The rising incidence of breast cancer places a financial burden on national health services and economies. The objective of this review is to present a detailed analysis of the research and literature on indirect costs of breast cancer.English literature databases from 2000 to 2020 were searched to find studies related to the objective of the present review. Study selection and data extraction was undertaken independently by two authors. Also, quality assessment was done using a checklist designed by Stunhldreher et al.The current study chose 33 studies that were eligible from a total of 2825 records obtained. The cost of lost productivity due to premature death based on human capital approach ranged from $22,386 to $52 billion. The cost burden from productivity lost due to premature death based on friction cost approach ranged from $1488.61 to $4,518,628.5. The cost burden from productivity lost due to morbidity with the human capital approach was reported as $126,857,360.69 to $596,659,071.28. The cost of lost productivity arising from informal caregivers with the human capital approach was $297,548.46 to $308 billion.Evaluation of the existing evidence revealed the indirect costs of breast cancer in women to be significantly high. This study did a thorough review on the indirect costs associated with breast cancer in women which could serve as a guide to help pick the appropriate method for calculating the indirect costs of breast cancer based on existing methods, approach and data. There is a need for calculations to be standardised since the heterogeneity of results in different domains from various studies makes it impossible for comparisons to be made among different countries. Breast cancer has now surpassed lung cancer as the leading cause of global cancer incidence in 2020, with an estimated 2.3 million new cases, representing 11.7% of all cancer cases . AccordiThe impact of this disease is clear not only in terms of mortality and morbidity but also in terms of economic consequences for all National Health Services (NHSs) and from a social point of view , 6. The Ranganathan et al. suggested that due to the high economic burden of breast cancer in LMICs, the need to improve the management of patients with breast cancer in these countries is of great importance . In thisThe cost of illness is investigated using a variety of methods . From a Factors associated with impaired productivity include adverse effects and treatments, such as progression and exacerbation of disease, cognitive and neurological disorders, poor physical and mental health, chemotherapy, and the time and cost required to receive treatment . In ZhenDespite the simplicity of expressing the components of indirect costs, the proper method of measuring and evaluating the productivity costs of breast cancer can be problematic. There are several methods to measure indirect costs . The mosTherefore, the aim of this study was to systematically review the indirect costs and the monetary value of productivity costs due to breast cancer in women.This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .We included published studies meeting the following criteria: (1) participants were female patients with breast cancer, (2) the outcome measures were related to indirect costs due to breast cancer. Cost of illness studies which included estimates of indirect costs of breast cancer at a municipal level  or within certain organizations  were also taken into account, (3) as for the design, only original articles were considered, and (4) only papers published in English were included in the study. Moreover, economic evaluation studies, reviews, letters, abstracts, conference papers, and general commentary or perspectives were excluded from the study.A systematic search was conducted in six electronic databases including PubMed, EMBASE, Scopus, Web of Science from 2000 until September 30, 2020.Groups of keywords were chosen to search in selected databases without language restriction. Search strings were limited to the title, abstract and keywords. The keywords and scripts were developed using the US National Library of Medicine’s Medical Subject Headings (MeSH) and Emtree from Embase database. A complete search strategy for databases showed in Table The qualitative analysis was carried out by two researchers (SM and NAG) using a checklist designed by Stunhldreher et al. . The resThe list of publications generated from the literature search were entered into EndNote V.X8.1, and subsequent duplicates were removed. For controlling the validity of the study, two researchers (S.M and R.J) independently screened each retrieved record by reviewing the title and abstract. After that, two researchers (S.M and S.S) independently screened the full texts of the selected publications to match the eligibility criteria. The results of this analysis was scrutinized by the third researcher (J.J.N). The researchers reported the characteristics of the included studies, and a summary table of various checklists was completed to inform the assessments of the methodological quality of the cost of illness studies. The following details were extracted for each included study: first author’s name, publication year, reference year for cost, region, sample size, methodology of the study, costing approach, components of indirect costs, and estimated indirect costs. Also, in order to make comparisons among different studies, all costs were converted into US dollars based on the purchasing power parity index in 2020. Moreover, if an article did not mention the year for which the expenses were assumed, the year of publication of the article was considered the basis for the cost adjustment.As a result of searching the target databases, 2825 relevant items were retrieved using the search queries. After discarding 1174 duplicate items, the number of items was reduced to 1651 items. We selected 53 records for full-text screening to reach the eligibility for analysis. finally, 33 articles were included based on the inclusion and exclusion criteria. Figure The quality of the all 33 studies were evaluated based on the cost of illness (COI) tool, and all studies were considered appropriate to be included in the review. More details about quality assessment are reported in Table Study characteristics of included articles shown in Fig. The regional distribution of the studies shows that the research was undertaken involving 185 different countries.Based on World Bank Clasification and country income groups, most of the studies were conducted in high-income countries. As shown in Table While studies have been conducted in different regions, one study was global and investigated all members of WHO countries. In addition, two studies were in European Union and investigated this Union’s countries. Regardless of these three studies, United States (n = 9) and Iran (n = 4) had the majority of studies in indirect costs of breast cancer.The study findings displayed heterogeneity to varying degrees. The studies differed in terms of sample size, methods used, costing approach, study perspective, cost calculation, and data report per patient and per death. However, all studies reported indirect costs and cost productivity costs.Regarding the study sample, the biggest sample size  was related to the study of Wan et al. . And theEstimating the various items of indirect costs among women with breast cancer showed in Table A further evaluation of the retrieved study showed that 17 studies employed the human capital approach (HCA) , 55, 58,The current study found that the HCA was more commonly used to calculate indirect costs. This method derives the monetary value deterred from the productivity costs due to disability or premature death based on a person's wage prior to disability or death. This is considered an easy approach employed by many studies owing to the ease of access to the required data. The drawback of this approach is that it only considers the work that gets paid and does not include costs associated with home care and responsibilities outside the work place, like the case of housewives.We conducted a systematic review of recently published studies on the indirect costs of breast cancer with the goal of identifying those whose methodological similarities would allow us to make comparisons and draw conclusions from the indirect cost burden of the disease . AccordiThe evaluation of the studies showed that most studies have calculated the productivity costs due to premature death, which can be because of easier access to the mortality data, while more data are needed to calculate other costs. The cost burden imposed by the productivity costs from premature death contributes profoundly to indirect costs and decreases productivity/efficiency. This number, as reported, ranges from $22,386 to $52 billion with the HCA and ranges from $1488.61 to $4,518,628.5 with the FCA. Moreover, housewives, too, get diagnosed with breast cancer alongside working women, more often resulting in early death, further contributing to the premature death rate. The cost of informal care, which involves non-monetary assistance provided by those around the cancer patient, was also witnessed to be high. With the HCA, this amount ranged from $297,548.46 to $308 billion. This is because of the fact that basically a cancer patient needs to be supported by family or friends either to be accompanied to the treatment centre or to receive high quality treatment at home. This forces the accompanying person to take time off to serve the patient.The current study found that the HCA was more commonly used to calculate indirect costs. This method calculates the monetary value deterred from the productivity costs due to disability or premature death based on a person's wage prior to disability or death. This is considered an easy approach employed by many studies owing to the ease of access to the required data. The drawback of this approach is that it only considers the work that gets paid and does not include costs associated with home care and responsibilities outside the work place as with the case of housewives.The study noted that five studies used the incidence approach and three studies used the prevalence approach. The incidence approach only examined new disease cases, but the prevalence approach examined both new patients and patients from the previous years. Unfortunately, the heterogeneity of the studies made it impossible to combine the results together to provide a single output in this field. Thus, this necessitates more research in this area. When evaluating indirect costs, the study perspective should be either focused on patients or communities. In addition, the community perspective tends to be the one widely used in the studies.The magnitude of variability can be explained by the finding that different indirect cost elements are evaluated. Moreover, different methodologies for evaluating the same cost elements were used, and country differences can also provide reasoning to some extent . VariousComparing indirect costs between the studies revealed in the systematic review is very difficult because of the possibility of the application of two different methods: the HCA and the FCA . The resDue to the methodological heterogeneity of the studies included in the review, focus was given to the qualitative analysis . Thus, aIt appears that since breast cancer did not cause morbidity to the extent of, the DALY index (the disability-adjusted life year) was not used except in two studies , 58. TheThe great variety of indirect costs resulted from different cost components and macroeconomic indicators that were used for estimation purposes . EconomiWith regards to indirect costs, studies usually considered the average wage or per capita as a representative of lost earnings on working days. However, wage rate in developing countries such as Iran may be lower than optimal/average due to low labour productivity, but this is not expressed in the indirect costs.Methods used to estimate disease costs vary widely across studies in the literature, which is probably due to the lack of consensus on the methodology. Few studies have been carried out around the world with a control group , 50. ConHowever, it should be added that comparing the costs between a group of patients with a disease and others that match in terms of confounding variables lends a better understanding of the cost burden of the disease. A study in Iran showed that the covid-19 pandemic caused an average of 16.44 absenteeism days and cost of $671.4 per patient . It shouA review of the studies showed that the researchers did not focus on foreseeing the indirect costs of this disease, and only one study foresaw the indirect costs of breast cancer . TherefoThe current review provides important evidence of indirect costs associated with breast cancer which enables the economic burden of breast cancer to be predicted. Evaluating and measuring indirect costs give a better grasp of the reasons for the decline in productivity, for instance, informal assistance from those around the patient to the patient, the productivity costs from missed work days, the cost resulting from premature death and the damping cost elicited through the analysis of indirect costs. Women today make up a large portion of the labour force, while still in some communities they are responsible for household chores; hence, more focus on the disease often associated with women could provide more insight on the disease burden and its impact on the economy. While the findings of this study could be used to distinguish indirect and direct costs of breast cancer, it will also be helpful in economic evaluations of different treatment methods for this disease. Furthermore, it is necessary to mention the study approach  to designate the appropriate sample size. Our study found that the indirect costs of breast cancer add highly to the cost burden of the disease. Also, the heterogeneity of various study results does not allow a consensus to be reached; therefore, it is imperative to standardise calculations, and since most of the studies have been conducted in high income countries, policy makers of the healthcare in middle and low income countries must prioritise research of such contexts.We suggest that more studies estimate the indirect costs of breast cancer in low- and middle-income countries as well. Also, our data on the costs related to breast cancer can be used to facilitate more economic evaluations.Unfortunately, the present study did face some limitations. For instance, the heterogeneity of studies—the study population, geographical location, and calculation methods—were all diverse. Our study only reviewed studies that were published in English and excluded studies done in other languages. Studies of grey literature were also not included.


Pregnancy is a special period in a woman’s life when her organism undergoes multiple physiological changes so that the fetus has optimal conditions for growth and development. These include modifications in the composition of the microbiome that occur between the first and third trimesters of pregnancy. There is an increase in Akkermansia, Bifidobacterium, and Firmicutes, which have been associated with an increase in the need for energy storage. The growth in Proteobacteria and Actinobacteria levels has a protective effect on both the mother and the fetus via proinflammatory mechanisms. The aim of the study is to review the research on the relationship between the mother’s intestinal microbiome and gestational pathologies. Changes in the maternal gut microbiome is probably one of the mechanisms that occurs in various pregnancy diseases such as preeclampsia, fetal growth restriction, gestational diabetes mellitus, excessive gestational weight gain, and premature birth. For this reason, it seems vital to pay attention to certain interventions that can benefit the affected patients both in the short term, by preventing complications during pregnancy, and in the long term, as one of the mechanisms occurring in various gestational diseases is dysbiosis of the maternal intestinal flora. Pregnancy is a special time for a woman, when her organism undergoes various physiological changes so that the fetus has optimal conditions for growth and development ,2. TheseThe genome of microbiota is estimated to be 150 times larger than the human one . The micThe intestinal microbiota consists of various types of bacteria, the most numerous of which are Firmicutes and Bacteroidetes, followed by Actinobacteria and Proteobacteria . DiversiIn the first years of a child’s life, the transition of Enterobacteriaceae dominance is observed as an increase in the number of Bacteroidaceae. This indicates the maturation of the intestinal microflora, which may vary depending on the type of delivery and the infant’s diet ,24. The Taking all of this into consideration, the aim of this article is to present associations between the maternal gut microbiome and gestational pathologies.https://www.prisma-statement.org/ (accessed on 2 August 2022)). The databases were checked by two independent authors. The following listings were searched for: (microbiota or microbiome) AND pregnancy; intestinal microflora AND preeclampsia; gut microflora AND fetal growth restriction; intestinal microflora AND gestational diabetes mellitus; intestinal microflora AND obesity; intestinal microflora AND premature birth; gut microflora AND cervical insufficiency. The downloaded articles were first selected based on title and abstracts. As a result, we identified a total of 3125 articles related to the topic of interest. After considering the inclusion/exclusion criteria and eliminating duplicates, 87 studies were selected for analysis.Systematic searches were conducted in June 2022 using electronic databases such as PubMed, Science Direct, and Google Scholar in accordance with PRISMA guidelines  is a common obstetric complication and may also be known as intrauterine growth restriction (IUGR). The factors involved in the pathogenesis of FGR include: infections, maternal age, malnutrition, genetic disorders, and insufficient placenta to supply the fetus with nutrients . MultiplDen Hollander et al. showed a correlation between Helicobacteri pylori and the occurrence of FGR in a group of 6000 pregnant women . Groer eThere is an increasing trend towards the occurrence of GDM worldwide, contributing to an increased risk of obesity, T2DM, and metabolic syndrome ,71,72,73Karamali et al. did not show an increase in the number of Lactobacillales in the second and third trimester of pregnancy in patients with GDM despite supplementation with probiotics . It seemFerrocino et al. revealed an increase in Firmicutes and a reduction in Bacteroidetes and Actinobacteria in pregnant patients with GDM between 24 and 28 weeks of pregnancy in a sequencing study of 16S fecal microbiome amplification . A metagMany researchers compared the composition of the intestinal microflora of pregnant women with GDM and normoglycemic mothers. Pregnant women with GDM were characterized by an increase in the number of microflora of Collinsella, Rothia, Desulfovibrio, Actinobacteria , FirmicuThe molecular mechanisms by which intrauterine exposure to hyperglycemia in mothers with GDM contribute to the development of obesity and diabetes in the future lives of their offspring remain to be elucidated . It is pOverweight and obesity affects the occurrence of metabolic and autoimmune diseases during pregnancy. Considering the fact that two-thirds of pregnant individuals exceed the recommendations for weight gain during pregnancy, excessive weight gain during pregnancy appears to also be a significant obstetric problem. Not only is overweight and obesity associated with complications in the offspring, but excessive weight gain in pregnancy is also, although the mechanisms are still unclear .Studies have shown that most of the gut microflora in overweight people was made up of Bacteroides and Firmicutes . The finThe research of Angelakis et al. showed an increase in the number of Bacteroidetes and Firmicutes types, which includes the Lactobacillus species in obese and overweight people compared to adults with a healthy body weight . In two In a study conducted among 98 pregnant patients, the inverse correlation of Firmicutes to Bacteroidetes was obtained in obese mothers compared to the control group . FurtherObesity in pregnant people correlates with the specific microbial composition of the human intestine ,89,104. Pre-pregnancy overweight and obesity increases the probability of obstetric complications; despite the developed molecular analysis techniques, the pathogenesis of these phenomena is still not clear . It seemCervical failure affects 1% of all pregnancies and 8% of patients with recurrent mid-trimester losses ,118. ManPregnancy can be regarded as a special period in the life of a woman, inducing multiple transformations in various organs and systems, including modifications to the immune system . One of It can be argued that various complications arising during pregnancy may predispose mothers or their offspring to develop lifestyle diseases later in life, including type 2 diabetes, cardiovascular disease, obesity, and metabolic syndrome. Thus, it seems vital to scrutinize certain interventions benefiting the patients not only in the short term—by preventing complications during pregnancy—but also in the long term. A number of diseases such as GDM and preeclampsia can affect the future of the mother and her offspring as they participate in maternal and fetal programming.Further research on the biomarkers of inflammation should be conducted, as they may constitute an important tool for the assessment of pregnancy complications, as well as for the introduction to early prevention of multiple metabolic and immune disorders. We are waiting for the results of research which, by using cutting-edge and costly methods, will bring us closer to discovering the impact of the intestinal microflora on various complications observed during pregnancy.


Hypertension is a leading cause of mortality and morbidity globally. Pharmacists can play a substantial role in decreasing the burden of the disease.The primary aim of this study was to develop and validate a scale assessing the pharmacist role in hypertension management in the community pharmacy setting. The secondary aims were to assess the services/interventions in hypertension management that were performed in the real-life setting, as well as the patient satisfaction from these services/interventions.This cross-sectional study was conducted in Egypt. The data were collected using a survey composed of three sections: a general section, the pharmacist role questionnaire section, and the patient satisfaction from the provided interventions/services section. The pharmacist role questionnaire was developed based on the pharmaceutical care practice conceptual model and included 23 questions. The face validity, content validity, reliability testing using Cronbach alpha, and construct validity using exploratory factor analysis were determined. The percentage of the frequency by which each role was reported to be performed was determined. Patient satisfaction from the provided interventions/services was determined by means of an overall rating. The correlation between practiced roles and patient satisfaction with received interventions/services was determined.The questionnaire was valid with a 4-factor structure and a Cronbach alpha >0.75, reiterating the main pharmaceutical care practice domains: medication management, disease-state education, disease-state management, and care plan monitoring. Roles falling in the domains of disease state management and disease state education were significantly more practiced than roles falling in the other domains.Pharmacist practice in hypertension management in the community setting was inclined towards contemporary roles, such as disease state education and management. Patients seem to be satisfied with these roles.  Cardiovascular diseases are the leading cause of mortality and morbidity worldwide.6In an attempt to reduce hypertension prevalence and improve its treatment and control, evidence-based clinical guidelines were developed. These guidelines focused on setting a holistic approach for hypertension management that encompasses screening strategies, blood pressure target goals, treatment modalities, and lifestyle modifications.9However, despite these guidelines and available therapies, only 1 in 5 hypertensive adults (21%) have their blood pressure adequately controlled, with the lowest control rates observed in developing countries.12–18Uncontrolled hypertension can cause significant complications, such as but not limited to, congestive heart failure, myocardial infarction, angina, left ventricular hypertrophy, arrhythmias, stroke, and kidney failure.8Being the most accessible health care provider, the pharmacist can play a substantial role in the care of patients with chronic diseases and namely hypertension.This is a cross-sectional survey-based descriptive study that was conducted from November 2018 to June 2019, in Alexandria, Egypt.A survey was developed to serve the purpose of this study. It consisted of three sections and was initially developed in the English language and then translated to the Arabic language. The first section of the survey, which is a general section, collected patient data and disease state-related information. It included 11 items varying between open and closed ended questions depending on the nature and the objective of the item. Collected data included age, gender, education level, number of medications taken daily, frequency of visiting the physician for follow-up on hypertension, and duration since diagnosis with hypertension. The second section tackled the pharmacist role in the management of hypertension in the community setting and was developed and validated initially before its administration to the final sample of participants. The last section aimed to assess the patient satisfaction from the pharmacist interventions/services. It included 6 items, rated from 1 to 5 (1 (strongly disagree to 5 (strongly agree)) based on the extent of agreement with the item statement included in this section. The statements were the followings: (1) It is easy to access my pharmacist when I have a question related to my hypertension condition or medications, (2) my pharmacist gives enough time to explain my hypertension condition and medications, (3) my pharmacist provides me with information on my hypertension condition and medications in a way that I can understand, (4) my pharmacist provides me with appropriate support to solve my hypertension-related issues, (5) my pharmacist serves my best interest, (6) I am overall satisfied with the interventions/services provided by my pharmacist.The pharmaceutical care practice model was used as the conceptual framework for the development of the pharmacist role questionnaire. Based on this conceptual framework, four main role domains were identified for the pharmacist. These included medication management, disease state education, disease state management, and care plan monitoring. Preliminary relevant items for each of the four domains were drafted based on the United States pharmacopeia (USP) medication counselling behavior guidelines,The survey was administered in simple Fusha Arabic since it was used in an Arabic speaking community. All questions of the role of the pharmacist questionnaire section were developed initially in English and then translated from English to Arabic and then back translated to English. The forward and backward translation were conducted on two separate stages. First, members of the research group performed the process of forward and backward translation and then the original survey was sent to an independent translation agency for another trial of forward and backward translation. The two versions of the final translated survey were compared, and discrepancies were addressed before its use.Adult individuals aged 18 years old or more, visiting community pharmacies, outpatient hospital clinics, private clinics and public places including social clubs and city malls all over Alexandria were approached randomly by a member of the research team. They were asked whether they have hypertension and were treated with at least one antihypertensive medication for a duration of 1 month or more. If they were so, they were explained the purpose of the study and invited to participate. The recruitment was a multistage procedure. Firstly, lists of pharmacies and clinics were obtained from the pharmacy syndicate. List of malls was obtained from the municipality office. Pharmacies, outpatient hospital clinics, private clinics, social clubs, and city malls were selected from each geographical area by random sampling. Each centre was visited several days in a row during two time periods (morning or evening shifts) for 4–6 hours/ period, until recruiting the target number of patients/center. Selection of the appropriate sample size for validation is controversial, since the ratio of participants to item would range from 5:1 to 30–1 and samples range from 100 to 1000 participants.The pharmacist role questionnaire was distributed among sixty experienced practicing community pharmacists and they were asked if the pharmacist role questionnaire truly assess their role in managing hypertensive patients. Twenty-one experienced pharmacists responded and agreed that all items truly assess their roles and had no major amendment on the questionnaire.For this type of validity, 30 experts in the field of pharmacy practice education and practice were approached and only 10 agreed to participate. The questionnaire was e-mailed to the experts who agreed to participate in this study (academicians (5) and practicing pharmacists . They were contacted by the researchers and asked if the questionnaire covers all aspects of the pharmacist’s role in managing hypertensive patients and whether the included items truly assess the research concept. In addition, their feedback on the coherence of the questionnaire, the order of the questions, the relevance, difficulty, and clarity of the items was collected. Only minor modifications were suggested at this stage. Besides, it was recommended to putting emphasis that the questionnaire is addressing the pharmacist’s and not the pharmacy technician’s role. This was taken into consideration while administering the questionnaire to the patients by verbally emphasizing this to the participants.The survey was pilot tested on a convenience sample of 30 antihypertensive patients who were not included in the final study sample. In the pilot survey, a response box inviting comments regarding the content and structure of the questionnaire was added. Feedback indicated that one item lacked clarity and required rewording.The reliability of the pharmacist role questionnaire and of the overall survey was evaluated using Cronbach alpha, which is a statistical tool to assess the internal consistency of surveys and questionnaires. A Cronbach alpha value of 0.7 or greater was considered an indicator of adequate internal consistency.36Exploratory factor analysis was used to assess the construct validity of the questionnaire and to calculate the factor loading of each component. The exploratory factor analysis determined the numbers of factors appropriate to our questions and categorized the questions according to their coherence to a specific factor. Factor analysis reduced the number of items by grouping the related items and identifying the unrelated items for removal. Principal axis factor method was used, and factors with Eigenvalue’s greater than one were chosen. To facilitate the interpretation of the factor structure, direct oblimin and Varimax rotation were both conducted with the latter being more reasonable since our variables are assumed to be uncorrelated and varimax yielded a simple structure which was easy to intercept. A Kaiser-Meyer Olkin measure and Bartlett’s test for sphericity were conducted to determine if the collected data were suitable for factor analysis. Before running a factor analysis, a correlations matrix of survey items was used to identify and remove highly correlated (>0.90) or weakly correlated (<0.30) items from the analysis. A cut-off value of 0.4 was used for the analysis of the communalities’ loadings.After validation of the pharmacist role questionnaire section, the survey was further used to collect data aiming at assessing the pharmacist role in hypertension management, as well as the patient satisfaction from the provided interventions/services. Collected data were analyzed to derive the percentage of patients who reported to receive the intervention/service at a specific frequency for each questionnaire item. Besides, a score was attributed for each Likert point level as follows: 2 if the intervention/service is performed every time the patient visits the pharmacist, 1 for sometimes, 0 for not sure, −1 for rarely, and −2 for never. The score for each role domain was then calculated by summing up the scores of the items included in this domain. An overall score for the whole pharmacist role questionnaire was also calculated. Based on possible total scores, the overall score was attributed to one of the following 4 quartiles: high score quartile for scores ranging between 23 to 44, average score quartile for scores ranging between 1 and 22, low score quartile for scores ranging between 0 and −22, and very low score quartile for scores ranging between −22 and −44. The percentage of questionnaires having scores falling into each quartile was then determined. Moreover, the overall rating for the patient satisfaction from the received interventions/services section was calculated. This calculation was done by summing up the rating of each item of this section. Finally, the correlation between the overall scores of the pharmacist role questionnaire and the overall patient satisfaction from the pharmacist interventions/services rating was evaluated.The study was reviewed and approved by the Beirut Arab University institutional review board (IRB) with code 2017H-001-P-R-0003 and complies with the declaration of Helsinki. Approval from the participating institutions was also obtained. Furthermore, all participants had to provide a written consent prior to participating in the survey. Moreover, it was clearly stated to hypertensive patients that the participation in the survey is voluntary, that they can withdraw from the study at any point in time, and that collected data will be treated anonymously, with confidentiality, and used to only serve the study purpose.t-test (when comparing two groups) and ANOVA (when comparing more than two groups) with post-hoc analysis. Pearson correlation and regression analysis between the overall scores of the pharmacist role questionnaire and the rating scores of the patient satisfaction from provided interventions/services section was done.IBM SPSS Statistics software version 27 was used for all the statistical analysis. Besides the exploratory factor analysis, data derived from the survey were analyzed using descriptive statistics. Percentages were derived for categorical data and were compared using Kruskal Wallis test. Means with standard deviations were determined for continuous variables  and compared using the Student’s A total of 36 centers were included in this study, distributed as follows: 2 social clubs, 2 city malls, 8 clinics and 24 pharmacies. A total of 650 hypertensive patients were identified, out of which 460 patients accepted to participate in this study. Forty-eight filled surveys were excluded from further analysis because of missed or incomplete data. The first two hundred and fifty surveys were used to validate the role of the pharmacist section of the survey. Patients’ characteristics and disease state information collected from the first section of the survey are presented in The total number of items of the questionnaire was 23 yielding as 11:1 ratio of variables to participants. The Kaiser-Meyer-Olkin (KMO) was 0.913 which is high indicating adequate sample size and the Bartlett’s test of sphericity was <0.001 which is statistically significant. Twenty-two out of 23 items were above 0.4, which is the cut off used in the analysis. An eigenvalue greater than 1 yielded a 4-factor structure with a cumulative variance of 54.8%. These four factors were the four domains of the pharmacist roles ie, medication management, disease-state education, disease-state management and care plan monitoring. Factor loading of items into their respective domains after varimax rotation is presented in The overall scores for the role of pharmacist questionnaire ranged between −44 and 44. As shown in 2 = 0.103 (p < 0.001) between the overall scores of the pharmacist role questionnaire and the patient satisfaction from the pharmacist services overall ratings.This study aimed to develop, validate, and apply a questionnaire that is able to assess the pharmacist role in the management of hypertensive patients in the community setting. The exploratory factor analysis demonstrated that the developed questionnaire has a four-factor structure that reiterated the pharmaceutical care practice model domains namely medication management, disease state education, disease state management, and care plan monitoring. The internal consistency test demonstrated that this questionnaire is a reliable tool for assessing the pharmacist role in hypertension management in the community setting.Results of this study showed that the roles that pharmacists performed in hypertension management fall into the four practice domains of the pharmaceutical care model. However, the overall score assessment of the pharmacist role demonstrated that there are gaps in the performed pharmacist role in hypertension management, since more than half of the questionnaires had scores falling within the low and very low score quartiles. As identified by the score distribution for each domain, these role gaps were present in all domains, but were mainly related to the care plan monitoring and medication management domains. These gaps could generally compromise the pharmacist role in optimizing the patient’s care plan.37Based on the results of this study, the community pharmacists practiced more roles that fell into the domains of disease state management and disease state education. This result suggests that there is a slight drift towards contemporary practice. This may be the result of the advancement of pharmacy education. Indeed, during the past decade, many pharmacy schools in Egypt have revamped their curriculum and introduced clinical pharmacy education courses.39Among the most practiced roles in the disease state management domain, pharmacists were measuring their patients’ blood pressure, telling them their target blood pressure levels, stressing on the importance to continue their therapies despite reaching their BP target levels, and referring them to their physicians when needed. These actions, namely measuring accurately, acting rapidly, and partnering with patients were deemed necessary to improve the patient hypertension control level.As for the roles in the medication management domain, pharmacists tended to give their patients clear instructions on how to administer their medications, make sure that they understand these instructions, check their adherence to their medications, and provide them with tools that would help them to adhere to their medications. Simplifying the dosage regimen for patients was reported as a strategy to improve adherence.55Despite that care plan monitoring is an essential component of the pharmaceutical care process, pharmacists seem to play very trivial roles in this domain. Care plan monitoring is useful for following the patient’s progress towards the achievement of goals of therapy and the desired outcomes and avoidance of potential adverse effects that would affect adherence to drug therapy.61Despite the above mentioned role gaps, patients seem to be satisfied from the interventions/services provided by their pharmacists related to the management of their hypertension, as evidenced by the overall rating of the patient satisfaction section. This result suggests that patients are appreciating the transition of the community pharmacist role from drug focus to pharmaceutical care practice. It supports the fact that the introduction of pharmaceutical care in pharmacies improves patient satisfaction.67This research has several strengths, such as being one of few studies addressing the pharmacist role in the management of chronic diseases in the community setting of a developing country, being multicenter, and having data generated by a validated questionnaire.This study has also several limitations. First, the cross-sectional and quantitative nature of the research impeded the investigation of causalities as well as reasons behind the pharmacist role pitfalls. Second, the patients were not randomly selected; thus results from this study cannot be generalized. Third, the questionnaire was self-filled by the participants, therefore recall bias could have affected the collected data. Moreover, the blood pressure readings for the patients were not recorded at the time of the survey administration. Assessment of the impacts of the pharmacist role on the disease control was not, therefore, possible. Finally, some patients were recruited from pharmacies. This can be considered as a point of strength since recall bias would have been minimized in patients who had just received pharmacist services. This also can be considered as a point of weakness, since the presence of the participants in the pharmacy during the filling of the survey would have posed some psychological pressure pushing them to exemplify the interventions/services to gratify their pharmacists.Despite these limitations, this study has yielded information about the practices and gaps in the pharmacist role in hypertension management in the community setting. It also shed the light on the need for interventional programs that would address these gaps to optimize patient care of patients with hypertension.In conclusion, this research provided insights about the situation in a developing country (Egypt) concerning the pharmacist role in hypertension management in the community setting. Results of this study demonstrated that community pharmacists started to practice contemporary roles in the management of hypertensive patients. However, these roles are still incomplete, which would impede the optimization of patient care and thus the achievement of desired outcomes from hypertension management. This result calls for interventional programs that would address role gaps. Besides, it highlights the need for further research that investigate the reasons behind the gaps in the community pharmacist role and the barriers to the effective implementation of this role in hypertension management in the community setting.


However, the process of admitting patients to inpatient rehabilitation is a complex process. This is yet to be standardised across the European Union, as the approach to geriatric rehabilitation tends to vary from one Member State to another. (2) Objective: To discuss evidence-based practice with clinical experts, in order to define geriatric rehabilitation and admission criteria based on the Maltese population. (3) Method: The study entailed conducting four panel sessions using a purposive sample of thirteen local clinicians with extensive knowledge in clinical rehabilitation and healthcare management. A total of 48 items, based on the literature and clinical experience, were presented to the panel. Data analysis was done quantitatively and qualitatively, using IBM SPSS Statistics Version 24 and thematic analysis. (4) Results: The panel formulated a definition of rehabilitation, which shared common elements with the definition provided by the World Health Organization (WHO) and other sources/literature. The panel agreed on a list of eight criteria for appropriate inpatient geriatric rehabilitation admission in Malta. Consensus was also reached on: the need for a consultant-led multidisciplinary approach to assessment; the adoption of a standardised assessment processes for an equitable chance for all older adults assessed; the benefit of digital health in assessments; and the consideration that most patients would have some form of rehabilitation potential, depending on availability of resources. (5) Conclusion: Inpatient geriatric rehabilitation hospitals should have a unified strategy for rehabilitation services. The conclusions reached by the panel, could be useful in supporting the clinical evidence and establishing future rehabilitation guidelines and standards for inpatient rehabilitation. An ageing population is inevitably linked to increasing rates of morbidity and disability. By the end of 2020, 18.9% of Malta’s total population was aged 65 years and over [Malta’s only state-run rehabilitation hospital admits, among other patients, older adults for inpatient rehabilitation. Since this hospital has a limited number of inpatient beds, appropriate admission criteria would be essential in ensuring that truly eligible patients are admitted.Rehabilitation consultants and geriatric consultants, who assess patients for admission to inpatient rehabilitation, make daily clinical decisions on patients’ rehabilitation potential and eligibility for inpatient admission. There is currently neither an established systematic approach to assessing patients for rehabilitation potential nor a clinical guide for rehabilitation admission criteria ,3,4. ResIn view of the above, the aim of this study was to pitch published evidence-based practices to the panellists and for them to discuss it, in order to define GR and admission criteria with reference to the Maltese population. Through the use of the Delphi method, we sought to involve a panel of national experts towards reaching a consensus on fundamental principles in GR.The Delphi method is a planned procedure that uses rounds of questions to gather experts’ opinions, without requiring face-to-face meetings . The resA set of criteria was established by the study team to identify the ideal experts to form part of the Delphi panel, taking into account the criteria required when forming a panel ,15. In oThe research team identified thirteen experts through purposive sampling. These were individually contacted by e-mail and, upon expressing their interest in participating in the study, were provided with an information sheet and a consent form, which provided a detailed explanation of the aims of the study and what their involvement entailed. All of the selected experts that were invited consented to participate in the study. The panel of experts consisted of MDT professionals working in inpatient rehabilitation, namely: (1) geriatricians and rehabilitation consultants; (2) allied health professionals, including physiotherapists and occupational therapists; (3) nurses; and (4) social workers, all in management positions in rehabilitation, including that of older adults. These experts all worked on a full-time basis within the same Maltese rehabilitation hospital and had been fulfilling the same role for a minimum of five years.In Malta’s rehabilitation hospital, members from the multidisciplinary team hold weekly meetings to discuss individual patient cases, progress, and plans for rehabilitation. These meetings are geriatric-consultant-led, and include the nurse, physiotherapist, occupational therapist, and social worker. Therefore, realistically, the panellists chosen for the study consisted of these professionals. This made the findings more contextually relevant.SurveyMonkey, an online-survey platform, was used for all the rounds of Delphi. The surveys planned were sent individually to each panel expert, through an e-mail link. The participants were given one week to submit their responses; any panellist who had not yet filled in the questionnaires received a reminder in the week following the set deadline. Maintenance of participation levels between 50 and 80% was necessary to ensure that a valid consensus could be reached ,17. In oThe aim of the Delphi survey was to define geriatric rehabilitation (GR), discuss admission criteria for inpatient GR, discuss the composition of the MDT, and discuss the use of digital technology to help guide clinicians to make consistent, transparent decisions on GR admission, for the Maltese population. The statements presented in the rounds were mostly based on evidence regarding rehabilitation and GR potential, and on responses given by the panellists from previous rounds.The first round of Delphi, served to create a baseline for the panel, in order to ensure that the points for discussion and the theme of the study were clear and concise ,14. PartThe first round concerned: rehabilitation definitions; domains that affect RP; admission criteria; assessment measures; and outcomes of rehabilitation—all of which were initially compiled from the literature. This was an introduction that served as the foundation of the questions in the remaining rounds. Indeed, the second questionnaire was created using the experts’ responses from the first Delphi round, eliminating the items that had already attained a high level of homogeneity, and maintaining the ones that had not shown a sufficient level of consensus. The ideas generated by the experts in their remarks from the first round were taken into consideration when these elements were revised and reintroduced to the panel in the second round. New multiple-choice questions were also included. A total of 48 items were presented to the panel during the rounds. Consensus was considered to have been achieved if at least 70% of the panellists responded to the same statement from among a choice of ‘strongly agree’ and ‘agree’, or ‘strongly disagree’ and ‘disagree’ ,11. ThisOn the other hand, qualitative data analysis was carried out manually. Each question was evaluated thoroughly, and the main points and common themes were grouped together. This process is called thematic analysis, as described by Bryman .This study was reviewed by, and received approval from, the University of Malta Research Ethics Committee. Each panellist was given one code which they were required to apply when completing the rounds. A second code was allocated to each participant, which was only known by the researcher . This coThe results of the rounds are presented in sections. The first section  providesThe panel consisted of thirteen experts—53.8% male and 46.2% female—with 38.5% aged between 45 and 54 years; 46.2% held a master’s degree, while 46.2% worked in rehabilitation for over 20 years, across clinical and managerial roles. All experts were Maltese nationals. Further demographic and educational characteristics of the participants is presented in The first round involved the circulation of two questionnaires, one aimed at collecting the experts’ demographics and one covering questions regarding the topic under discussion. The latter was composed of eight questions, one of which was quantitative in nature. Most questions showed similarities and convergence, and the aim of this round was to generate ideas and link the responses to the literature . Most reThe second round consisted of six questions, one of which was open-ended. The first three questions were reproduced from the first round. The remaining three questions were first introduced in this round. The participants were required to respond to more defined statements regarding definitions of rehabilitation, which domains have the highest implication on rehabilitation, and which outcome measures should be used to assess these domains. The round also considered which clinician/s from the multidisciplinary team (MDT) would be the most suitable for conducting the assessment, and if digital technology could aid this assessment process in any way.Percentage consensus was calculated, with three questions showing convergence, and hence were eliminated from subsequent rounds. Three questions were reintroduced in the following round, even though there were similarities in the responses. These similarities emerged through the ‘additional comment’ field following the questions, as some panellists clarified the statements that merited further discussion and thus offering higher convergence.The questionnaire in the third round consisted of ten questions, which included sub-questions to a total of twenty-one items. This round sought to gather the panel’s views on the MDT involvement in assessment, the admission criteria, and the use of digital technology in the assessment process. The questions that were reformulated from the second round were intended to narrow down the responses, aiming for a more concise and homogenous answer from the panel.A good degree of convergence was achieved in three of the five questions asked on the MDT approach to assessment, in three of the four questions asked on digital technology use in assessment, and in five of the twelve questions asked on admission criteria to inpatient rehabilitation. This meant that the following round required further clarification and reformulation of statements regarding admission criteria.The questionnaire in the fourth round consisted of four questions, with sub-questions to a total of thirteen items discussed. These included re-submitted questions on the MDT assessment process and on digital technology involvement, and also re-introduced and new questions on admission criteria to inpatient rehabilitation. The aim of this round was to continue evaluating the panel’s views on which patients should be considered eligible for inpatient rehabilitation, and which would benefit from other services instead.Convergence was noted in most replies. However, four items did not deliver a homogenous reply and the responses were distributed throughout the five-point Likert scale, and thus were not conducive to reaching a final conclusion. This was noted in statements that did not reach consensus in the previous round, and not in new statements introduced. For this reason, and since this was the final round of the Delphi survey, these items were excluded from the list of appropriate admission criteria. A summary of the survey results was sent to the panel. A total of 20.8% of the questions asked were open-ended in nature. The main themes were extracted, and the statements were formulated and presented to the panel for discussion. Any themes that obtained immediate consensus were eliminated from subsequent rounds.In the first round, the participants were presented with standard definitions of rehabilitation, geriatric rehabilitation (GR), and rehabilitation potential (RP), and were asked to comment on the statements. A total of 84.6% agreed with these definitions but added to the description of rehabilitation potential. The remaining 15.4% maintained that there should be no distinction between rehabilitation and GR. The results were collated together and one statement to define rehabilitation was sought and presented to the panel in the second round, which subsequently obtained a 92.3% consensus.The panellists were asked about domains that affect RP and the open-ended follow-up question was to ‘list any other factors that affect rehabilitation and a patient’s potential’. A total of 76.9% maintained that the patient’s character, motivation, and willingness to undergo rehabilitation would play a key role in the patient’s performance, and thus the outcome. The comments also included the mental state of the patient, including depression and anxiety, and the ability to participate in, and benefit from, rehabilitation.Three questions achieved consensus in the first round, which aided in the formulation of the admission criteria statements that were presented in Rounds 3 and 4. The responses obtained in the close-ended questions were compared to these results, and are presented in the following section.In contrast to the above, two questions did not reach consensus during the first presentation of the open-ended question, and required clarification and re-discussion in the ensuing round. These questions concerned which outcome measures should be used when assessing patients for GR inpatient admission. There were a number of outcome measures mentioned in this section, none of which were mentioned by the majority. In total, 34 outcome measures were mentioned, with the most commonly mentioned being the Barthel index or BI (14.7%), the functional independence measure or FIM (14.7%), the mini mental state examination or MMSE (11.8%), the clinical frailty scale or CFS (11.8%), and the Montreal cognitive assessment or MoCA (8.8%). The responses obtained were compared to the existing literature  and a liThe remaining two questions were free-text questions, which allowed the panellists to comment freely on anything that was discussed during the panel sessions. These were asked during Rounds 3 and 4. The panellists commented on various topics of the survey, including the benefits of a standardised approach to patient assessment, the benefits and risks of using digital technology to compile and store assessment data, and the challenges faced by clinicians when trying to identify the most adequate admission criteria. In these two questions, none of the themes extracted showed convergence. Hence, these responses were used as a basis for further statements or to enhance the robustness of already discussed statements.Notwithstanding the above, similarity was noted within the panel in mentioning that GR assessment should be patient specific, and depending on individual characteristics, patient motivation, and rehabilitation potential. In view of clinical complexity and the frailty of referred patients, the panel questioned the ability of clinicians to predict rehabilitation outcomes in an effective manner, in the absence of a standardised approach to assessment, or the presence of only one clinician, assessing the patient and making the decision alone.A total of 79.2% of the statements were close-ended in nature. Convergence was noted in 52.6% of the statements, more specifically: 2.6% on rehabilitation definitions and potential; 7.9% on outcome measures and domains; 10.5% on composition of the MDT; 18.4% on statements on admission criteria; and 13.2% on the use of digital technology in the assessment process.The panellists were presented with a list of domains, extracted from the existing literature , and werThe MDT involvement in patient assessment constituted 15.8% of the statements, of which 10.5% reached convergence. The panel agreed that the admitting team should consist of a consultant geriatrician or rehabilitation specialist, a physiotherapist, an occupational therapist, and a social worker, with the potential addition of a speech and language pathologist, psychologist, dietician, and other pertinent professionals, depending on the individual patient’s needs. The panel responses are shown in The remaining 5.3% of the MDT statements showed a lack of agreement on the involvement of nurses. The panel was asked whether nurses should be involved in GR patient assessment, with 46.2% of the panel being in agreement. Since consensus was not reached, the statement was represented to the panel in the following round, noting an increase to 61.6% agreement. The panel showed conflicting responses that the nurse should be involved mostly in cases where the patient would require specialist nursing, such as wound management or pain management, on a referral basis.The panellists were asked what they considered to be a ‘good’ outcome of rehabilitation and a ‘poor’ rehabilitation potential. A total 46.2% of the panel maintained that a good outcome of rehabilitation would occur when the patient could be reintegrated within the community, in previous housing or living with a family member, while 30.8% considered a patient reaching their maximal potential as a good outcome. Another 30.8% mentioned reaching patient and caregiver’s goals and objectives of rehabilitation. In contrast, most panellists (84.6%) considered poor prognosis and multiple comorbidities to be the lead determinants of poor RP. The panel argued that decreased medical stability tended to lead to a decrease in ability to co-operate during therapy sessions, thus rendering rehabilitation more challenging. Co-operation would be further decreased in the presence of impaired cognitive function, as mentioned by most panellists (61.5%), and possibly leading to a lack of willingness and motivation to adhere to treatment sessions. A lack of social support was considered by 38.5% of the panellists, along with 15.4% believing that the level of independence prior to the event that led to hospitalisation would have an impact on the success of the rehabilitation phase.Based on the above-mentioned responses, the panellists were then asked to discuss which admission criteria they deemed necessary for inpatient GR. Two particular statements represented a higher disagreement level, yet did not reach dis-consensus. These statements addressed the medical stability of the patient and read as follows: ‘Has a need for daily nursing and medical care’ and ‘Multiple admissions in the previous year’. Therefore, by not reaching a suitable level of agreement, the panel shifted towards admitting patients who would be sufficiently medically stable to withstand intensive rehabilitation programmes.Another statement that remained inconclusive concerned the cognitive status of the patient. There was no agreement with the statement that patients with moderate-to-severe cognitive impairment should be excluded from GR. While some panellists maintained that patients with cognitive impairment could still be rehabilitated if the staff would be well trained and the environment adequate in accommodating their needs, others maintained that if the cognitive impairment were to be a hindrance to rehabilitation compliance, or the impairment should cause a challenge for the relatives if the patient were to be rehabilitated, then the patient should be excluded from inpatient GR. Delirium and premorbid cognitive status were also mentioned as important considerations for GR admission. Furthermore, panellists mentioned the importance of assessing cognitive status to be in the best position to plan treatment sessions accordingly.The panellists were also presented with questions regarding the use of digital technology in the process of patient assessment for admission to GR. The panel agreed that a digital standardised assessment should not be the final and definite decision that would replace clinical judgement. Nevertheless, it should serve as an assistive tool that would ensure that the patient be assessed in a holistic manner, identifying patient needs and expectations, and supporting the better planning of treatment and rehabilitation care. A total of 15.4% of the panel highlighted the point that a standardised digital approach would offer greater transparency in the assessment process, and would allow increased ease of communication with other healthcare entities and professionals, as well as the patients themselves and their caregivers.This study was the first in Malta to employ the Delphi method in seeking to identify what is understood by rehabilitation and which admission criteria are the most appropriate for inpatient geriatric rehabilitation (GR). There was a 100% response rate in all four rounds, with all the panellists replying to the questionnaires within the set time frame. Consensus was not reached on: the nurses’ involvement in inpatient admission assessments and on admission criteria concerning patient cognitive level; previous long-term care applications; the need for daily nursing care; and the number of admissions to hospital in the previous year.Having stated the above, similarities were noted in the responses, even when the panel chose ‘neutral’ in their scale response. This suggests that there were implied shared criteria of acceptability among the panellists, despite there being no current standardisation of assessment. By the end of the panel sessions, the experts agreed on a list of eight criteria for appropriate inpatient GR admission . AdmissiThe definition of rehabilitation that was agreed upon among the panellists was as follows: ‘Rehabilitation is a multidisciplinary approach of interventions, aimed to maximise functional independence and facilitate psychosocial adjustments to residual disability, to allow a patient to function successfully in the community’. This was similar to the definition offered by the WHO  and thatIn the current study, it was ultimately agreed that GR assessment was an extensive and detailed process that would require a multidisciplinary approach. This would help structure a patient-oriented rehabilitation plan. Inpatient GR services should evaluate the assessment process on a regular basis, to detect any flaws, or areas of improvement. This could be based on evaluation of: duration of stays in hospital; rates of mortality during rehabilitation; fluctuating numbers of admissions and patients referred for long-term care institutions; and functional abilities in the community with follow-ups . The assIt appeared that some of the experts on the panel expressed their views not solely based on their clinical expertise and knowledge, but were also influenced by the administrative and managerial problems encountered in the day-to-day running of rehabilitation in Malta. The panel indicated that the assessment process should be more standardised and thorough, portraying some similarities with the comprehensive geriatric assessment (CGA) model ,22,23. HAlthough the majority of the panel maintained that RP and admission criteria should be based on improving the patient’s functional abilities, a few panellists also mentioned the importance of offering rehabilitation even in cases requiring higher levels of medical, adaptive, or palliative care ,25. FurtThe panel did not reach consensus on admission criteria regarding the cognitive level of the patient. The panellists had conflicting responses as to whether patients with dementia or cognitive impairment tended to have lower RP and lower compliance rates to treatment, as was noted in at least one study . In contFinally, a number of panellists also mentioned that no patient should be denied rehabilitation, and that patients should be equally eligible for inpatient GR, irrespective of their premorbid or current condition. Nevertheless, it was also pinpointed that the available resources presented ethical challenges and the need for prioritisation of service allocation. This may be viewed as a contradiction to the comments provided above.It should be noted that the use of the Delphi method approach is not intended as an alternative to rigorous scientific research, but to inform it ,13. ConsSample size recommendations varied across literature, with minimum numbers including five, ten, or twelve panellists to be sufficient to enable consensus ,28,29. TThe anonymity and confidentiality employed during the rounds helped minimise the bias in the panel responses, which may have otherwise been influenced by existing relationships between the panel and the researchers involved. The Delphi method reduced the possibility of any panel members being reluctant to express their views if these contradicted others or if some panel members were more expressive than others. Existing literature has also highlighted this advantage of the Delphi method ,14,17.This study proposes that geriatric rehabilitation (GR) and its assessment is a complex decision-making process through which clinicians are required to make clinical judgements on the patient’s potential and expected outcomes if admitted to an inpatient GR programme.The panel agreed about the need for a consultant-led multidisciplinary approach to rehabilitation assessment and management. The inclusion of other stakeholders, such as the patients themselves and their caregivers, could offer a wider view of rehabilitation in older adults. This research focused solely on clinicians working in the field of rehabilitation, but a further step could be taken to include these stakeholders in future research. The panel believed that, while all patients had some form of rehabilitation potential, the provision of rehabilitation would depend on the wishes of the patients and caregivers, and on the resources available.The conclusions obtained by this panel could be useful in supporting the existing clinical evidence and establishing rehabilitation guidelines and standards for inpatient rehabilitation. Inpatient GR hospitals should have a unified strategy for rehabilitation services. Considering that the Delphi panel findings represent local expert opinions, rather than more far-reaching scientific evidence, further research to solidify the conclusions would be crucial . Neverth


This is a fictional case study for training that encourages participants to interact and apply theory into practice. A febrile illness of unknown cause that occurred in Upper Egypt in 2002 was chosen for the events. The location of Aswan was selected to define the climate, topography, and location with the characteristics that support the events. Data obtained from applied research work in Egypt was included. The case study deals with the incidence of severe cases of fever of unknown origin accompanied by neurological and intestinal symptoms, as well as a high percentage of deaths. Most of the symptoms appear in people with direct contact with farm animals especially equines and birds, or those who were near waterways, either tourism workers or tourists. Most of the infected cases or deaths have accumulated in Aswan and some in the neighbouring governorates. This case study focusses on the steps taken during an outbreak investigation, and deals with investigative challenges as well as concepts of biosafety and biosecurity. This is a fictional case study and some of its real data was obtained from an applied research work and investigations in Egypt [1]. The details of the original research work have been modified to enhance learning objectives and support the instructional goal. Fifteen (15) participants should be matched to two facilitators in a training room, preferably at a round table. Each participant should be issued a copy of the case study prior to its implementation. The facilitator guide remains with the facilitator. The facilitator introduces the learning objectives of the case study and materials that participants should have at hand before starting the case study. Participants take turns to read the case scenario and the questions or tasks that follow. The participants then discuss and attempt to provide the answer to the question. The facilitator should stimulate participants to discuss and arrive at the correct responses.Health care providers, epidemiologists, clinicians, undergraduate/ postgraduate students and public health professionals.Before using this case study, participants should have received lectures or other instruction in outbreak investigation.Note book, pen, flipcharts, chart papers, markers, calculators and laptops.Novice - Outbreak investigationThe expected time for the case study is about 3 hoursEnglishDownload the case study student guide (PDF - 1.38 MB)Request the case study facilitator guide: contact info@gibacht.org


Globally, dementia is one of the highest priority public health policy issues. This study was conducted to analyze the spatial distribution pattern of dementia prevalence using geographic weighted regression analysis and to identify preventable risk factors at the regional level of dementia prevalence. For the data to be analyzed, this work used the 2020 regional dementia prevalence index of the Korea Central Dementia Center and the regional health statistics of the Korea Centers for Disease Control and Prevention Agency (KDCA). Spatial autocorrelation analysis, hot spot analysis, and geographic weighted regression analysis were performed to identify regional associations of dementia prevalence, cluster regions with high dementia prevalence, and risk factors for regional dementia prevalence. As a result of the hot spot analysis, the regions corresponding to the hot spots with the high prevalence of dementia were found to be adjacent to each other, such as in Jeonnam, Jeonbuk, and Gyeongbuk, and the regions corresponding to the cold spots with the low prevalence of dementia were adjacent to each other, such as Seoul, Gyeonggi, Incheon, Busan, and Ulsan. The results of geographic weighted regression analysis showed that educational level, walking practice rate, hypertension prevalence, and a low-sodium diet preference were found to be risk factors for the prevalence of dementia. These results suggest that there is a need for a dementia prevalence management strategy to increase the walking practice rate and low-sodium diet preference rate, and decrease the hypertension prevalence, centering on the hot spot area, which is a cluster area with high dementia prevalence. This study is expected to be useful as basic data that can help in prioritizing health policies considering spatial characteristics for community health promotion. Recently, more attention has been paid to not only personal health but also health on a community level around the world. Macintyre et al. reported that the physical characteristics of the environment, the services provided to support people in their daily lives, the sociocultural characteristics of the community, and the reputation of the region were the factors affecting the health of a community . It has Dementia is one of the highest priority public health policy issues today. The number of people with dementia worldwide was estimated to be about 46.8 million in 2015, and it is expected to increase to 74.7 million in 2030 and to 131.5 million in 2050 . With thAs there are regional differences in the prevalence of dementia in Korea ,12,13, iGeographically weighted regression analysis is a study method that is used for ecological research at the regional level, and it is a spatial statistical technique that reflects regional spatial characteristics and derives regional health risk factors . GeograpWe identify the interregional spatial dependence of dementia prevalence in Korea.We identify clusters in regions with high dementia prevalence through hot spot analysis.We identify risk factors for dementia prevalence in Korea through geographic weighted regression analysis.Therefore, in this study, the prevalence and risk factors of dementia among regions in Korea are identified and used as basic data for effective dementia prevention and management projects. The specific goals of this work are as follows:In Korea, public health centers in administrative areas are the institutions that carry out and manage regional health management projects. In this study, 246 administrative regions in Korea, wherein public health centers are installed and operated, were analyzed as the target regions. To confirm the spatial dependence of the prevalence of dementia in Korea and analyze hot spots, we collected the dementia prevalence index from the Korea Central Dementia Center in 2020 (246 regions). To identify risk factors for the prevalence of dementia, the 2020 regional (246 regions) index data of the Korea Disease Control and Prevention Agency (KDCA) regional health statistics were collected. The study was conducted in accordance with the Declaration of Helsinki. Ethical review and approval were waived in this study because it used anonymous public open data and not an individual’s personal data.Dementia prevalence, as a dependent variable, was defined as the proportion (%) of dementia patients among the elderly population over 65 in Korea, according to the definition of dementia prevalence by the Korea Central Dementia Center. The risk factors for the prevalence of dementia, which are independent variables, were selected in consideration of previous studies ,20 and cp < 0.05), then the prevalence of dementia in the target region can be judged to have spatial dependence, which is a spatially strong cluster. The data in this study were analyzed using the IBM SPSS 27.0  and ArcGIS pro 2.6.0  programs. Descriptive statistical analysis was conducted to understand the prevalence of dementia and the general characteristics of dementia risk factors in the analysis target region. To confirm the spatial dependence of dementia prevalence in Korea, the regional distribution of the dementia prevalence rate was identified through mapping, and a global spatial autocorrelation  analysis was performed. Global spatial autocorrelation  analysis is a representative spatial statistical technique for determining spatial dependence by measuring spatial autocorrelation. Moran’s Index, a spatial autocorrelation index calculated through global spatial autocorrelation analysis, has a range from −1 to 1. If Moran’s Index is 0 or more and close to 1 and statistically significant  of each index of the dementia prevalence rate between hot spot regions and cold spot regions.Hot spot analysis was conducted to identify hot spot regions, which are clusters of regions with high dementia prevalence. In the hot spot analysis, hot spot regions with high statistical values and cold spot regions with low statistical values were classified according to Getis Ord’s Descriptive statistics were conducted to analyze the general characteristics of the study regions . As a reTo determine the regional correlation of dementia prevalence, the regional distribution of dementia prevalence was tested, and spatial autocorrelation analysis was conducted. Mapping the regional distribution of dementia prevalence in Korea, as shown in Spatial autocorrelation analysis confirmed that the prevalence of dementia was clustered between regions in a statistically significant manner. Therefore, hot spot analysis was performed to identify hot spot regions, which are clusters of regions with high dementia prevalence. Geographically weighted regression (GWR) analysis was conducted to identify risk factors for the prevalence of dementia at the regional level . The majp < 0.05). It was found that dementia prevalence risk factors had a greater influence in the hot spot regions than in the cold spot regions.To prioritize the management of dementia prevalence by region, an independent sample t-test was conducted on the difference between the values of risk factor index values for dementia prevalence and the influence (regression coefficient) of each index in hot spot and cold spot regions . RegardiFor the prevention and management of dementia, it is first necessary to manage the risk factors affecting dementia prior to the diagnosis of dementia. In this regard, studying the effects of regional characteristics on health has great practical implications for public health policy . This isAs a result of spatial autocorrelation analysis of the dementia prevalence rate, Moran’s index appeared to be 0.371 and Moran’s index p-value was 0.000. The prevalence of dementia is found to be clustered in a statistically significant manner between regions, which can be considered based on Tobler (1970)’s first law of geography, which states that, although everything is related, factors that are closer spatially are more closely related ,24. ThisTo effectively manage the prevalence of dementia, it is necessary to first find a region with a high prevalence of dementia, and then to conduct intensive management activities centered on such regions. Hot spot analysis is used to identify regions with statistically significant high or low values in data obtained by region, such as disease incidence . As a reAs a result of geographic weighted regression analysis aiming to identify risk factors for the prevalence of preventable dementia at the regional level by reflecting the spatial characteristics of the region, the major risk factors significantly affecting the prevalence of dementia in the region were the education level, the hypertension prevalence, the walking practice rate, and a low-sodium diet preference rate. The prevalence of dementia was found to be high in regions with a high proportion of low educational attainment, which is consistent with the results of previous studies ,30,31 shAs a result of hot spot analysis and geographic weighted regression analysis to select regional dementia prevalence management priorities, the ratio of the population with a below middle school education level and the prevalence of hypertension were higher in hot spot areas than in cold spot regions. The walking practice rate and low-sodium diet preference rate were higher in the cold spot regions than in the hot spot regions. These results suggest that there is a need for a dementia prevalence management strategy to increase the walking practice rate and low-sodium diet preference rate as well as lower the hypertension prevalence, centering on the hot spot area, which is a cluster area with high dementia prevalence. This also suggests the need for collaborative dementia prevalence management in spatially adjacent hot spot areas for effective management. In Korea, dementia management projects are being actively carried out through collaboration between public institutions, community groups, and community members. In fact, with the support of the state and cooperation with various organizations, early diagnosis and prevention of dementia, and integrated service provision are being carried out, and there has been an improvement in the screening rate for early dementia . In the In this study, using the spatial autocorrelation analysis method validated in previous studies ,39,40,41In this study, the spatial distribution pattern of the dementia prevalence rate reflecting spatial characteristics between regions was identified, and the characteristics of clustered regions with high dementia prevalence rates were identified as well. The results of this study showed that the regions could be classified into cluster areas with a high prevalence of dementia (hot spots) and cluster areas with a low prevalence of dementia (cold spots), which also means that there is health inequality between regions. Factors affecting health are not evenly distributed across regions. The socio-demographic characteristics, physical environment, and awareness and participation of community residents are all community factors that affect health . Therefo