contain a selection of apps that can be passed through subsequent processing steps, which can, for example, following manual review of the list, consist of content-based quality assessments. SARASA allows the implementation of a flexible filter strategy, adaptable to the needs of the user. Automatic and manual analyses are easily combined when using SARASA. In the future, current functions will be supplemented by additional features, such as algorithmic topic analyses or sentiment analyses of user-provided comments . The area of application is currently only limited to Apple's App Store, although expansion to other stores is planned. The method stands or falls with the transparency of app store providers and manufacturers, and their will to make relevant meta-information available. It is up to them to liberalize information and restrict censorship to provide clients, customers, and users truly fair circumstances finding their way around the app market. However, based on the available information, a fully automated selection, assessment, and recommendation of apps is not the aim of the SARASA method: The final decision about whether an app really has desired characteristics can only be made by reviewing and analyzing the metadata provided on the store as well as the apps themselves, which, for the time being, is not feasible without human intervention.


Background: Professional pharmacists should be directly involved in patient healthcare as members of therapeutic teams are not the only dispensers of medication. Public perceptions of the professional role of pharmacists is expressed through patients’ attitudes, trust, and expectations as health and illness consultants, or qualified retailers of medicines. This perception is influenced by numerous determinants, both health-related and social. Objective: This research intends to describe the range of social roles pharmacists play from the perspective of potential pharmacy customers/patients. Methods: The data presented in the article comes from cross-sectional survey-based research, undertaken in 2018, on a representative sample of 600 Polish adults. Results: Over-the-counter medication is purchased by almost all Polish adults, but they do not tend to ask for advice at pharmacies. Most respondents consider a pharmacist to be “a person qualified to sell medicines”, with some of the participants regarding pharmacists as “ordinary retailers”. A small number of respondents are interested in benefiting from pharmaceutical care, but the pharmacy is still perceived to be a point of purchase for medication. Conclusions: Respondents do not treat pharmacists as health advisors and reduce its role to that of dispensing medication. Sociodemographic variables have no significant effect on social perception of pharmacists. Ongoing transformations in the range of roles played by professional pharmacists have a global reach. According to the WHO, pharmacists should not only be dispensers of medication, but also members of a therapeutic team, actively tending to the healthcare needs of patients , who in The benefits of pharmacists taking on more primary healthcare activities can be significant—both in terms of improving patient quality life and increasing financial benefits ,10. UnfoThe perception of the range of roles played by professional pharmacists is influenced by numerous determinants, both health-related and social. In Poland and other Central European countries, an important role is also played by the socioeconomic transformations of the last century. In the period before the Second World War, a pharmacist running a private, usually family-managed, pharmacy served as a local authority and health advisor for many members of the immediate community. In the post-war communist administrations, the nationalization of pharmacies and mechanisms of the socialist economy (in 1951) changed the professional and social circumstances of pharmacists, who became employees of centrally-managed state pharmacies. Their role was limited to the ‘distribution’ and dispensing of medications prescribed by doctors. Losing their decisive role in pharmacy management and doctors’ dominance of the treatment process weakened pharmacists’ aspirations to describe themselves as a professional group, contributing to their occupation’s social devaluation. The re-privatization of pharmacies after Poland’s political transformation in the 1990s again changed the occupation of pharmacist’s conditions and range of responsibilities, allowing pharmacists more professional autonomy and opportunities to re-establish their standing among other medical occupations. A 2018 amendment to Polish pharmaceutical law, stipulating that a pharmacy can only be owned by a pharmacist , led to Another important challenge in Poland is the organization of pharmaceutical care. Since 2008, this has been sanctioned by law as a duty of pharmacists themselves , yet in The objective of the conducted research was to describe how the public perceive pharmacists working at pharmacies, what expectations they have surrounding their skills, and the extent of their professional role. This is particularly interesting within the context of the political changes that have occurred in Central Europe, clearly evidenced by Poland’s example. A particular motivation for undertaking this research was the dearth of academic studies examining public perceptions of the occupation of pharmacist in Poland after the political transformations.The research was carried out on 600 people over 18 years of age. The sample was random, and selection was calculated on the basis of them being representative of the Polish population in the following areas: Sex of respondents ), age of respondents , the number of respondents in a given voivodship calculated on the basis of the population distribution throughout the country , place of residence , level of education .The sample was primarily selected using random-route as a default method  technique), while gaps in the metrical data (collected using the computer-assisted telephone interviewing [CATI] technique) were filled-in using a number generator to draw telephone numbers from a database of active numbers, issued by Polish landline and mobile operators. The maximum acceptable statistical error of measurement was 4% with a confidence interval of 95%.The data comes from cross-sectional survey-based research carried out in 2018, using a mixed-mode survey technique, comprising 84% CAPI (the default technique) and 16% CATI . The questions included in the questionnaire would examine the respondents’ perceptions of the professional role of pharmacists. The study was a part of the wider research project on the perception of medical professions in Poland.The three items that were assessed on a ranking scale examined the frequency with which respondents made over-the-counter (OTC) medication purchases and their willingness to use pharmaceutical care. The respondents were asked how often they bought OTC over-the-counter medication without consulting a doctor . The next question related to consultation with pharmacists before buying OTC (“How often do you consult a pharmacist when buying OTC medication?”) could be responded by using the following scale: Always, often, sometimes, or never. The question about pharmaceutical care  could be responded using the following scale: “Certainly”, “I tend to”, “I tend not to”, “under no circumstances”.The remaining statements were related to the perception of the pharmacist’s occupational and social role. In response to the question “who is a pharmacist working at a pharmacy is to you?”, respondents could indicate one answer from the following: “An ordinary retailer”, “a person qualified to sell medical products”, “a person able to substitute a doctor during the initial stage of treatment”, “a health consultant”, “a business owner trying to increase the pharmacy’s profitability”. Whereas, when answering the question: "What does a contemporary pharmacy primarily mean to you?", respondents could only choose no more than two of the following responses: “a profit-seeking enterprise”, “a place at which patients purchase medicines”, “a place where important decisions about patients’ health are taken”, “a place where doctor-prescribed medicines are prepared”, “a place where patients seek advice about treatment methods”, or “a drugstore/shop that sells other products/merchandise, as well as medicines”.The analysis was carried out using frequency measurements and a percentage of independent variables, as well as the respondent’s answers. The role of independent variables was assigned to sex, age, level of education, place of residence, self-assessment of health and material circumstances.p < 0.05 was adopted as the level of significance. All data attained in the research was analyzed statistically using the IBM SPSS Statistics ver. 25 package .Due to the specificity of the analyzed variables, two non-parametric sets of statistics were used: Spearman’s rank correlation coefficient and the Mann–Whitney U test. A value of There were 51% women and 49% men among the respondents. Respondents up to 29 years of age accounted for 17.7%, those up to 39 years accounted for 21%, those up to 49 years—17% and those up to 59 years—16.3%, while people aged 60 and over constituted 28%. While, 2.2% of respondents described their education as primary or gymnasial, 19.3% described it as basic vocational, 35.4%, as medium-level, 21.8% said it was a higher undergraduate, and 21.3% attained a higher master’s degree level. The vast majority of the respondents lived in cities, in most cases, large or medium-sized cities. The detailed characteristics of the studied group are presented in N = 50) stating they “never buy over-the-counter medication”. A third of respondents do this at least once a month . A similar percentage state they make such purchases several times a year , while 22.3% do this occasionally (once a year or less). Younger people turn to over-the-counter medication much more frequently. A slightly higher prevalence of women buying OTC medicines is observable, but this is not a statistically significant difference  of patients ‘always’ consulted a pharmacist when purchasing OTC medicine, 15% (N = 90) ‘often’ did this, and 56.3% (N = 341) ‘sometimes’ did. A quarter of respondents never sought advice. Women, people from small towns, and those who either have poorer health or are materially disadvantaged are much more likely to consult a pharmacist when buying OTC medication  of respondents stating they would decide to do this. Over half  would be “unlikely” to be interested in such care, while a fourth  would “certainly” not be interested. No correlation was noted between readiness to take advantage of pharmaceutical care and such variables as: Sex, age, education, place of residence, state of health, and material circumstances  of medicines via a pharmacy. This predominant reductionist perception of the occupation limits community pharmacists’ range of responsibilities to dispensing medicine and sometimes provide information about medicinal products. The role of pharmacists is poorly understood, as is clear from the reluctance of most respondents to consult a pharmacist when purchasing medication or take advantage of pharmaceutical care.It is extremely clear from the conducted representative research that Poles are not prepared to entrust a range of issues, related to their own health, to a pharmacist. The pharmacist is much more often perceived as a dispenser/retailer of medicinal products than a health and illness consultant. Interestingly, pharmacists perceive their role similarly. It is clear from the research conducted at Polish pharmacies that pharmacists do not perceive themselves as advisers of health and illness issues. For most pharmacists, administering pharmaceutical care and providing advice about self-medication issues are not what their occupation primarily entails. Instead, their main task is to dispense medicinal products, and provide information and advice related to medicines’ effects ,16.In other countries, where pharmacists’ new roles are developing more dynamically, some patients are not aware or need convincing of these roles, so fail to take the best advantage of the wide range of pharmaceutical services on offer ,18,19. RIn the UK, the community pharmacist’s role, as perceived by the public, ranged from 32% who saw pharmacists as primarily business people, to 26% who considered they were mainly concerned with health, and 42% who saw them as having a commitment to both health and business . AccordiHowever, in some countries, public perceptions of pharmacists’ range of roles are broader. According to Australian research undertaken by E.C. Tan et al., patients in this country recognize the contribution pharmacists make to primary healthcare and express a high level of satisfaction with consultations conducted at pharmacies , althougOur results are limited by cross-sectional methods and it is impossible to establish trends and changes in social attitudes towards pharmacists. We cannot also compare our results with other research because studies of this kind have not yet been conducted in Poland. The comparative analysis is limited because of methodological differences  in other countries make it impossible to directly compare our results with theirs. One of the limitations of the undertaken research was the use of non-standardised research tools, which prevents the comparison of the attained results with the data of other authors. Another problem is that the range of professional roles actually filled by Polish pharmacists, employed at pharmacies, is much narrower than in other countries, making direct comparison impossible.Polish society tends to reduce the role of pharmacists to retailers/dispensers of medicines, and is not interested in pharmaceutical care or treating pharmacists as health consultants. Sociodemographic variables have no significant effect on this perception of the occupation of pharmacist. The research results indicate that the professional community of pharmacists is faced with the substantial challenge of changing their professional image in society: From retailers employed at a ‘drugstore’ to consultants responsible for patients’ health.When designing future studies, it would be advisable to undertake a detailed analysis of the level of acceptance that both Poles and pharmacists express for each component of the expanded professional role of pharmacists employed at pharmacies. It would also appear to be extremely important to study the factors determining the narrow perception of the pharmacist’s role, identified in the current research. Many factors bound up with health provision in Polish society indicate a demand for the pharmacist’s role to be expanded, yet this demand is not expressed by patients or pharmacists. Evaluating the causes of this situation could help to improve patient-pharmacist relations, and result in both the expansion of the role played by pharmacists and improve their image within the community.


In 2016, we wrote an article discussing the relationship between evidenced-based medicine (EBM) and evidence-based policy, informed by the particular evidence supposed to constitute the basis for decision-making , FretheiWe identified and organised the official publications from NOKC to an empirical corpus of typical ‘top-of-the-line’ evidence represented by SRs adhering to EBM standards. From a total of 151 SRs published by the NOKC from 2004 and 2013, a purposive subsample  was examined, addressing their potential as policy decision tools.Supported by theoretical perspectives from rhetoric of health and medicine, we assessed and interpreted the persuasive power of the conclusions mediated by the concepts used, taking terms indicating positions of certainty or reluctance as our point of departure . AnalogoIn 2012, 57,368 studies were screened, identifying 351 that were included for synthesis in 14 SRs. For each SR, the average number of hits was 4098  and on average 25 (range 3–91) studies were included. Caution in various forms was advocated as the major rhetorical pattern in the SR conclusions. Some of the SRs stated that no certain conclusions could be drawn, while others used very cautious terminology in their conclusions, such as ‘probably increases’, ‘possibly increases’, ‘increases perhaps’, ‘may reduce’, ‘uncertain’, or ‘difficult to conclude’. These reservations were apparently reflecting the GRADE rating system […we assessed the persuasive power of the conclusions mediated by the language used, especially with regard to terms indicating positions of certainty or reluctance” [Rhetorical analysis is an interpretative methodology exploring interaction between arguments, actors and policy. Assessment of how a statement may function as an argument can be conducted in different ways, depending on purpose and context. We read Fretheim’s comments as a fundamental disagreement upon paradigms. Highly skilled in statistical meta-analysis, Fretheim dismisses the assumption of subjective judgements and theoretical reflection as essential elements of interpretative research methods. Assessing validity by trying to replicate analysis and expecting identical findings makes no sense, since there is no single correct answer to the questions asked in this kind of studies. This does not mean that the results are casual outcomes of cherry picking, but rather that different preconceptions, theoretical frameworks, background, positioning and methodological approaches have an impact on the interpretations and explain different findings. Referring to Segal , we decluctance” .In Fretheim’s judgement, 4 of the 14 reports included findings without major reservations about uncertainty. Our interpretation – with a different aim, a different method for analysis and a different philosophical foundation – implied that the conclusions of 12 of the reports were characterised by major caution regarding their potential as policy decision tools. We do not argue that Fretheim’s analysis is wrong. In fact, Fretheim’s judgement supports our suggestion that most of the reports advised major caution. The minor discrepancies between our assessments of the reports are easily explained by different interpretation strategies. Given Fretheim’s methodological position, it is no surprise that his understanding of the conceptual validity of the cautious terminology is dissimilar from ours. His institution has been pivotal in the development of the GRADE system, which offers a tool for systematic assessment of the evidence quality and strength of recommendations . Fretheiexcluded” [Although we argued in the article that the SR methodology is better suited for synthesis of medication efficacy studies than for complex public health interventions, we did not assume or claim that any SR about medication efficacy studies would serve as an adequate policy decision tool. Discussing the potential of SRs concerning medication efficacy studies, we believe that Fretheim’s expression “xcluded”  refers tWriting this article, we intended to offer critical reflection upon the tools used for development of evidence. Although our analysis has demonstrated some limitations for SRs, we do not argue that they have no place in policy-making processes in general. However, several of the SRs in our sample dealt with the synthesis of randomised controlled trials from complex and contextually dependent interventions, which are neither easily conducted nor standardised , 7. We aIt is possible to dismiss the contemporary wave of science scepticism without believing that research knowledge is a universal resolution to any problem. The ‘knowledge translation’ metaphor represents the ‘know-do’ gap to be bridged between scientific facts and policy-making as a simple pipeline model , 9, ofte


While the negative effects of housing insecurity on health are well known, the mechanisms and mediators of these effects have been less well studied. The aim of this study is to identify perceived mediators involved in the relationship between housing insecurity and health.We used a participatory action research approach, the Photovoice methodology. It promotes a reflective process where participants critically discuss housing insecurity and human health and make recommendations to find solutions for the issues identified. This study was conducted with 18 members of the Platform for People Affected by Mortgages who were living in a situation of housing insecurity in Barcelona during the first half of 2017.Participants took 990 photographs, of which 147 were printed for analysis in discussion sessions. 109 of these photographs were then selected for categorization by the participants. 11 major categories emerged, representing various factors related to housing insecurity and health. Most categories were acknowledged as possible mediators of the housing/health problem, including: psychological changes; housing-related material aspects; health-related behaviors; eviction; harassment by financial institutions; and family, neighbors and social network. Others were considered as modifiers that could alter the effects of housing insecurity on health. Co-existing determinants may interact with housing insecurity, thereby increasing negative effects on health.Through this participatory approach, the Photovoice project gives insight into the mechanisms underlying the relationship between housing insecurity and human health, and provides valuable recommendations to combat this serious public health issue.The online version of this article (10.1186/s12939-019-0943-0) contains supplementary material, which is available to authorized users. Housing is a key social determinant of health that includes both physical and socioeconomic dimensions –4. This Systematic reviews published in recent years agree that housing unaffordability, foreclosures and the eviction process can have negative consequences for both mental health  and physical health  –12. TherThe Spanish housing market was strongly affected by the ‘subprime’ property crisis in 2007. Due to the increased unemployment, thousands of families were forced to make monthly mortgage and rent payments that they could not afford, leading to a rise in foreclosure, eviction and other types of housing insecurity, such as squatting . BetweenIn response to this crisis, several social organizations have been fighting for housing rights, the most important of which is the Platform for People Affected by Mortgages (PAH). Its objectives are to: stop evictions, obtain reasonable relocation alternatives, and to promote legislative initiatives aimed to increase the social housing stock, ensure basic amenities such as electricity, gas and water, and restore renting to a secure and affordable type of housing tenure , 19. CurWhile the negative effects of housing insecurity on health are well known, the mechanisms and mediators underlying these effects have been less well studied. In general, the published evidence focuses on psychosocial pathways and how feelings of personal failure, guilt, fear and insecurity can lead to psychological distress and poor mental health , 20–22. The aims of this participatory action research are: i) to identify perceived mediators of the relationship between housing insecurity and health among affected groups with the PAH; ii) to promote a reflective process where participants critically discuss housing insecurity and health based on photographs that they have taken; iii) to make recommendations for tackling the pathways identified, and improve the health of people affected by housing insecurity; and iv) to inform policy makers about these recommendations. This paper identifies perceived mediators of the relationship between housing insecurity and health and summarizes the proposed recommendations.This study employs a Participatory Action Research (PAR) approach, which considers community members, researchers and other stakeholders as equals throughout the research and action processes. A community-based knowledge platform is created, with the ultimate aim of improving the lives of the participants , 26. OneThis study was conducted with members from the PAH living in the metropolitan area of Barcelona during the first half of 2017, and who are, or have been, in some of the aforementioned housing insecurity situations.To represent all agents involved, a steering committee was formed at the beginning of the study and consisted of four researchers from the Public Health Agency of Barcelona, two members from PAH, and the project’s photographer. This group led and organized the entire process.Recruitment began two weeks prior to the first meeting with the participants. It took place at the PAH headquarters in Barcelona after a brief presentation of the project to the general PAH assembly. Participants were selected using the snowball technique by PAH members of the steering committee, either at the meetings themselves, or via social media. The inclusion criteria were: > 18 years old; living or having lived under the threat of eviction, illegal occupation or doubling-up; able to operate a camera; and willing to attend a two-hour training session and five 90 min discussion sessions.“Aproximación cualitativa a los mediadores entre la seguridad residencial y sus efectos en salud” (n° 2017/7287/l).All participants gave informed written consent and the study was approved by the Ethics Committee of Parc de Salut Mar, Barcelona, as part of the project named Photovoice activities were conducted between April and July 2017. We set up two groups of 9 participants each: Group 1 consisted of 5 women and 4 men, and Group 2 consisted of 6 women and 3 men. Both groups attended six weekly sessions of approximately two hours at the PAH headquarters in Barcelona. Meeting days and times were decided by each group independently.A total of 9 sessions were conducted, 6 by each group independently and 3 joint sessions. In each session, 2 facilitators from the steering committee explained the aims of the session, encouraged the involvement of every participant and led the discussions. In addition, 2 non-participant observers took field notes to record nonverbal language and key ideas that emerged, as well as the dynamics and functioning of each session. Sessions 2 to 6 were audio recorded and transcribed with the permission of the participants.The first session consisted of training, including: a) an overview of the study ; b) a workshop conducted by a professional photographer to learn how to use the digital cameras given to the participants, as well as basic technical, esthetical and ethical aspects of photography; c) the administration of a brief anonymous survey to gather basic socioeconomic information of the participants; and d) signing of the consent form by each participant. Participants were asked to photograph what they considered to be the mechanisms and pathways that link housing insecurity and health using the following instruction: “photograph the things that have changed in your daily life due to your current residential status, and which are affecting (or might affect) your health or well-being”.Participants brought their photographs to sessions 2 to 5. They chose three to five pictures, which were printed out and discussed. The main purpose of the second session was to reinforce the ideas to be captured by the participants’ photographs, for the photographer to give feedback to participants concerning technical, esthetical and ethical issues, and to start to discuss the photographs. During sessions 3 to 5 the participants discussed and shared their photographs with the group. The SHOWED method was used to guide the discussion, including five questions: What do you see here? What is really happening? How does this relate to our lives? Why does this problem or strength exist? What can we do about it? .In the sixth session the participants brought their final five selected photographs that best reflected the issues each was trying to capture and had already been discussed in previous sessions. Participants then grouped all the selected photographs to establish categories in order to represent different mediators involved in the relationship between housing insecurity and health.Finally, in sessions 7 to 9, participants from the two groups worked together to share and select the final photographs and categories, and proposed recommendations to tackle the identified factors.Data analysis began with the selection, categorization and discussion of the photographs by the participants during the sessions. When both groups finished their meetings, four members of the steering committee  devised an analysis of the themes and content using the transcripts of the sessions. These four members identified and coded themes using the categories proposed by participants as a frame of reference. The participants then convened to compare and discuss differences in the analysis made by the four members of the steering committee and the two groups of participants. Themes were then re-coded and classified, identifying common patterns and convergences and divergences in data through an iterative process of constant comparison. Finally, the proposed categories were refined and enhanced by the other members of the steering committee and the participants of both groups in a devolution session (session 7).In order to ensure data quality, the information was verified using the field notes, the transcripts from each session, and related literature.The socio-demographic characteristics of the participants are shown in Table Psychological changes and negative feelings related to housing problem were one of the most photographed topics. Participants reported that feelings such as shame, guilt, uncertainty, fear and powerlessness, as well as a lack of control of their daily lives, negatively influenced their wellbeing and health. Uncertainty and fear were the most photographed emotions, which both groups depicted in the photograph, “our lives in boxes” Fig. . This ilParticipants captured and emphasised that their health was directly affected by dampness, lack of proper insulation (problems with windows and doors), faulty electrical outlets and connections, and inability to deal with maintenance costs due to lack of savings. Physical health is jeopardized due to the risk of electrocution, allergies, and contracting respiratory diseases and infections. Similarly, the distress and shame of seeing one’s house in bad condition can cause psychological harm. M.E., a 61-year-old man, said: “I have 6 o 7 sockets I cannot touch them because if I touch one I will get electrocuted and then I will be in real trouble”, while F.H., a 57-year-old man, explained: “I’m ashamed to invite someone to my house. I have a “partner”, who lives well and sometimes she tells me “let’s see when I go to your house”, and I say “no, you can not come to my house”, and she does not come to my house, because I am really ashamed.” Fig. . AccordiParticipants observed that unhealthy behaviours have been more common since their housing problems began. The photographs analysed included sedentary behaviour, less self-care , sleeping problems, unhealthy diet and increased consumption of alcohol and sleeping pills.Regarding sedentary behavior R.N., a 34-years-old woman, said: “I love sports. I used to bike a lot, but not anymore [since the housing problem]”]  it’s a way of ... how can I put it? To seek complicity with me (...) and we show it at home, in actions, in any way we can, we get rid of the discomfort, stress, nerves, powerless, everything” Fig. While unemployment and shortage of money are causes, more than mediators, participants agreed that these factors strongly interact with housing insecurity and its effects on health. In all cases, losing a job led to losing the dwelling. Further, the difficulty in finding a new job in a precarious job market makes it harder to have enough resources to overcome housing insecurity, thereby exacerbating the negative consequences on health. As M.L., a 56-year-old woman, added: “I cannot work. I cannot work anymore in my job. So they screwed up my life. Because with my work, I earned money. I had the apartment, I had everything, more or less. But when I could not keep working, what can you do?”. T.V., a 56 year-old man, added: “We cannot make ends meet” Fig. .Fig. 8MaThe association between unemployment and housing insecurity is often a two-way process. People under threat of eviction said that they spend a lot of their daily time in legal and administrative proceedings such as negotiating with financial institutions, attending social service offices, and meeting with lawyers. I.G. said: “You can go so far as to lose your job to fight for a house, like what happened to me. I lost my shop. I was not doing very well but it was me and it showed, and I have lost my way of life because every day for three months I had go to the housing office, court, social services ... daily, in person”.People experiencing housing insecurity often have to choose between paying their rent or mortgage and paying basic amenities . Participants explained that they usually prefer to pay rent before paying for energy, despite saving as much as possible by cutting their energy use prior to making that decision. Therefore a lot of daily provisions, such as heating and food, cannot be afforded, which has negative consequences for their health. As L.B. said: “I do not have air conditioning or heating, so I’m sick of course. It’s cold, and on top of that, I’m sick with bronchitis. This time I’ve been like this for three months in bed, because I’ve had pneumonia, and of course, I can’t, I can’t put on either the heating or the hot water.” In addition, the people affected reported high levels of anxiety due to an imminent cut in their energy supply due to payments arrears. For instance, C.G. mentioned: “I’ve been ‘stuck’ for a long time [using] the plug until I said one day “to hell with it”. I mean, I unplug and that’s it. As I know there is no electricity [standby light], because I unplugged, because I do not have to turn on the TV in the morning to see if they have turned off the electricity or not ... so I’m calmer”. Fig. .Fig. 9TrAll participants agreed that the PAH is the most important protective factor that mitigates the negative effects of housing insecurity on health, by modifying several of the aforementioned mediators, namely preventing eviction, creating new social networks, and empowering people by tackling psychological hardships. Participants reported that people arrive at the PAH emotionally damaged, with feelings of shame, guilt and powerlessness. However once they start to participate, positive changes rapidly occur Fig. a. As T.VAnother characteristic of the PAH that diminishes negative health consequences is that collaborative work gives people motivation to take positive action. As L.B. mentioned: “For me it is great therapy because seeing that I can help that person, it is something that enhances me, that is, I am no longer alone, I no longer feel insignificant, I know I can do something positive, something great, for others as well as for me.” The PAH usually provides people with a new social network and a peer support group where they can be understood and helped. This is relevant considering the impact housing insecurity has on the social fabric, as mentioned above. I.G. said: “I have also found friends, maybe not close lifelong friends, but you can have a great friendship coming to the PAH, because here we do not look at race, colour or social status, here we all come to do the same” Fig. b.Both groups agreed that public services, such as primary health care, social services and housing assistance offices might modulate the negative effects on health. Although this topic was considered a point of contention, as the response and attitude of public service personnel can lessen or increase negative health effects among people with housing insecurity. For instance, public servants sometimes make recipients of their services feel guilty about their situation, undermining their self-esteem and mental health. As F.H. explained: “And you have that person there who is dealing with you, you know that she is in a good position and she is treating you as if you do not want to work, like you are practically a squatter, and then you have to explain to her. Lots and lots of these people who are there, they think that we are “living the life”, but we and the people that I know are not like that.” On the other hand, E.V. stated that a warm reception and empathy by public service workers make participants feel supported and understood, which reduces the stress and bad feelings of their situation: “When I met the social worker, it was a service that gave me life ... that woman [the social worker] to me, has given me life, because she has treated me so excellently right up to today, where this case has taken me.” Fig. .Fig. 11MAlthough the current situation of the housing market in Barcelona was not recognized as a direct mediator between housing insecurity and health, participants agreed in underlining it as a main structural cause of their residential status. They reported that real-estate speculation, massive tourism and gentrification are leading causes of the housing crisis, and are making them feel angry and powerless. They complained about the increased numbers of dwellings for the investment and tourism markets, instead of being allocated for people who are suffering housing unaffordability and exclusion Fig. . As L.B.Participants reported that stressful life events, such as the death of a relative, family break down or chronic disease are closely linked to negative health consequences. These events can act either as triggers of housing insecurity or as interacting factors that worsen that insecurity. For instance, L.C., a 55-year-old-woman, said: “My husband and I work thinking that we would be in this apartment all our lives, but since my husband died I have a problem. So [in this photograph] I’m imagining that I surely have to leave the apartment”. Fig. .Fig. 13“The recommendations proposed by the participants to tackle these factors are available in the supplementary data , which are widely recognized as determinants of poor health outcomes , 33. LibAnother noteworthy finding was the relationship between energy poverty and employment and housing insecurity. Despite not being direct mediators, participants reported that both determinants are closely linked to housing insecurity and can most likely worsen the negative consequences on health. Regarding energy poverty, Cook et al. reported that young children living in households suffering energy poverty are more likely to suffer housing insecurity and fair or poor health, although they did not analyze possible interactions between both determinants . In turnThe response of public services and participation in community-based organizations, such as the PAH, emerged as two important modifiers of the effects of housing insecurity on health. They help alleviate some of the described mediators and pathways of poor health. Social services can improve household income through subsidies, promote social inclusion of affected families, provide legal and administrative solutions to stop evictions and integrate affected people into the social protection system. Primary health care centres may address health-related behaviours and psychological changes using a comprehensive approach. Housing offices can offer social housing, rent subsidies and other measures to assist people under housing insecurity. In contrast, lack of empathy and inadequate responses from public services can worsen the feelings associated with housing insecurity among the recipients, leading to poorer mental health outcomes. In addition, participants agreed that the lack of specific training in housing insecurity phenomenon for public services personnel and problems related to the efficiency of bureaucratic processes  jeopardize a timely response to urgent issues related to material living conditions  which can be another mechanism to poor health. There was unanimous agreement among participants that the PAH was the greatest protective factor. Peer-to-peer support, empowerment and social inclusion were described as the first steps in easing feelings of guilt, embarrassment and personal failure. The PAH carries out several actions to tackle housing insecurity. Evictions can be prevented through nonviolent resistance. Collective repayment negotiations are carried out with banks. Evicted tenants are re-housed, ideally in nearby neighbourhoods. Attempts are made to push for revision of local and national laws to change the unfair conditions of the housing system. In combination, all of these actions modulate most of the described mediating factors, reducing the negatives effects on health . In addiThis study used a Participatory Action Research approach, in which a Photovoice methodology engaged participants and other PAH members who themselves made decisions and validated results from the beginning. This allowed us to obtain reliable information about the pathways to poor health of a hard-to-reach section of the general population. In addition, the study has produced political recommendations for interventions by the PAH, such as advocacy actions with policymakers and other stakeholders


Although pregnancy is the trigger for many women to stop smoking, often they are unable to maintain cessation, undoing any health benefits for themselves and their children. Smoking is a complex phenomenon both before and after pregnancy, influenced by social background, relationships, and the specific experience of pregnancy and delivery. Therefore, it is necessary to clarify the experience and process of changes in women’s smoking status from pregnancy to after delivery. To explore possibilities for better smoking cessation support, the objective of this study was to clarify the changing process of smoking status from pregnancy to after delivery in women for whom pregnancy triggered a smoking cessation. We analyzed data obtained through semi-structured interviews with 31 women, using the grounded theory approach. Women reconsidered their smoking status, either quitting or smoking fewer cigarettes, because of externally motivated changes due to concerns regarding the influence of smoking on pregnancy and children. To prevent smoking relapse, it is important for the women themselves, as well as those around them, to appreciate their cessation, facilitating internal motivation and assessment of the situation. Furthermore, it is important to provide support, by implementing the process revealed in this study, not only during pregnancy but for an entire lifetime. Many studies have reported the harms that smoking among pregnant women can cause to both mother and child. Smoking in pregnant women has been shown to influence not only the fetus, resulting in low birth weight, preterm birth, and stillbirth, but also the occurrence of obesity  and asthIn addition to the influence smoking during pregnancy has on the fetus, the effect of passive smoking on children who are in close contact with women who smoke is not negligible. Studies have shown that passive smoking in children can increase the risk of sudden infant death syndrome, respiratory disease, and arteriosclerotic disease , and thaTherefore, the objective of this study was to clarify the changing process of smoking status from pregnancy to delivery in women for whom pregnancy was the trigger to stop smoking, to help explore smoking cessation support for women.We used the grounded theory approach  to clariThe participants were women whose pregnancies had triggered smoking cessation and who were able to provide narratives about their experience and the process of changing smoking status from pregnancy to after delivery. The inclusion criteria were as follows: (1) aged 20 or older, (2) having been a smoker since before knowing about the pregnancy, (3) having stopped smoking for three months or more continuously, and (4) caring for a child aged three years or younger. In order to recruit a larger number of different participants there was no upper age limit for participants. However, to minimize recall bias, there was an inclusion of criterion (4) participants were caring for a child aged three years or younger. Participants were included regardless of smoking status at the time of the survey. However, we excluded those who had difficulties in (1) participating in the interview owing to psychological or physical problems and (2) responding to questionnaires or responding verbally in Japanese.Recruitment at a pediatric clinic involved distributing handouts, displaying posters, and providing oral explanations of the study at the time of medical consultations. Candidates who were interested in participating in the research contacted the researcher using the supplied recruitment information. We gave detailed information about the research and obtained consent. The participants were all Japanese and recruited from one pediatric private clinic.The data were collected by (1) a multiple-choice and self-administered questionnaire, composed of 15 questions covering participant characteristics such as age and working status, as well as smoking status-related factors including the age of smoking initiation and the number of cigarettes smoked in a day and (2) a semi-structured interview on the changes in smoking status to date and associated situations, feelings, and thoughts. The data were collected from March to July 2018 at the pediatric clinic or the participant’s home.The interview data were analyzed based on the Grounded Theory Approach. Transcripts were generated from the recorded interviews. After reading through the transcripts, the data were segregated and detached from context and then labeled using properties and dimensions. Labels were integrated to extrapolate categories by checking the similarities between labels and agreement between label properties. Then, the relationships between categories were examined. Structures were created by continuously comparing data in the process of analysis to capture the generated relationship between concepts in terms of both properties and dimensions. The data of 31 participants were analyzed by the method described above to understand the whole picture of the changing process of smoking status in women for whom pregnancy triggered smoking cessation.The research protocol was approved by the Institutional Review Board of Tokyo Medical and Dental University, Japan . Prior to conducting the investigation, we informed the participants of the research purpose and procedures and their rights in both verbal and written form. All participants provided written informed consent. We also obtained the participants’ permission to audio record the interviews.During the study period, our study group was supervised by researchers specialized in qualitative research, public health nursing, and psychiatric nursing. Furthermore, the validity of data interpretation and analyses were increased through regular supervision by researchers specialized in the grounded theory approach. In addition, the reliability of data interpretation and analyses were confirmed not only by study participants, but also by nursing and medical professionals with experience in providing support to pregnant women and mothers.This study had 31 participants, whose characteristics have been depicted in objective review of present smoking status, and eight subcategories. The following signs will hereby be used: { } for core category,  for category, “ ” for category property, and  for participants’ narratives.As per the analysis results, within the changing process of women’s smoking status triggered by pregnancy, we identified one core category, Women who started to (reconsider smoking triggered by pregnancy), whether by stimulating pregnancy or knowing about the pregnancy, either (smoked fewer cigarettes) or (initiated smoking cessation), depending on “the degree of recognition of the necessity for smoking cessation during pregnancy” or “the level of commitment toward smoking cessation”. Women who started smoking fewer cigarettes or stopped smoking entirely  through various “measures and approaches for smoking cessation”. When a low “degree of conviction to continue smoking cessation” and a high “level of desire to smoke” coexisted with no “measures and approaches for smoking cessation”, there was the possibility of unfavorable results. Many women, however, engaged in an {objective review of present smoking status} by effectively managing “periods when smoking cessation became difficult” and “factors that could increase the possibility of a smoking relapse”. Women generally tended to easily accept (support for smoking cessation) when the “level of self-evaluation of smoking cessation”, “level of others’ evaluation of smoking cessation”, and “level of recognition of merits of smoking cessation” were high. Women (maintained smoking cessation) when they had (support for smoking cessation) and “reasons to resist smoking relapse”. However, cases where the “level of self-evaluation for smoking cessation”, “level of others’ evaluation for smoking cessation”, and “level of recognition of the merits of smoking cessation” were low and when there was no (support for smoking cessation), women conducted an . (Smoking relapse) occurred when women considered it acceptable to smoke a few cigarettes when they were irritated, choosing to consider smoking a “countermeasure for stress”.• Theme 1: Pregnancy as the trigger to reconsider smoking, leading to reduced cigarette intake or cessationThe “timing of reconsidering smoking” could correspond to various aspects of pregnancy, such as when women started to hope to be pregnant, during infertility treatment, when they knew they were pregnant, and if they had previously experienced a miscarriage. The following were identified as “opportunities that triggered the reconsideration of smoking”: the desire to have children, being aware of pregnancy, pregnancy at a very young or relatively old age, having a friend with a smoking habit who delivered a child with Down syndrome, and having information about the influence of smoking on the fetus from documents obtained from health centers.Women had negative thoughts associated with smoking, such as a sense of guilt and concerns regarding the influence on children, which led to a lack of enjoyment in smoking. They obtained “knowledge about tobacco” using “sources of information” such as the internet, smartphones, TV, magazines, hospitals, and health centers. This increased “the degree of recognition of the necessity for smoking cessation during pregnancy” and “the level of commitment toward smoking cessation”, causing them to (initiate smoking cessation).However, some women chose to (smoke fewer cigarettes) instead of quitting, for reasons such as not being able to give up smoking suddenly and believing that the associated stress is not good for the fetus. We found that the women had various “ways to smoke fewer cigarettes during pregnancy”, such as promising their husbands that they would smoke a limited number of cigarettes and smoking only the ends of their husbands’ cigarettes. Some, however, experienced a (smoking relapse) owing to anxiety regarding delivery and stress related to lifestyle changes caused by pregnancy. A woman who reduced her cigarette intake instead of quitting mentioned the following:In many cases, the “time to initiate smoking cessation” was when women knew they were pregnant. A woman who was a heavy smoker prior to her pregnancy had a low “level of difficulty in quitting smoking” as her “reason for smoking cessation” was concern regarding its influence on her child. In her own words:The “confidence in the ability to quit smoking” was increased by physical reactions to smoking, such as morning sickness, and previous experience of smoking cessation triggered by pregnancy. On the contrary, being a heavy smoker and previous failed smoking cessation attempts decreased the “confidence in the ability to quit smoking”. Women engaged in various “ways to stop smoking”, which included (1) making a firm decision to quit without focusing on specific “ways to stop smoking”, (2) being patient, (3) autosuggestion, (4) making a declaration about quitting, and (5) being fined for smoking. In some cases, the “level of acceptance of smoking cessation” was high as pregnancy was considered a good opportunity for smoking cessation, while some “limited the period of smoking cessation” to the pregnancy or breastfeeding period. A woman who limited the period of smoking cessation to her pregnancy and resumed smoking after the delivery said the following:The “factors aiding smoking cessation” were as follows: (1) the discomfort caused by morning sickness, (2) making a joint effort with the husband to quit smoking, (3) having many friends who stopped smoking during pregnancy, and (4) feeling the movement of the fetus. A woman who used the picture of the fetus obtained during ultrasonography as a smoking cessation tool stated the following:• Theme 2: Objective review of present smoking status after dealing with the desire to smoke[smoking cessation requires a strong will], and there were many cases where they did not have specific “measures and approaches to manage the desire to smoke”.The “level of desire to smoke” in women ranged from none to strong. They took various approaches to deal with the desire, such as not being alone, spending time with non-smoking friends or family, ceasing to buy tobacco, taking deep breaths, eating something when they felt the urge to smoke, looking up the harmful effects of smoking, and making an effort to recall the difficulty associated with smoking cessation. However, as a woman mentioned, It was apparent that the “period when smoking cessation became difficult” was when the women no longer experienced morning sickness, after they had delivered, at the conclusion of breastfeeding, when they returned to work, and when a child entered nursery school. One woman began to experience the desire to smoke immediately after delivery. At “times when the desire to smoke was particularly strong”, such as when they were away from children, when they were drinking alcohol, when they saw their family and friends smoking, and when they were faced with the same situations that would lead them to smoke in the past, they need to . Furthermore, the “reasons increasing the possibility of a smoking relapse” were as follows: being surrounded by smokers, having cigarettes for the family in the house, and having no one to stop them from smoking. One woman told us about how seeing others smoking triggered within her a strong desire to smoke, as follows:Many women dealt with such difficult situations and demonstrated an {objective review of present smoking status}. Women recognized the merits of smoking cessation and performed self-evaluation for smoking cessation by “recognizing the influence of smoking on a child”. When the “level of self-evaluation for smoking cessation” was high, they (1) were satisfied with their present life after smoking cessation, (2) felt that it was good to quit smoking, (3) could be satisfied without smoking, (4) did not need to be conscious of stopping smoking, and (5) recognized the merits of smoking cessation for themselves.Furthermore, women received “others’ evaluation for smoking cessation”. The “evaluators” were people around them, such as children, family, colleagues, and friends, or health care professionals. As part of “others’ evaluation for smoking cessation”, they were told that it was normal for them to stop smoking or that it was great that they stopped smoking, while some women said that they did not receive any evaluations.Furthermore, women had “opportunities to have their smoking status checked”, such as when they were issued the maternal and child health handbook, on home visits by public health nurses, and during workplace health checkups and general medical examinations. Although there are social trends against smoking, such as smoking being banned in the workplace, there is the possibility of the “surrounding environment leading to smoking”, such as living with a smoker or having friends who smoke despite having children.Out of concern, some “surrounding smokers” did not smoke near pregnant women, while others asked them to join them when they smoked. Women sometimes had contradictory “thoughts related to the surrounding smokers”; while the smell of smoke could make them feel envious of smokers and make them desirous of smoking, they could also be bothered by the smoke and by the fact that they could not make others quit smoking. and [Now cigarettes are getting really expensive. My husband dislikes cigarettes].Furthermore, (support for smoking cessation) included “supporters of smoking cessation” such as husbands, children, public health nurses, obstetricians, and gynecologists quitting smoking together; discussion regarding the anxiety related to smoking cessation; receiving support in housework; being taken out for a change of scene; and the people around them, such as their husbands and children, disliking smoking. The type of “people expected to be supporters” included husbands, nurses, and those who watched over them. The “reasons to not want to resume smoking” included recognition of the negative influences of smoking, the hope that their children would not smoke, a lack of enjoyment upon smoking for the first time after delivery, and the possibility of becoming pregnant in the future, leading to (maintained smoking cessation). Women spoke of being cautious of a relapse as follows: While performing an {objective review of present smoking status}, when the “level of self-evaluation for smoking cessation” was low, the conclusion of delivery and breastfeeding lowered women’s resistance to smoking, and its apparent merits exceeded those of cessation. Some considered it acceptable to smoke, while some were caught between guilt and desire.Furthermore, concerns over the influence of passive smoking on children led some women to use heated tobacco products after the delivery, in turn, reducing the sense of guilt over smoking. One woman stated the following:• Theme 3: To evaluate stressful situations, either maintaining smoking cessation or relapsingWhen the “level of self-evaluation for smoking cessation”, “level of others’ evaluation for smoking cessation”, and “level of recognition of the merits of smoking cessation” were low, the women performed .In addition to the stress of smoking cessation itself, the “stressful situations” included (1) the husbands failing to comprehend the difficulty involved in smoking cessation, (2) the husbands continuing to smoke while the women stopped smoking, and (3) the inability to feel refreshed because of the constraints on going out associated with taking care of children. Furthermore, arguments with husbands and older children being in a rebellious phase were also included among the “stressful situations”. When they had no other “countermeasures for stress”, some women took to smoking, or deemed it acceptable to smoke a few cigarettes when they were irritated, leading to (smoking relapse). However, some women coped by using effective “countermeasures for stress”, such as talking to their husbands or mothers, and by having a room in their minds for they do not think too much about smoking cessation. One woman told us her story of (maintaining smoking cessation) despite the difficulty involved, as follows:This study was conducted to clarify the changing process of smoking status from pregnancy to after delivery in women for whom pregnancy triggered smoking cessation. From the results, (1) being vigilant about opportunities where women may reconsider smoking, and providing support for cessation, (2) supporting an objective review of present smoking status and (3) strengthening women’s ability to manage stress in order to support smoking cessation in society are important, when health care professionals support smoking cessation and to prevent smoking relapse from pregnancy to after delivery. We will discuss these three themes and support for women’s smoking cessation, based on the roles of health care professionals who assist women during pregnancy and childcare, as well as the present situation of the Japanese health and medical systems.As shown in previous studies ,10,12,13It has been shown that the motivation for smoking cessation among pregnant women is external, and that they view the changes as being imposed on them . ParticiDuring pregnancy and after delivery, women have various opportunities to interact with health care professionals. It is, therefore, important for these interactions to be used as a platform to provide support for smoking cessation. In Japan, based on the Maternal and Child Health law, women may be asked about their smoking history when they seek guidance during maternal health checkups, as well as during the interviews held at the time of issuing the Maternal and Child Health Handbook. Interviews regarding smoking history are an important first step in the provision of smoking cessation support. “It is said that successful intervention is primarily dependent on the identification of pregnant smokers, and that descriptive questions can eliminate the problem of non-disclosure associated with asking only “Do you smoke?” . FurtherAfter changing their behaviors based on a reconsideration of smoking status, women objectively reviewed their present smoking status by dealing with the desire to smoke. There were various challenges involved in the process of managing the desire to smoke. In many cases, there were no specific countermeasures for the desire to smoke or approaches toward smoking cessation. In such cases, they tried to cope with the increased possibility of smoking and instances when the desire to smoke was the strongest. It would be important to enhance self-evaluation for smoking cessation through encouragement to perform a valid evaluation of the present situation and their self-care ability to deal with the desire to smoke.Furthermore, in addition to self-evaluation, women were concerned about how their smoking and cessation were evaluated by others. They desired affirmation of their smoking cessation, expecting people watching over them to act as supporters. It has been shown that smoking cessation requires high self-efficacy . Thus, iAs in previous studies ,13,14,25Furthermore, it is important for health care professionals to have up-to-date knowledge. Recently, an increasing number of smokers have begun using heated tobacco products or electronic cigarettes, requiring close monitoring of and attention to the emerging tobacco-related market . The useThe word “stress” was mentioned by many of the women who experienced smoking relapses. The stressful situations identified in this study included not only those related to smoking, but also childcare and family relationships. A worsening of depressive and stress symptoms over postpartum was associated with an increased risk of smoking . Women eAs providing smoking cessation support is difficult, health care professionals may feel helpless, faced with situations that may cause them to lose confidence in their ability to provide care. As women have numerous concerns other than their smoking habits throughout pregnancy, delivery, and childcare, smoking cessation support and enhancing women’s own health may not be given the highest priority. It would be optimal for supporters to be empowered to provide smoking cessation support with confidence. For this purpose, it is important for supporters to have information-gathering opportunities, such as workshops and lectures, and it is imperative to create a network of smoking cessation supporters. Furthermore, parental smoking is known to be a significant risk factor for allergies asthma and other lung diseases among children ,32. QuesFurthermore, the population approach to smoking cessation is sometimes insufficient by itself. The difficulty of initiating and maintaining smoking cessation can be related to various individual and social high-risk factors, such as the relationship between smoking and psychiatric disorders, including substance use disorder and attention-deficit/hyperactivity disorder ,34,35, vTherefore, various medical and public health institutions, such as the maternal and child health department, health and welfare department, psychiatric health department, obstetrics and gynecology department, pediatric department, psychiatry department, and smoking cessation clinics, are important resources for the initiation and maintenance of smoking cessation support in women. In order for women to start and continue smoking cessation, collaborative assistance, linking women, family, and supporting institutions, is essential.The data in this study were based on subjective narratives related to women’s memories of smoking-related situations. As the data were self-reported, the possibility of response bias cannot be eliminated. However, based on the objective of identifying the changing process of smoking status from pregnancy to after delivery, we tried to minimize the time since the associated event  by only recruiting female participants caring for children aged three years or younger.Furthermore, we recruited participants who provided consent to participate in our project from one study site. Although we attempted to sample women from diverse demographic, social economic, and family backgrounds, since smoking status and others’ reactions to smoking may be influenced by social and cultural background, the scope of the study could be further extended.Additionally, we did not include women who continued smoking despite pregnancy. It can be expected that such women have a greater dependence on tobacco and experience more difficulty in smoking cessation as compared to our participants. Therefore, similar research in women with a high dependence on tobacco is required.Our study clarified the changing process of women’s smoking cessation triggered by pregnancy. In order to ensure that women do not experience smoking relapses, it is important for them to have an appropriate, objective review of present smoking status, which enhances their internal motivation for smoking cessation. To accomplish this, it is important for health care professionals to (1) provide accurate information based on medical evidence, (2) take a positive approach to women’s cessation efforts and their self-care ability, (3) promote the utilization of social resources by assessing the periods and situations that make smoking cessation difficult, and (4) identify high-risk cases and refer them to specialized institutions.Furthermore, it is important to support smoking cessation not only during pregnancy but for the entire lifespan by making use of the processes identified in this study.