The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor. The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor. Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes.We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria , 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings.Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium.The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor. A general taxation scheme would be most desirable, but this is not feasible in several low- and middle-income countries because people are poor and many work in the informal sector, making revenue collection difficult.Some poor countries have chosen community health insurance schemes as a way of providing access to basic health care for those in rural communities and the informal sector.,Community-based health insurance (CBHI) schemes refer to voluntary, nonprofit health insurance schemes organized and managed at the community level. While CBHI schemes vary in design and implementation, all are based on the principle of risk pooling and involve regular payments of a small premium in exchange for reducing direct payments at the point of service.,,CBHI schemes share 3 common characteristics: they include (1) not-for-profit prepayment plans, (2) community control, and (3) voluntary membership.Community-based health insurance schemes include not-for-profit prepayment plans, community control, and voluntary membership.,The focus of this article is on demand for CBHI by the poor. Demand for health insurance is influenced by the benefit consumers expect to derive from health insurance, by the amount they are expected to pay as premium, and by their income. Additionally, demand for health insurance is influenced by consumers' probability of getting sick  and their aversion to risk. Risk-averse consumers are willing to pay higher premiums to avoid the risk of a greater loss.,,,,,,Demand for health insurance is negatively influenced by other factors such as inadequate knowledge or awareness of the existence of a health insurance scheme and how to enroll in the scheme,–Effect of socioeconomic status on willingness to join and pay for CBHIEffect of socioeconomic status on actual enrollment in CBHIEffect of socioeconomic status on use of CBHI by enrolleesEffect of socioeconomic status on drop-out rate from CBHI schemesAlthough CBHI has been shown to be helpful in increasing the use of health services and reducing catastrophic health expenditure,Although there have been previous reviews of health insurance schemes in low- and middle-income countries, to the best of our knowledge this is the first review that is focused on the effect of socioeconomic status on willingness to enroll, actual enrollment, and use of CBHI in low- and middle-income countries.This review focuses on the effect of socioeconomic status on willingness to enroll, actual enrollment, and use of community-based health insurance in low- and middle-income countries.Health Financing for Poor People: Resource Mobilization and Risk Sharing,The authors searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information  for studies on willingness to enroll in CBHI, enrollment in CBHI, use of services by CBHI enrollees, and drop-out from CBHI. We also searched a collection of articles on health financing for the poor published by the World Bank, We conducted the literature search in August 2014 and restricted our search to studies published between 2000 and August 2014 to obtain current information on CBHI. In addition, we restricted our search to articles written in English. Furthermore, we searched the reference list of identified articles for additional resources.After we completed the literature search, we reviewed all the articles based on our predetermined inclusion criteria. The inclusion criteria were that the study must have been conducted in low- and middle-income countries and involved analysis based on socioeconomic status. Varied measurement of socioeconomic status was accepted, including self-reported income, assessment of assets, self-reported expenditures, and community wealth ranking . There was also no restriction on the type of study that was included in the review. The titles and abstracts of articles were first reviewed based on our inclusion criteria. The full text of selected articles that met the inclusion criteria were then reviewed in full.We developed a data extraction sheet, and one author extracted the data from the included studies while the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. Data were extracted from the included studies on: (1) characteristics of the study ; and (2) the findings of the study. The findings of the studies in the different subsections were analyzed to identify their similarities and differences and to identify any methodological differences that could have accounted for contradictory findings.A total of 49 articles were included in the review. Our initial search of the relevant databases and other sources yielded 755 articles. After removing duplicates, 722 articles remained. Of these, 645 articles were excluded after screening the titles and abstracts because they did not meet our inclusion criteria. The full text of the remaining 77 articles were evaluated in more detail, of which 34 were excluded because they did not include analysis based on socioeconomic status. The remaining 43 articles were included in the review, as were an additional 6 articles that were identified in the reference lists of the 43 included articles .49 articles were included in this review.The studies that were finally selected for review used a range of study designs, including pre- and post-test with control, pre- and post-test without control, post-test with control, post-test without control, and cross-sectional community-based pre-intervention surveys. The selected studies were conducted in Africa ; Asia ; and South America (Ecuador).–There were mixed results on the effect of socioeconomic status on willingness to join a CBHI program . SeveralSeveral studies found that socioeconomic status was positively associated with willingness to pay for community-based health insurance.,However, studies in NigeriaA study in rural Ecuador did not find any association between wealth and willingness to join a CBHI program, although those who were less educated were more willing to join.–––The amount that individuals and families are willing to pay as premium appears to be directly related to the socioeconomic status of the individuals/families. Studies from Burkina Faso,The premium amount that individuals and families were willing to pay appears to be directly related to their socioeconomic status.,,–In Nigeria,Conversely, the poor are willing to pay a higher proportion of their income as premium. In India, those in the lowest income quintile were willing to pay 1.8% of their income as premium compared with 0.84% for those in the highest income quintile.In-depth interviews conducted in India,,Furthermore, studies in Nigeria showed that the rural poor would be more willing to enroll in a CBHI scheme if they were given the option of paying their premiums using commodities. In a study in southwest Nigeria, respondents in rural areas were willing to pay 2.6 times more if they were to pay in-kind, rather than with cash. Conversely, respondents in urban areas were willing to pay 0.8 times less if they were to pay in-kind instead of cash. It is important to note that 61% of the rural respondents were in the lowest 2 wealth quintiles.Studies in Nigeria and Tanzania showed that the rich are willing to pay a higher premium to cross-subsidize the poor. In a study in southeast Nigeria, 53% of the respondents were willing to contribute money to cross-subsidize the poor, with 75% of those in the richest quartile willing to cross-subsidize the poor.Some studies have shown that the rich are willing to pay a higher premium to cross-subsidize the poor.,In summary, studies on socioeconomic status and willingness to join a CBHI scheme suggest that in the absence of factors that might negatively affect demand for insurance ,,,,In most studies, actual enrollment in CBHI was directly associated with socioeconomic status , meaningIn most studies, actual enrollment in community-based health insurance was directly associated with socioeconomic status.P < .001).However, a study in Rwanda in 2000 did not show any relationship between socioeconomic status and enrollment into the CBHI scheme.–,Our review also showed that as premium decreased the number of poor people who enrolled in a CBHI scheme increased. This shows that enrollment is price-elastic for the poor. Some households that could not afford the CBHI's initial high premium were able to enroll when the premium was lowered. Studies in Burkina Faso showed that providing subsidies increased enrollment for the poorAs premium decreased, the number of poor people who enrolled in community-based health insurance increased.Studies in China showed that co-pays may be a disincentive for poor households to join CBHI schemes. An analysis of 4-year panel data on a voluntary CBHI scheme in rural China  showed that the low-income group was less likely to join the subsidized CBHI scheme than the middle- and high-income groups. One of the reasons that was given for this was that the co-pays might be too high for some poor people who then choose not to join.Co-pays may be a disincentive for poor households to join community-based health insurance schemes.To summarize, in the absence of factors that might negatively influence enrollment into CBHI, the rich are more likely to enroll into CBHI than the poor. In addition, CBHI enrollment is price-elastic, and the higher the premium, the smaller the number of people that will enroll in the scheme. Furthermore, we also saw that in Rwanda, supporting the poor to pay premiums removes the relationship between socioeconomic status and actual enrollment in CBHI. Finally, co-pays could negatively affect enrolment in CBHI and use of services even after enrollment.,There were mixed results on the effect of socioeconomic status on use of health care among those enrolled in CBHI . Studies,,A study in Rwanda did not find any difference in health service utilization between rich and poor enrollees.CBHI schemes that reimburse enrollees after paying for services out of pocket seem not to favor the poor. A study of the Self-Employed Women's Association (SEWA) insurance scheme in India, a CBHI scheme whereby members settle their hospital bills out of pocket and are reimbursed by the insurance scheme, suggested that there was an inequitable submission of claims among rural members. The mean socioeconomic status of rural claimants was significantly higher than the mean socioeconomic status of all rural members of the scheme. The poorest 30% of the members accounted for only 20% of the claims. Qualitative data revealed that the poorest in the rural communities might lack the money to pay bills at the time of hospitalization and so will use less of the services. Furthermore, the poor may also not be literate enough to fill the insurance claim form and so do not apply for reimbursement even after being hospitalized.However, in another SEWA survey there was no significant difference in hospitalization among the different wealth quintiles. This could be due to the small sample; there were only 28 admissions among the SEWA respondents in the 1-year recall period.In summary, being insured was found to increase use of services compared with being uninsured. Although there were inconsistent findings on the relationship between socioeconomic status and use of health services among those enrolled in CBHI schemes, some studies showed lower use of services among the poor than the rich, which could be due to co-payments, travel costs, or non-financial barriers to use of services. Additionally, schemes that reimburse enrollees after they pay for services out of pocket seem to decrease use of services by the poor.Some studies showed lower use of services among poor enrollees than rich enrollees, which could be due to co-payments, travel costs, or non-financial barriers to use of services.We noticed a high drop-out rate from CBHI schemes in the studies included in our study . AlthougSimilarly, in a survey of 382 households in Senegal, the overall drop-out rate from the CBHI scheme was 72%. Those who dropped out were poorer than those who did not, although the difference was not statistically significant. The lack of statistical significance could be due to the small sample size.In summary, there is a high drop-out rate from CBHI schemes mainly due to inability or unwillingness to continue paying premiums. This affects all income groups and calls into question the effectiveness of CBHI programs as a means of achieving universal health coverage in low- and middle-income countries.There is a high drop-out rate from community-based health insurance schemes mainly due to inability or unwillingness to continue paying premiums.,As we stated earlier, a general taxation scheme is more desirable for providing comprehensive health insurance coverage for families, but this is not feasible in several low- and middle-income countries because people are poor and many work in the informal sector, which makes revenue collection difficult.Offering flexible payment plansProviding premium subsidies for the poorEliminating co-pays for the poorRemoving or reducing the waiting period after premium paymentAvoiding making patients pay out of pocket for services and getting reimbursed laterThe idea of CBHI schemes in most low- and middle-income countries is to provide improved health care access by the poor who might not be able to purchase private insurance or pay out of pocket for services. That explains why many of the CBHI schemes are located in areas where people are poor or work in the informal sector of the economy. However, for the scheme to be effective in achieving its goal of reaching the poor, several program features must be carefully designed. From our review, the measures in designing a CBHI scheme that would be beneficial to the poor include:,A flexible payment plan or schedule in which the poor can pay in installments would be beneficial to the poor, although this might be administratively more expensive for programs to implement. Giving people the option to pay monthly, quarterly, or semiannually has been shown to help the poor pay their premium.Giving people the option to pay monthly, quarterly, or semiannually has been shown to help the poor pay their health insurance premium.Enrollment into a CBHI scheme is highly price-elastic for the poor, meaning that with highly subsidized premiums, more poor people will enroll in CBHI. The big questions are how to fund the subsidy and how to identify the poor. For nationally supported community health insurance schemes, government might subsidize the poor using money raised from taxes and external donors. A challenge is that not all countries might mobilize the financial resources to subsidize premiums for the poor in the face of other competing priorities. However, countries should prioritize premium subsidies if they want to increase scheme participation by the poor.For small local CBHI schemes where funds are pooled at the community level, it becomes more difficult to raise money to subsidize the poor. Since studies have shown that the rich are willing to cross-subsidize the poor, one way is to have a progressive premium where the rich pay a little extra to cover the premium for very poor families. This is unlike many current CBHI schemes in which everyone pays a flat premium rate irrespective of income. Organizations such as churches, clubs, wealthy individuals in the community, and international donors can also be approached to make donations to subsidize the poor or to take up the premiums of specific very poor families who are willing to be so supported. This proved to be effective in the early stages of the CBHI scheme in Rwanda.–The bigger question, however, is how to identify the poor who will receive the subsidy. Four common ways of identifying the poor include (1) means testing (identifying the poor using self-reported income or expenditure), (2) proxy means testing (classifying socioeconomic status based on ownership of assets and access to services), (3) geographical targeting , and (4) community wealth ranking (community members identify poor households based on their own definitions and perceptions)–In means testing, a questionnaire, such as the Living Standards Measurement Survey (LSMS) developed by the World Bank, is used to collect detailed information on household expenditure and consumption. Means testing is expensive because it involves collecting very detailed data through a household survey. This is in addition to other challenges such as the difficulty of assigning monetary value to food that local farmers harvest from their farms and recall bias for expenditures.–Proximal means testing is being increasingly used to measure household socioeconomic status. Data on ownership of assets and access to services are collected from households, which are then used as proxies to determine household socioeconomic status. Some drawbacks of proximal means testing include cost of survey, inconclusive evidence that assets are good proxies of socioeconomic status, and the possibility of wrongly classifying the poor as not poor.–In geographical targeting, families are classified as rich or poor based on the neighborhood in which they live. For example, families living in urban slums would be classified as poor. It could also involve the use of national survey data such as Demographic and Health Survey data to identify poor communities. However, geographical targeting could lead to the poor who are living in non-poor neighborhoods being excluded from the subsidy while the non-poor living in poor neighborhoods receive the subsidy that they do not need.–In community wealth ranking, the community decides on the criteria that will be used to categorize the poor in the community. Then the community chooses key informants who have lived in the community for a long time and know all the households. The key informants individually categorize the families into different wealth groups. Then all the key informants meet to reach a consensus on the wealth categories of all the families. The advantage of this is that it is a fast and cost-effective way of assessing poverty level in the community. In addition, it is done by the community and because of the community participation, it will be easy for community members to agree to cross-subsidize the poor.One particular method of assessing the poor might not work in all settings. To improve the ability to correctly identify the poor in a cost-effective manner, countries can combine more than one means of identifying the poor, such as first identifying the poor using community wealth ranking or geographical targeting and then using means testing or proximal means testing to screen those identified. It is left to the CBHI schemes to discover the method(s) that will best work for them in the specific locations and circumstances where they operate.To improve the ability to correctly identify the poor cost-effectively, countries can combine more than one means of identifying the poor.,Although co-pays are put in place to prevent excessive use of health care services by those who do not need them , it is detrimental to the poor who really need the health care services but cannot afford the co-pay.In a bid to reduce adverse selection, some CBHI schemes introduce a waiting period  between the payment of premium and coverage by the insurance scheme.,CBHI schemes should consider the use of other methods that have been shown to be effective and are less harmful to the poor in preventing adverse selection. The use of enrollment at the household level where everyone in the household must be enrolled has been shown to be effective in reducing adverse selection.The SEWA insurance scheme in India that reimbursed expenses after payment seemed not to favor the poor as there was an inequitable submission of claims, with the poorest 30% submitting fewer claims than the richer members.Achieving universal health coverage in low- and middle-income countries through CBHI schemes will be a difficult feat. For CBHI schemes to succeed in providing access to health care by the poor, and especially the poorest of the poor, such programs need to provide a subsidized premium for the poor and not to charge a premium at all for the poorest of the poor. In addition, providing flexible premium payment plans will help improve enrollment into CBHI schemes. Furthermore, removal of co-pays  for the poor and removal of the waiting period between payment of premium and coverage by the health insurance scheme are steps that will be very beneficial to the poor. It is important to state that our recommendations are subject to the context of different countries in which the CBHI schemes operate.


This debate neatly illustrates one of the many diagnostic dilemmas with which resource-poor countries struggle. It also illustrates the need for more, and better, evidence about diagnostic questions in these countries.In 2009, a debate started about whether there was enough evidence to change current guidelines, from presumptive malarial treatment of children under 5 years who present with fever, to testing these children before treating them.The ultimate question here may be whether we should test before treatment. The optimum study design would be a randomised controlled trial in which one arm is tested before treatment, and the other arm is treated presumptively. Before such a trial will be granted by ethical committees, health-care workers, the public or the patients, however, more knowledge is needed on the accuracy and reliability of the available malaria tests. Only when the accuracy of these tests is high enough will policy makers, ethical committees, health-care workers and patients put their trust in them. Furthermore, it will be possible to make a sensible decision about which test to use in the trials only when the accuracy of the available tests is known.5The accuracy of a diagnostic test depends on its ability to distinguish people with a target condition from people without the specified condition. A target condition can be either a disease or a specific stage of a disease. Accuracy is expressed often as sensitivity , and specificity . Other measures to express accuracy include the predictive values, likelihood ratios, area under receiver operating characteristic curve, and diagnostic odds ratios. In a study evaluating the accuracy of a test, the results of the test under evaluation are compared to the results of a reference standard. A reference standard is the best available test or method to diagnose a target condition accurately.6 It constitutes the highest level of scientific evidence.8 A systematic review may, or may not, include a meta-analysis, which is a statistical method of summarising the results of primary studies into a single and precise estimate.6 The benefits of systematic reviews are substantial. Firstly, they help to summarise a large volume of information into a form that can be read easily and can be used to make decisions. Secondly, systematic reviews establish whether scientific findings are consistent and can be generalised across populations and settings, or whether findings vary significantly according to subgroups. In addition, systematic reviews are of use in identifying the risk of bias in primary studies. The rigorous methods used in systematic reviews limit bias and improve the reliability and accuracy of conclusions. As a result they can assist effectively in guideline development and in translating research into practice.10A valid scientific evaluation of the accuracy of tests is required in order to assist health-care providers, researchers, and policy makers in making rational and evidence-based decisions about the use and interpretation of diagnostic tests. A valid scientific evaluation can be carried out by summarising the results of previously published studies systematically. Such a systematic review is a scientific tool that objectively and methodologically identifies, appraises and summarises the existing data from quality primary studies.11 Diagnostic test accuracy reviews are also useful in comparing tests, or combinations of tests, or different diagnostic strategies.12Systematic reviews of diagnostic test accuracy in particular are useful to establish why the accuracy of tests vary. Test accuracy has been shown to vary with factors such as the patient population, spectrum of disease, disease stage, the type of test used, the method of test administration and the expertise of the people who administer the test.13 These variations and inconsistencies constitute a hindrance to decision making and guideline development. In this setting, therefore, systematic reviews of available studies on the accuracy of diagnostic tests will be useful in evaluating inconsistencies objectively, and in identifying sources of bias and variation. More so, in a situation where resources are limited, both an accurate diagnosis and the choices made towards that diagnosis are crucial for the optimal use of those resources. The adoption of quality systematic reviews of diagnostic test accuracy will facilitate rational decisions related to which diagnostic tests resources should be allocated.Effective diagnosis in Africa is impeded by limited financial and human capacity, and poor laboratory infrastructure. Poor laboratory infrastructure includes poor assurance mechanisms or a lack of quality assurance mechanisms, a lack of appropriate laboratory reagents and equipment, and logistical challenges in specimen collection, storage and transportation. These factors may lead to numerous variations or inconsistencies in diagnostic results; therefore, even when laboratory services are available, health workers perceive them as unhelpful and unreliable.14 Access to scientific literature is hampered further by slow Internet connections that make it difficult to download articles.15 Concerted efforts are therefore required to promote the use of scientific literature and to build Internet capacity. In its bid to enhance the quality of laboratory practice in Africa, the newly established African Society for Laboratory Medicine can help to advocate for the use of high standard diagnostic test accuracy reviews to guide evidence-based diagnostic practice.16Unfortunately, the capacity to prepare systematic reviews in developing countries is limited by a shortage of skills and a lack of access to scientific literature because of insufficient finances to pay for subscriptions to medical journals.17 Although it is committed to global participation in the use of systematic reviews, the Cochrane Collaboration is still dominated by authors and articles from developed nations. The evidence from Cochrane reviews, therefore, may not be applicable to developing countries, which have the largest burden of disease.18Currently, the most prominent organisation that is actively promoting the preparation and use of systematic reviews is the Cochrane Collaboration.19In order to address this challenge, the Cochrane Collaboration has embarked on initiatives to promote participation from developing countries actively. These include building capacity of local authors through the provision of training opportunities, fellowships and by forming partnerships with local institutions. For instance, the Reviews for Africa Programme (RAP) trains and mentors African health researchers to prepare Cochrane reviews. RAP is a partnership between the South African Cochrane Centre and the Liverpool School of Tropical Medicine. This programme focuses on systematic reviews on diseases that are applicable to Africa, such as HIV and AIDS, malaria and tuberculosis.20The Collaboration for Evidence Based Health Care in Africa (CEBHA) was formed recently to further promote evidence-based practice in Africa. This organisation is the result of collaboration between international and local African researchers, with its main aim being the facilitation of knowledge and the implementation of evidence-based health care in Africa. One of its pillars is the support of African scientists to develop systematic reviews through training and mentorship. It is currently focusing on eastern African countries and plans to expand to other African countries in the future.21Additionally, in order to enable scientists from developing countries to gain access to scientific literature, the World Health Organization (WHO), in collaboration with major publishers, set up the Health Internetwork Access to Research Initiative (HINARI). This programme offers free or low cost access to medical journals for eligible developing countries. This enhanced access to literature can enable African researchers to prepare systematic reviews.22Even though Internet connectivity in Africa is still limited, it has witnessed a marked improvement in penetration and speed. Latest estimates report an increase of 2633% in Internet users between 2000 and 2011. Broadband initiatives have also been put in place to increase bandwidth, with the latest being the availability of fibre-optic cables in certain African countries. As Internet access and speed continue to improve, access to scientific literature will improve as well.In a nutshell, systematic reviews, when prepared rigorously, objectively summarise the findings from available studies and provide a strong source of evidence. In order to promote the use of diagnostic test accuracy reviews in Africa, the African Society for Laboratory Medicine can help to promote the use of high standard diagnostic test accuracy reviews to guide evidence-based diagnostic practice. Secondly, the importance of these reviews ought to be disseminated to African researchers through workshops, and their capacity needs to be built through training and mentorship. These can be performed in partnership with the Cochrane Collaboration, CEBHA, or other researchers well versed in developing these reviews. Finally, the use of the HINARI programme that was set up to enable researchers from developing countries to access scientific literature should be encouraged.


The present study was to investigate the status of the family relationshipsof elderly patients with Alzheimer’s disease from a caregiver’sperspective.A total of sixteen relatives/caregivers of AD patients were assessed byapplying a semi-structured questionnaire about family relationships.Frequency tables containing categorical variables  were compiled. Descriptivestatistics were calculated of continuous variables such as age. Answers toopen questions were submitted to Bardin’s content analysis. The data wereheld on the Epidata program and statistical analysis was performed using theSPSS v.17.0 software package.In line with the literature, the family was the main source of caregivers andthe typical caregiver profile was female. In contrast to other studies,emotional burnout was not a major complaint in the sample studied. The tiescreated among family members and the life experience of each individualinfluences how interviewees cope with AD.The family relationships of caregivers of AD patients represent a constantchallenge, due to changes in roles within the family structure as well as todisease progression. However, participation in psychological andsocio-educational activities run by pioneering institutions in Brazil, actas a mediator of stress in the lives of both caregivers and patients. These organs were notnecessarily concerned with everyday or generational reproduction as a specific orexclusive function, at times playing primarily political and economic roles.The family is not a natural occurrence but a cultural achievement, being deep-rooted in ahistory of creation and transformation.1conceived family as a tight network of personal ties which provide a sense of belongingand group with limits, ideals, rules and modes of communication which may or may notdifferentiate interindividual human relationships. To this day, the family unitconstitutes the main source of support at times of need.2It is important to clarify that family is not exclusively a single and inflexible nucleusof a psychological, sociological and anthropological nature, as decades-old theorieshave described. Falcão2On this note, studies involving caregivers are relatively recent in the literature.Studies on caregivers of psychiatric patients first emerged in the 1960s, followed bystudies on caregivers of frail elderly, and in the 1980s and 1990s by research oncaregivers of demented elderly, including patients with Alzheimer’s disease.3 a lesser proportion (10%) require help to perform basictasks such as taking a bath, getting dressed, using the restroom, feeding oneself, orgetting in and out of chairs and beds. These data reflect concerns of more 6 millionindividuals and families, and the one and a half million highly dependent elderly inBrazil, based on information from the 2001 National Household Sampling Survey(PNAD).4Studies have revealed that around 40% of individuals aged 65 years or older need somekind of assistance with at least one task, such as shopping, handling finances,preparing meals or doing the cleaning. According to Karsh,5 According toLeitão and Almeida,6 thecaregiver is an individual who assumes responsibility for caring, provides support, orassists in a need of the cared person, in an effort to improve their health.Nascimento7 defined a caregiveras an individual who provides care to cater for temporary or permanent functionaldisability. Another question that is the focus of debate relates to the factorsdesignating the caregiver type needed by each dependent elder, and to attempts toclassify caregivers into informal, formal, primary or secondary categories.3 According to Sommerhalder,8 formal caregivers encompass allprofessionals and institutions that render care in the capacity of service providers,whereas informal caregivers include family members, friends, neighbors, fellow churchmembers, etc. With regard to the distinction between primary and secondary caregivers,the frequency of care and degree of involvement are determinants, whereby primarycaregivers are considered those who have full or greater responsibility for careprovided in the home, while secondary caregivers perform activities consideredsupplementary to those of the primary caregiver.9However, the concept of “caregiver” remains the subject of intense debate, with noconsensus having been reached over its definition, interfering in studies on the act ofcaregiving.3 four factors areconsidered in designating those who take on the personal care of a debilitated elderlyperson: kinship (spouses), gender (predominantly women), physical proximity (livetogether), and affective proximity . The gerontologicalliterature shows that, in the vast majority of Western countries, the care-related tasksare generally attributed to women. Since women are more long-lived than men, andgenerally younger than their husbands, the preferential family caregiver is the wife. Inthe absence of a wife, the second generation descendents tend to take on the task ofcaregiving.10According to Karsch,11Besides, generational, gender and kinship factors influencing the attribution of the taskof caregiving, other aspects such as living under the same roof, having the financialmeans and time available, are common determinants of eligibility as caregiver. Inaddition, affective ties, the caregiver’s personality, past relationship with theelderly person, the reason and ability to donate, also affect availability ascaregiver.12Nevertheless, it should be noted that although having a caregiver who is a relative maybe important, this is not relevant for all elderly since many older adults have nofamily. On the other hand, some elderly come from very poor families whose members areunable to give up their jobs to take on the role of caregiver. Such situations canexacerbate morbidity.12In view of the peculiarities of Alzheimer’s disease, the caregiver performs a key rolesince they are involved in virtually all aspects of care, taking on a progressivelyincreasing number of responsibilities. In other words, as the disease progresses, thepatient needs ever more help to carry out instrumental activities of everyday life, suchas managing finances and medicines. At more advanced stages of disease, caregivers areneeded to provide assistance with more basic activities of daily living, such aspersonal hygiene, bathing and feeding. Caregivers dedicate, on average, 60 hours perweek to performing this task, making the role of caregiver a contributory factor toburnout.In this scenario, the importance of the work by multiprofessional team in maintaining thequality of life of both the elderly and their family becomes evident. The aim of thepresent study was to ascertain the status of the family relationships of patients withAlzheimer’s disease and other dementias, and to verify the meaning of theserelationships from the standpoint of formal and familial caregivers.A study with a qualitative, exploratory, and descriptive design was performedwhich sought to investigate the experiences of the family members that care forelderly relatives with Alzheimer’s disease. The study sample included formal andinformal caregivers who frequented support programs for family and caregivers ofpatients with Alzheimer’s disease. Participants had taken part inpsychoeducational interventions run in June 2009 by support institutions fordementia patients, including individuals with Alzheimer’s disease.14The present study was performed at two support institutions for elderly withAlzheimer’s disease and their relatives and/or caregivers: the BrazilianAssociation of Alzheimer’s or Similar Diseases (ABRAz); and the Geriatric DayCare Hospital Program - Psychiatry Institute - Hospital das Clínicas. Thelatter runs a program called the Rehabilitation Center and Geriatric Day CareHospital at the Institute of Psychiatry (IPq) of the Hospital dasClínicas (USP School of Medicine - HCFMUSP) which selects patients overthe age of 60 in the initial phase of Alzheimer’s disease, who are undergoingtreatment with medicines. Patients selected took part in a program offeringcognitive and functional stimulation activities, in conjunction withpharmacological treatment.13This program also offers two activities aimed at formal and informal caregivers,namely, “Psychoeducational Intervention Group for Caregivers of Elderly withAlzheimer’s Disease” and the “Psychogerontologic and Socioeducational Care Groupfor family members and caregivers”, both of which aim to orient individualsinvolved in caregiving on the process and demands related to the disease. Theprograms provide a forum in which participants can share experiences. Each groupmeets on a weekly basis, where activities are run over a series of 30sessions.Prior to conducting the interviews, all participants were given an Informed andFree Consent Term. This was followed by a letter of presentation about theinterviewers. After participants had formally given their consent, the interviewwas conducted by applying a semi-structured questionnaire containing both openand closed questions to family members and caregivers.After selecting the institutions, initial contact was made with theadministrators of each unit. The interviews were carried out after (or before)the performing of socio- and psycho-educational activities, under thecoordination of psychologists and with participation of Gerontologyundergraduate interns.Frequency tables of categorical variables  were built to provide a profile of the sample. Descriptivestatistics were calculated  of continuous variable such asage. The data were held on the Epidata program and statistical analysis wasperformed using the SPSS v.17.0 software package.16 Based on this theory, content analysis aims toobtain a description of the content of the messages and indicators, which may ormay not by quantitative, to enable the inference of knowledge regarding theproduction and reception of these messages.Bardin’s analysis theory was employed to perform content analysis ofparticipants’ responses to the open questions.Thus, content analysis is generally done by frequency deduction or analysis bythematic category. Frequency deduction entails performing a count of theoccurrences of the same linguistic sign (word) which frequently repeat, andnumeric descriptions and statistical analysis based on it. Analysis by thematiccategory on the other hand, is based on judging the codifier, which identifiesmeanings and characterizes them into one of the equivalent classes.Content analysis involves three steps:[1] pre-analysis, which entails organizing the contentcollected by means of floating reading, hypotheses, objectives anddevising of indicators on which to base interpretation;[2] exploitation of the content, in which the data arecodified from registration units; and16[3] treatment of results and interpretation, in whichcategorization takes place, entailing classification of elementsaccording to similarity and by differentiation, with subsequentregrouping in the event of common characteristics.The majority of caregivers had been caring for the elderly patient since the onset oftheir disease. However, some children reported having always taken care of theirparents by helping on money matters for instance. It was evident that, overall, themembers of the family are the first to be contacted to help in caring for the elder.Indeed, the family predominates as an option in the informal support system forelderly  and 2.Of the caregivers of AD patients interviewed, 31% reported they were caring for theelder satisfactorily, while 25% stated they were fatigued. Results also showed thatfrom the perspective of caregivers and family members of elderly with Alzheimer’sdisease, the main role of the family is as caregiver. Most of the caregiversinterviewed reported they had some kind of formal or informal support. The mostfrequent response was that the family was the provider of the majority of thesupport (50% frequency). Changes in the relationship between caregivers or familymembers and elderly following the onset of Alzheimer’s disease, were noted  and 6.17 while 16%present with some degree of cognitive and/or functional decline.18 These studies indicate thatcognitive decline, as well chronic diseases, represent an important public healthissue, in virtue of the dependence and family burden they cause.Brazilian epidemiological studies report that approximately 7% of elderly meetcriteria for dementia,19Spouses were most often the caregivers, given the marriage bond. The social norms ofcaring for the elderly show that the wife tends to head the hierarchy, followed bythe eldest daughter, and then widowed or single daughters. On this point, studieshave shown that male caregivers are the exception since it is the man who is thebreadwinner and the moral head of the family.20Against this background, the present study sought to ascertain the status of familyrelationships of elderly dementia patients. The study findings corroborated data inthe literature indicating that women are the predominant caregivers for the elderly.This constitutes a secular female duty. Women are more long-lived and generallyyounger than their husbands.21 hasreported that, in most cases, the caregiver of the elderly in Spain are married,older adults, and both lend assistance in caring for the elder. Moreover, the factthat these caregivers are not in paid employment, the absence of care support andthe substitution of their role as caregiver by other family members, rarely takesplace.However, studies confirm that in fact, the caregiver is often the person mostavailable and best prepared. The choice of caregiver tends to be based ongenerational, gender and kinship factors as well as living under the same roof,having the financial means and time available, and emotional attachment, congruentwith the findings of the present study. In this context, the Spanish Society ofGeriatrics and Gerontology22reveals not a main caregiver figure, but rather a network of caregivers . The family dynamic shiftsover the course of the disease, such that the roles of the provider, decision-makingand power are taken over by other members of the family. Alzheimer’s disease affectsthe whole family nucleus and not only the dementia patient. The disease leads to afamily restructure and, as the disease progresses, greater care isrequired.23 Familieschange the modus operandi in order to reorganize, by rotating thetasks of caring for instance. At this point, early conflicts resurface and there maybe resistance to assuming the roles, which in turn affects the quality of life ofthe elder as well as that of their family members.1However, the study by Santos23 affirmed that is was common for society to holdthe family responsible for providing care to the elderly who have become dependentsin some way. This stance on elderly and their family members often boils down to aquestion of culture, since most societies consider intergenerational interaction asthe mainstay of their culture. According to Lima and Marques,24 80% to 90% of care is provided byfamily members of the elderly, and ranges from nursing and medical care, andpersonal services, to help in carrying out activities of daily living.Based on the results of the present study, it is clear that from the perspective ofcaregivers and family members of elderly with Alzheimer’s disease, the main role ofthe family is as caregiver. Similarly, Fonseca and Soares24 believe that family relationships are stronglyunderpinned by emotions and feelings, such as affection, love, union,responsibilities and moral and ethical duties.Another point considered equally important in the present study was categorized asunion, being cited by 5 respondents. Lima and Marques25 have reported that informalcaregivers see more positive aspects in the task of caregiving. The cited studyinvolving caregivers of dementia patients in Canada showed that companionship,fulfillment, satisfaction, providing quality of life, and having a purpose or aim inlife, were feelings that stood out in relation to the burden of caregiving. Thesepositive aspects are experienced when the caregiver perceives that the task ofcaring is being fulfilled and the elder recognizes the assistance they are beinggiven. However, tension, stress, compromised physical state, psychologicaldisorders, helplessness and financial difficulties may also affectcaregivers.8Corroborated by our findings, studies such as that by Cohen et al.27 highlighted thatthe family was deemed the most important source of support to the elderly, sincethey assisted both financially and in the provision of care in the event ofillness.Interviewees in the present study also reported that the family was important incaring for AD patients. Lima and Marques26 affirmed that the familial caregiver who assumesresponsibility for the elder in terms of emotional and cognitive impairments alsotakes responsibility for their protection and maintenance.Comfort and security were also cited by the participants in the present study,suggesting that the presence of the family provides both comfort and a sense ofsecurity for family members and elders alike. Neri27 family members and caregivers appreciate that the role ofthe family, besides providing care, is to give the patient a sense of well-being.Caring for an individual with AD can be a challenging task, calling for patience,dedication and above all, assistance in the form of task-sharing amongst familymembers, as well as with a team of multi-professionals. This is necessary becausepatients need full-time care, generating physical and emotional fatigue among thosewho are directly involved with the patient. Support networks for caregivers areneeded, especially in the social and health areas, such as guidance on homecare ofelders, technical support linked to the health area which carers can turn to in theevent of doubts and follow-up, all of which are often unavailable.22 Perracini and Neri28 carried out studies showing that,for middle-aged women and elders caring for dependent elderly, the existence of asocial support network was essential for maintaining psychological and physicalwell-being.Of those interviewed, only one cited that the role of the family is Acceptance andPatience, whereas according to the ABRAz,Patient interventions are aimed at maintaining the abilities which are stillpreserved in the individual, in a bid to achieve the optimal functional statepossible at each stage of the illness, reducing the decline inherent to the disease.The treatment of AD entails the use of pharmacological agents and multi- andinter-professional psychosocial and educational interventions aimed at reducing theimpact of the problems arising from the disease on the lives of patients, caregiversand their families.29 theindividuals giving care are most often the relatives who live in the same abode (80%of cases), followed by the children who do not live with the patient (around 49%).Shifts in support over to other relatives and non-relatives are less frequent, aphenomenon exemplified in the present study by a priest acting as caregiver for anAD patient.According to SAAD,15 Families are becoming increasingly nuclear, with asubstantial shift in roles played by family members, who find it increasinglydifficult to meet healthcare needs, potentially contributing to greatervulnerability among more severely debilitated elderly.19Studies in the literature indicate that many caregivers and/or relatives receive nohelp or support from other members of the family, which could be explained bydemographic changes or structural changes in families. However, some studies pointto an urgent need for reform in geriatric healthcare services.In summary, the aim of this study was to investigate the relationships betweenfamily/caregiver and AD patients through institutions providing support programs forfamily members/caregivers. The results point to the fact that the majority ofcaregivers are informal (children and spouses). Most of those interviewed weremarried. The family is the main nucleus providing care and serving as a supportnetwork. A broad spectrum of sentiments was expressed by caregivers, such as givingback, fatigue, feeling good about the act of caregiving, concern, unhappiness andresponsibility. The findings of the present study proved similar to data reported inthe literature.29Although the main aim of this study was not to assess the effectiveness of thepsychoeducational program for caregivers and dementia patients, reports by theparticipants showed that frequenting the interventions of the institutions changedthe way some felt as providers of daily care to the patients. On this point, data inthe literature suggest that psychoeducational interventions may provide extensivetherapeutic benefits, leading to a substantial improvement in the subjectivewell-being and outlooks on life of individuals with dementia syndromes as well ascaregivers and family members. Encouraging participants to make decisions, to reduceemotional overload and improve activities of caregiving to the elderly, contributesto a more amenable family atmosphere and to greater quality of care for patients andcaregiver alike.To conclude, the present study contributes to the gerontological literature byproviding new insights on the family relationships of formal and informal caregiversof patients with Alzheimer’s disease who take part in psychoeducationalactivities.However, the study has several limitations including the fact that pre and posttesting assessments could have been conducted in order to verify the impact of thepsychoeducational interventions on biopsychosocial aspects of participants.Secondly, the use of a control group would also have been beneficial to betterdescribe the impact of psychoeducational interventions on the care provided to thedementia patients.Future longitudinal studies should be conducted in order to associate length of timeparticipating in socioeducational programs and perceived quality of familyrelationships. Also, further studies could compare sociodemographics before andafter evolution of the disease in order to determine which factors in the life ofthe caregiver are most impacted. This would yield valuable information to enablepublic policies and more interventions to be implemented in the community.


This study aimed to identify the knowledge, skills and attitudes of Brazilian hospital pharmacists in the use of information technology and electronic tools to support clinical practice. Methods: A questionnaire was sent by email to clinical pharmacists working public and private hospitals in Brazil. The instrument was validated using the method of Polit and Beck to determine the content validity index. Data (n = 348) were analyzed using descriptive statistics, Pearson's Chi-square test and Gamma correlation tests. Results: Pharmacists had 1–4 electronic devices for personal use, mainly smartphones  and laptops . At work, pharmacists had access to a computer , mostly connected to the internet . They felt competent (very capable/capable) searching for a web page/web site on a specific subject , downloading files , using spreadsheets , searching using MeSH terms in PubMed  and general searching for articles in bibliographic databases . Pharmacists did not feel competent in using statistical analysis software . Most pharmacists reported that they had not received formal education to perform most of these actions except searching using MeSH terms. Access to bibliographic databases was available in Brazilian hospitals, however, most pharmacists  reported daily use of a non-specific search engine such as Google. This result may reflect the lack of formal knowledge and training in the use of bibliographic databases and difficulty with the English language. The need to expand knowledge about information search tools was recognized by most pharmacists in clinical practice in Brazil, especially those with less time dedicated exclusively to clinical activity . Conclusion: These results will assist in defining minimal competencies for the training of pharmacists in the field of information technology to support clinical practice. Knowledge and skill gaps are evident in the use of bibliographic databases, spreadsheets and statistical tools. The use of information technology and automation to support pharmacy practice dates from the 1970s . From 19In Brazil, the national curricular guidelines for undergraduate pharmacy education, published in 2002, define the principles, fundamentals, conditions and procedures for the training of pharmacists in this country. These curricular guidelines present the need to master the use of information technology to exercise competency in health care decision making, communication, leadership, management, and continuing education . In our In Brazil, the practice of clinical pharmacy is increasingly dependent on appropriate knowledge and practical skills in the use of information technology. The use of these tools facilitates professional communication, including the use of electronic medical records and the maintenance of accurate medication profiles. They are also used for pharmacotherapeutic follow-up, requesting and documenting laboratory and diagnostic tests and for the reporting of adverse drug reactions. The use of information technology is recognized as an essential requirement for the development of clinical pharmacy in Brazil .Information technology is also an essential element in the education of health professionals , 8 and iThe objective of this study was to determine the profile of Brazilian hospital pharmacists active in clinical practice with respect to basic skills in the use of information technology and electronic tools that support clinical practice. This would help to identify opportunities for professional development in this area to respond to the increasing use of information technology in Brazilian hospitals.This is an exploratory study conducted in Brazil, with clinical pharmacists, who work in public and private hospitals (n = 1373).The minimum sample size was calculated on the basis of the First Brazilian Census of Hospital Pharmacy, carried out by the Federal Pharmacy Council that indicates the number of hospital pharmacists in Brazil . ConsideA questionnaire totaling 26 questions was developed in Portuguese, with open and closed questions . The queThe questionnaire used in the present study was previously validated by a committee  composedThe specialists were invited to evaluate the relevance of each question and the clarity of the content of each item , 18, 19.For the validation of the questionnaire, we determined the index of content validity (CVI). This measures the proportion or percentage of evaluators who are in agreement on certain aspects of the instrument, and of its items for each question as well as for the questionnaire as a whole . Polit and Beck recommend a CVI of 0.9 of higher; questions with a CVI of less than 0.9 were adjusted and re-evaluated for incorporation into to the final questionnaire . The detThe study was approved by the Ethics in Research Committee, Federal University of Ceará, CAAE: 44308815.7.0000.5054The subjects of this survey were recruited from Brazilian hospital pharmacists that work in clinical tasks (n = 1373) and were registered by the Regional Pharmacy Boards of Brazil and members of the Brazilian Society of Hospital Pharmacy and Health Services-SBRAFH. The questionnaire, presented on the Google docs platform (Attachment 1), was sent by e-mail to participants. Each pharmacist provided informed consent and filled the questionnaire without intervention of the researcher. The response was linked to a Google account, allowing only one response per participant. The respondent’s email address was not recorded on the response form but was used to disallow a second response. Data collection occurred from July 27 to September 27, 2015.https://farmaceuticoclinico.com.br/, by a link that presented the research objective, the composition of the questionnaire, and reinforced the importance of the participation of invited pharmacists in the study.The research was widely disseminated in groups of clinical pharmacists on Facebook and on the website The administration of the questionnaire was carried out after validation. Responses were recorded by all pharmacists who provided consent and who also indicated involvement in clinical activities in hospital pharmacy. Responses were excluded from the study if the respondent indicated that he/she did not have clinical duties or was involved in clinical activities exclusively in non-hospital units. The exclusions (n = 9) did not alter the original estimate of required sample size.Data were analyzed using descriptive statistics. Pearson's Chi-square test was used for categorical variables and the Gamma correlation test was used to analyze the probability distribution. In this article we present the analysis of the results of questions 1–8; 10–13 and 15–17 from the questionnaire. The results obtained in the other questions will be presented later in other publications.The questionnaire was filled by 357 hospital pharmacists. After analysis of the responses, nine questionnaires were excluded from the study because the respondent indicated that they did not have clinical duties or was involved in clinical activities exclusively in non-hospital units . In thisResponses were obtained from all states of Brazil and the Federal District. The profile of participants is presented in Table 1With respect to the number of hours dedicated exclusively to clinical pharmacy practice in a hospital environment, the results did not show statistically significant differences between public and private hospitals (Chi-square test: p = 0.417), between hospitals in the capital (the main city of a state) and in interior (the cities that are not the main city) (Chi-square test: p = 0.286), or between the Northeast, Southeast and South regions (Chi-square test: p = 0.079). However, a positive association was found between the number of beds in the health care establishment and increased time dedicated by pharmacists exclusively to clinical pharmacy (gamma correlation test: p = 0.032).Pharmacists had at least one and at most four electronic devices (mobile or desktop) for personal use . These were laptops , smartphones , desktop computers  and tablets . In the workplace 89.4% (n = 311) had a computer and in most cases with access to the internet , facilitating access to information. Most pharmacists  believed that having access to the internet helped in clinical practice. Most respondents used a computer mainly to search for clinical information , exchange information by e-mail or intranet , and to control and dispense medicines .When questioned about time spent per week using devices connected to the internet , 59.5% (n = 207) reported being connected for longer than 11h per week and the preferred internet browser was Google Chrome . There was no significant difference in time of access to the internet between sexes (Chi-square test: p = 0.081), between age groups of the pharmacists (gamma correlation test: p = 0.726), and between respondents from the Northeast, Southeast and Southern regions of Brazil (Chi-square test: p = 0.078).With respect to basic skills in the use of the internet and software  most of In relation to skills in the use of spreadsheets, the percentage of pharmacists who considered themselves “very capable” was less than that of “capable,” possibly reflecting lack of formal education in the subject, reported by 55.2% (n = 192) of the pharmacists. The use of spreadsheets is common among Brazilian pharmacists, especially in hospitals with a low degree of computerization, and knowledge about them is important to allow appropriate use.Knowledge of the use of statistical analysis tools (examples: Epi Info and SPSS) can assist the pharmacist in analyzing data generated in clinical practice. In this regard, most pharmacists responded as being “somewhat capable” or “incapable” in the use of this software. This was probably due low rates of formal education in this discipline  . ConversIn searching for information, Google, Micromedex, Up to Date and Medscape were the most frequently used resources accessed daily. PubMed, BVS/Bireme, Google Scholar were also accessed regularly. MD Consult and Scopus were used rarely or never used by pharmacists to support clinical practice and were also associated the lowest levels of self-reported skill. The highest level of skill was reported with Google, Google Scholar and Micromedex. .Most of the hospital pharmacists (73.8% (n = 257) reported having access to UpToDate, MD Consult or others to search for evidence to support clinical practice, however, they used daily Google as their main search tool .Finally, 63.2% (n = 220) of pharmacists with clinical duties believed that they needed to expand their knowledge of the use of evidence search tools to improve their work. This need is perceived to be greater by the pharmacists that have less time in clinical practice  .By conducting this survey we found that hospital pharmacists with clinical tasks had several electronic devices for personal use, mainly smartphones and laptop computers and were connected to the internet for more than 11 hours per week. At work, most pharmacists also had access to a computer connected to the internet.Pharmacists believed that access to the internet facilitates access to information and assists in clinical practice. They also felt competent in performing basic activities in the use of the internet, such as searching for a web page, downloading files, using spreadsheets, searching using MeSH terms and searching for articles in databases, even though most reported not having received formal education for such activities. Regarding the use of statistical analysis software (Epi Info and SPSS), most pharmacists declared that they felt "not capable" or "incapable" of using them, and that they had not received formal instruction to do so. SPSS and Epi Info are the tools more frequently cited by Brazilian hospital pharmacists in articles published in the Brazilian Society of Hospital Pharmacy and Health Services-SBRAFH journal.Access to databases (such as MD Consult and UpToDate) was available to most pharmacists participating in the survey; however, most reported much greater use of Google, a non-specific search engine. Most hospital pharmacists in clinical practice in Brazil recognized the need to expand their knowledge about information search tools to improve performance in clinical tasks, especially those with less time dedicated exclusively to clinical activity.This study demonstrated that Brazilian hospital pharmacists performing clinical activities regularly access the internet and use electronic tools to support their clinical practice. However, the full potential for use of these tools is not being realized due to significant knowledge gaps and lack of training on this subject in the undergraduate program and during professional education , 21, 22.The Brazilian Society of Hospital Pharmacy and Health Services-SBRAFH, states in its minimum standards a recommendation that hospital pharmacists “should participate in activities overseeing the use of information technologies and should use evidence-based information in their practice” . HoweverIn this study, the obtained response rate was similar to the expected for electronic questionnaires (25 to 26%) , and ourThe use of Google as the main information search tool was also observed in a study conducted in among pharmacists in Greece  and in sWe also believe that in our study, similar to observations from the study of Greek pharmacists , that thOur study had limitations that could have influenced some of the results. The index of content validity used is subjective and this evaluation could have been supplemented by application of other psychometric measures. Also, the fact that the questionnaire was made available electronically and by means of Google Docs could have produced bias in selection, favoring professionals who use the internet more widely and those who have Google e-mail.To our knowledge, this is the first Brazilian investigation of the use of information technology and electronic tools to support the clinical practice of pharmacists. Therefore, we anticipate that these results will be used to justify training programs to address current gaps in knowledge and skills in the use of IT, software and evidence-based databases. This in turn should lead to improvement in clinical practice.For the future, it is strategic to investigate how the pharmacist is being trained to make the use of the information generated (big data); to obtain health information from everyday objects (internet of things) and to improve communication. In this sense, other research should be conducted in Brazil.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(XLSX)Click here for additional data file.