key: cord-0694437-iwyn32tv authors: Kretchy, Irene A.; Asiedu-Danso, Michelle; Kretchy, James-Paul title: Medication management and adherence during the COVID-19 pandemic: Perspectives and experiences from LMICs date: 2020-04-15 journal: Res Social Adm Pharm DOI: 10.1016/j.sapharm.2020.04.007 sha: 6af4bebf7e1931fd13229b04edc8a4f4f643255a doc_id: 694437 cord_uid: iwyn32tv Abstract The current coronavirus disease 2019 (COVID-19) pandemic is placing a huge strain on health systems worldwide. Suggested solutions like social distancing and lockdowns in some areas to help contain the spread of the virus may affect special patient populations like those with chronic illnesses who are unable to access healthcare facilities for their routine care and medicines management. Retail pharmacy outlets are the likely facilities for easy access by these patients. The contribution of community pharmacists in these facilities in managing chronic conditions and promoting medication adherence during this COVID-19 pandemic will be essential in easing the burden on already strained health systems. This paper highlights the pharmaceutical care practices of community pharmacists for patients with chronic diseases. during this pandemic. This would provide support for the call by the WHO to maintain essential services during the pandemic, in order to prevent non-COVID disease burden on healthcare systems particularly in low-and middle-income countries. The coronavirus disease 2019 (COVID-19) pandemic is putting a huge strain on healthcare 25 systems worldwide 1 projected that approximately 80% of ICU beds was going to be occupied by patients affected by 31 COVID-19 before April 2020 2 . In line with the challenge that this pandemic poses on healthcare 32 systems worldwide, the WHO in recognizing how fragile many of the world's health systems and 33 services were, proposed guidelines for countries to maintain essential health services 34 throughout the pandemic period 3 . 35 Healthcare systems in low-and middle-income countries (LMICs) are especially challenged 36 because of the effect this pandemic will have on the already weak health systems in these 37 countries. Before the COVID-19 pandemic, healthcare systems in LMICs faced considerable 38 challenges in providing high-quality, affordable and universally accessible care 4,5 . These health 39 systems had limited financial resources, inadequate health personnel and unavailable 40 medications 6-9 . 41 Again, inequitable health access within LMICs may be further widened by the COVID-19 42 pandemic. The socio-economic gap together with poor quality access to health care has 43 become even more glaring in these times. Persons of higher socio-economic standing are more 44 likely to have access to quality health information and medications for chronic health 45 management, given the current challenges with health care personnel, facilities and essential 46 medicines. Chronic diseases which are often managed poorly in persons of low socio-economic 47 standing is going to be further poorly managed and health outcomes can be projected to get worse. For patients who prior to the pandemic could not afford prescription refills and healthy lifestyle adjustments, a deterioration of their condition as a result of poor health accessibility 50 may be imminent. Thus in the face of this global COVID-19 pandemic, although some persons 51 with high socio-economic standing may struggle with keeping up good health behaviors and 52 medication adherence, the projection for persons with low socio-economic status may be rather 53 dire 10 . 54 55 Prior to the incidence of the COVID-19 pandemic, LMICs had a double disease burden of 57 chronic infectious and non-communicable diseases (NCDs) like HIV/AIDS, tuberculosis, 58 hepatitis, diabetes, cardiovascular diseases, cancers, chronic pulmonary diseases and mental 59 illnesses 11 . 60 Patients with chronic diseases are at a higher risk of threat from the pandemic as the COVID-19 61 is best combatted by a strong immune system. Yet, chronic diseases like HIV, diabetes and 62 kidney diseases are immunosuppressing, making patients more vulnerable to infections with 63 difficulties in management 12-14 . While stress and anxiety are normal reactions during crisis 64 situations 15 , the negative impact of COVID-19 outbreak may affect the clinical outcomes of patients with chronic conditions like mental illness and cardiovascular diseases whose 66 development and management are linked to stress and anxiety 16 . 67 In the face of the current pandemic, many countries have had to make tough decisions in order 68 to safeguard its people. These decisions include lockdowns and restrictions on people's 69 movement and mobilization of health personnel to the frontline of the COVID-19 infection. This 70 may be a major problem for patients with chronic diseases requiring revisits, follow-ups, check-71 ups and prescription refills since access to health facilities and their attending physicians may be denied. Also, the increased likelihood of being infected at hospitals has forced most patients to avoid their health facilities for physician consultations. 74 There is also unconfirmed information on the health benefits of some products for either 75 preventing or treating COVID-19 in some media outlets and this has caused a surge in unsafe 76 self-medication habits of some over-the-counter medications. In some reports, patients have 77 also relied on community pharmacies for their medication needs which should be available for 78 Unfortunately, LMICs often rely heavily on pharmaceutical imports and the impact of the 80 pandemic may be felt when essential medicines are unavailable and inaccessible to meet the 81 needs of all, especially those with chronic diseases. The global shut down worldwide has led to 82 fewer imports and exports and most pharmaceutical manufacturing firms have shifted their 83 focus to the production of medicines and medical equipment targeted at the fight against 84 COVID-19 in their nations. There seems to be a shift in the restrained import of pharmaceuticals 85 towards battling the current COVID-19 pandemic, thus leaving a huge gap for pharmaceutical 86 imports that target other chronic diseases. This focus by pharma industries will disadvantage 87 LMICs due to the rather vulnerable and inadequate pharmaceutical manufacturing capacities in 88 these countries to meet their general pharmaceutical needs and those for chronic diseases. 89 With limited supply to meet the increased demand created, the market values of medicines for 90 chronic diseases have escalated, making them unaffordable for several patients in LMICs who 91 require them. 92 In addition to ensuring that these medicines are available, chronic diseases rely heavily on 93 linear adherence patterns for adequate therapeutic outcomes 18 and this needs to be 94 emphasized especially during this COVID-19 pandemic. For instance, persons living with HIV 95 require optimal adherence to their medications to ensure better immunity, viral suppression and 96 treatment success, despite the stress and risk of infection. prevent complications such as diabetic ulcers and increased blood pressure which further 99 compromise their chances of survival if infected with COVID-19. In general, favorable 100 therapeutic outcomes across many chronic disease states will be achieved when optimal 101 medication adherence levels are maintained. 102 Unfortunately, the pandemic has left many in fear and with high stress levels 19 . While many 103 people struggle to cope with the constant news of the spread and effects of COVID-19 on their 104 media channels, they do not have adequate forms of social support to manage this stress as a 105 result of lockdowns and self-isolation. Yet, the negative effects of stress on disease outcomes 106 and medication adherence have been documented [20] [21] [22] . The psychological impact of this 107 pandemic might leave many patients with chronic diseases with little hope of improving their 108 health outcomes, thereby decreasing adherence and perhaps eroding health gains made prior 109 to the pandemic 23 . Again, in meeting the task of maintaining needed essential services, community pharmacists 154 need to engage their clients in frequent transparent communications especially with people with 155 chronic conditions to identify their medication needs and provide support appropriately. A strong 156 community engagement will also ensure trust in the health system by patients who will be 157 assured of continuity of health services to meet their essential needs at the community level 158 without having to risk being infected in health facilities. This is also important to ensure that 159 people continue to seek care when appropriate and have it available when needed. 160 pharmacists become crucial in the triaging diseases of common occurrence with similar COVID-170 19 symptoms for appropriate assessment and referral of suspected cases. 171 172 In an attempt to promote continuity of medication supply and accessibility to meet the demands 174 of persons with chronic diseases, while promoting social distancing and self-isolation during the 175 pandemic, community pharmacies can employ mobile delivery and courier services to promote 176 door-step prescription refills and other non-prescription supplies. This is to increase medication 177 availability within these times while preventing spread of COVID-19 to vulnerable patient 178 groups. Pharmacists are also collaborating amongst themselves on social platforms to source 179 medications for patients. This does not only enhance availability to medications for patients in 180 need but reduces social interaction of vulnerable chronic disease patients to the pandemic. pharmacists can constantly interact with their patients to emphasize the need for adherence to 206 their medications and lifestyle habits especially within this pandemic. In some instances, courier 207 services could be used for doorstep deliveries of essential medicines and prescription refills, but 208 in such instances, strict consideration for all anti COVID safety protocols should be adhered to. 209 210 As the pandemic continues to extend, the widespread demand on physicians has led to the 212 postponement of routine patient reviews and hospital visits for patients with chronic diseases. 213 Patients who would have required changes to their medications have been left with old 214 prescriptions to refill and patients who required minor procedures may require medications to 215 pharmacists can be entrusted with the responsibility using their judgement to review such 218 prescriptions and provide appropriate medication review management. For instance, patients on 219 opioid analgesics may have their prescription reviewed by the community pharmacist to prevent 220 tolerance and addiction. The roles and practices of community pharmacists may evolve after the 221 COVID-19 pandemic to embrace more prominent aspects of pharmaceutical care and 222 medicines management. 223 224 As the world concentrates on containing and delaying the spread of the COVID-19, many health 226 professionals have been burdened with this task and healthcare systems are challenged. Amid 227 this focus, healthcare systems may miss out on patients with chronic diseases whose 228 management may worsen with the pandemic. The contribution of community pharmacists in 229 managing chronic conditions and promoting medication adherence while other health personnel 230 battle the COVID-19 pandemic at the frontline is key to easing the disease burden on health 231 systems. 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