Failure to appropriately account for unmeasured confounding may lead to erroneous conclusions. Quantitative bias analysis (QBA) can be used to quantify the potential impact of unmeasured confounding or how much unmeasured confounding would be needed to change a study’s conclusions. Currently, QBA methods are not routinely implemented, partly due to a lack of knowledge about accessible software. Also, comparisons of QBA methods have focused on analyses with a binary outcome.We conducted a systematic review of the latest developments in QBA software published between 2011 and 2021. Our inclusion criteria were software that did not require adaption  before application, was still available in 2022, and accompanied by documentation. Key properties of each software tool were identified. We provide a detailed description of programs applicable for a linear regression analysis, illustrate their application using two data examples and provide code to assist researchers in future use of these programs.sensemakr performs the most detailed QBA and includes a benchmarking feature for multiple unmeasured confounders.Our review identified 21 programs with Software is now available to implement a QBA for a range of different analyses. However, the diversity of methods, even for the same analysis of interest, presents challenges to their widespread uptake. Provision of detailed QBA guidelines would be highly beneficial.The online version contains supplementary material available at 10.1186/s12874-023-01906-8. The main aim of many epidemiology studies is to estimate the causal effect of an exposure on an outcome . In observational studies participants are not randomised to exposure (or treatment) groups. Consequently, factors that affect the outcome are typically unevenly distributed among the exposure groups, and a direct comparison between the exposure groups will likely be biased due to confounding. Standard adjustment methods  assume the adjustment model is correct and a sufficient set of confounders has been measured without error . FailureThere are several approaches to assess causality which depend on assumptions other than “no unmeasured confounding” . When ntipr [Currently, QBA methods are not routinely implemented. A recent study published in 2016 found that the use of QBA for unmeasured confounding had not increased in the years 7 period , 9–18. Ood [tipr , the supod [tipr  providedod [tipr  reviewedod [tipr –28.The aim of our software review was to identify the latest available software to conduct a QBA to unmeasured confounding and to describe the key properties of each software program. Note that, we focused on QBA to unmeasured confounding caused by a study not collecting data on these confounders as opposed to mismeasurement of measured confounders. We then describe, illustrate and compare QBA software applicable when the analysis of interest is a linear regression. We illustrate how to apply these methods using a real-data example from the Barry Caerphilly Growth (BCG) study , 30, andS) study   U (assuming no other sources of bias). Generally, a QBA requires a model (known as a bias model) for the observed data, Y, X and C, and unmeasured data, U. The bias model will include one or more parameters (known as bias or sensitivity parameters) which cannot be estimated from the observed data. Therefore, values for these bias parameters must be prespecified before conducting the QBA. Typically, the bias parameters specify the strength of the association between U and X given C, and between U and Y given X and C [C with X and Y are used as benchmarks [We can use a QBA to quantify the likely magnitude and direction of the bias, due to unmeasured confounding, under different plausible assumptions about  X and C . Informa X and C , and fronchmarks  for the There are two broad classes of QBA methods: deterministic and probabilistic . A detercument}ϕ , 24. Aveiability .A QBA is often conducted as a tipping point analysis, where the analyst identifies the values of We conducted a systematic review of publicly available software implementations of QBA described in articles published between 1st January 2011 and 31st December 2021 (inclusive), and listed their key properties. We defined “software” to be either a web tool with a user-interface or software code that (i) was not specific to a particular data example , (ii) was freely available to download in January 2022, and (iii) was accompanied by documentation detailing the software’s features.Our literature search was conducted in three stages. In stage 1, we used Web of Science to identify papers that mentioned “quantitative bias analysis” and “unmeasured confounding” (or their synonyms) in either the title, abstract or as keywords .When supported by the program, we calculated benchmark values for Y, X, C and U.As this is an illustrative example of applying a QBA to unmeasured confounding, we have ignored other potential sources of bias (such as missing data) and only considered a small number of measured covariates. We restricted our analyses to participants with complete data on The BCG study is a follow-up of a dietary intervention randomised controlled trial of pregnant women and their offspring , 30. DatC were participant’s gestational age, sex, birth weight, and parents’ height and weight measurements. The strongest measured covariate was maternal weight. The unmeasured confounder U was a measure of childhood socioeconomic position (SEP)  at age 25 on being overweight at age 5 years (BMI cument}2 ). Measurfication ) with \dAfter excluding duplicates, our Web of Science search identified 780 papers  implement related QBA methods [sensitivitymw is applicable to matched sets with one exposed subject and a fixed number of unexposed subjects, and sensitivitymv to matched sets with one exposed subject and a variable number of unexposed subjects. Also, submax and sensitivityCaseControl exploit effect modification and different definitions of a case of disease, respectively, to further evaluate sensitivity to unmeasured confounding. Among the programs for mediation analysis, MediationSensitivityAnalysis evaluates sensitivity to unmeasured confounding of the mediator-outcome relationship only, while the remaining programs can also evaluate sensitivity to unmeasured confounding of the exposure-mediator and exposure-outcome relationships.Table  methods , 36 but survsens implements a QBA specifically for a Cox proportional hazards regression analysis and is applicable for survival outcomes with or without competing risks. All programs can be applied to a binary exposure and seven programs are also applicable to a continuous or categorical exposure. Also, all programs allow the analysis of interest to adjust for measured covariates C of any variable type and generally assume that U represents the part of the unmeasured confounder(s) that is independent of C. Nine programs use the measured covariates to calculate benchmark values for the bias parameters. The bias parameters represent the strength of the relationships between U and the exposure, outcome, or mediator. Programs treatSens, Umediation, mediationsens, and survsens also allow the analyst to vary the parameters of the marginal distribution of U  to be either binary or continuous. However, program isa, gsa, konfound, and R and Stata implementations of EValue). Note that, programs uMediation and ui summarise the bias-adjusted results using uncertainty intervals, which incorporates uncertainty about the values of the bias parameters and sampling variability. Fifteen programs generate a graphical plot of their QBA results.Almost all programs report the values of the bias parameters at prespecified tipping points. Also, most programs output the bias-adjusted results  at prespecified values of the bias parameter(s) , Y (adult BMI), C  and U (childhood SEP) were available for 542 participants. The naive estimate, C and U) was 2.19 kg/mU from the linear regression Y|X, C, U was U from the logistic regression X|C, U was Of the 951 individuals invited to the participate in the follow-up study, complete data for treatSens, causalsens, sensemakr, EValue, and konfound to data from the BCG study. For treatSens we used Probit regression for its treatment model because X was binary, for causalsens we used the one-sided confounding function because we assumed the exposure effect was the same in both exposure groups, and for EValue we calculated benchmark E-values by omitting one measured covariate at a time. We begin with a description of the outputted results from each program and then compare the results across the five programs.We applied programs treatSens outputs a contour plot  The black horizontal contour at C: pluses represent covariates positively associated with adult BMI, and the inverted triangles represent covariates negatively associated with adult BMI with those negative associations rescaled by Program causalsens outputs a line plot  and (b) .The robustness values for U and adult BMI and childhood overweight were at least 2.50 (or 1.93), on the risk ratio scale, then the exposure effect adjusted for C and U may be null or in the reverse direction . Supplementary Fig. 3  U would need to account for at least U with adult BMI and child overweight must both exceed 0.36.The percent bias was mentclass2pt{minimmentclass2pt{minimU and adult BMI and child overweight were half, once and twice as strong as the corresponding associations with the strongest measured covariate  then treatSens and sensemakr report that adjusting for C and U would give similar results to those of the naive analysis and konfound indicates the exposure effect would remain statistically significant. Also, sensemakr’s robustness values were substantially higher than the benchmark bounds for C . Conversely, causalsens suggests adjusting for U comparable to the strongest measured covariate could result in an exposure effect close to the null or more than double the naive estimate.Considering unmeasured confounding towards or away from the null, if mentclass2pt{minimmentclass2pt{minimU, childhood SEP, could be more than twice as strong as the strongest measured covariate, especially given that childhood SEP would likely be correlated with at least some of the measured covariates. Therefore, under these assumptions, treatSens, sensemakr, konfound, and EValue indicates robustness of the BCG study conclusions to unmeasured confounding by childhood SEP which was inline with the fully adjusted results. In contrast, causalsens suggested study conclusions could differ if we were able to adjust for childhood SEP.Provided the naive analysis included all of the important confounders then it seems unlikely that the confounding effect of We have conducted an up-to-date review of software implementations of QBA to unmeasured confounding, and a detailed illustration of the latest software applicable for a linear regression analysis of an unmatched study.All programs implement a deterministic QBA, and most are available in the free software environment R. The majority were developed in the latter half of the past decade and include programs available when the naive analysis is a mediation analysis, meta-analysis and a survival analysis. Many programs include features such as benchmarking and graphical displays of the QBA results to aid interpretation.episens [episensr [TippingSens [A limitation of our review was that we focused on software described in the published literature, in particular between 2011 and 2021 (inclusive). Consequently, our review excluded unpublished software implementations and example-specific software code of QBAs (which may explain the absence of probabilistic QBAs in our review). Our reasoning for focusing on published literature was to provide the reader with a certain amount of confidence regarding the quality of the software . Additionally, we focused on software implementations that do not require any programming adaptions to encourage the uptake of QBAs among all users irrespective of their programming skills. We recognise that additional software programs are available such as other implementations of QBA methods discussed in this review , publisepisens ), QBA meepisens , R packaepisensr  implemenepisensr ), and prpingSens ).treatSens which took about 10 minutes to run when applied to a moderately-sized dataset , reports a summary measure at prespecified tipping points  and conducts a QBA in a worse-case scenario of unmeasured confounding . Program EValue implements a flexible QBA which can be applied to a wide range of effect measures and makes minimal assumptions about the unmeasured confounding  and konfound only considers sensitivity to changes in statistical significance. The upside of the programs’ simplicity is that they require only summary data and so can be easily applied to multiple published studies, with the EValue extended to random-effects meta analyses [treatSens over the other programs are: (1) its imputation-style QBA method will be familiar to many analysts, (2) its bias parameters  are more likely to be reported by published studies than the bias parameters of the other programs . A potential weakness of treatSens is that it simulates U from a limited choice of joint distributions.Out of the five programs we compared analyses . Three skonfound and EValue can be applied to a binary outcome, with EValue also applicable when the exposure effect is a hazard ratio. Future work could compare QBA methodology for analyses of other types of outcomes such as survival and categorical outcomes.We compared software programs applicable when the analysis of interest is a linear regression since previous comparisons of QBA methods have primarily focused on analyses of binary outcomes , 21–28. sensemakr can provide benchmark bounds for its bias parameters based on a group of measured covariates which provides a useful aid when considering multiple unmeasured confounders. One noted issue with benchmarking is that the benchmarks tend to be based on the naive models, Y|X, C and X|C, and do not adjust for the omission of U [U can affect the benchmark values even when U is assumed to be independent of C [U include sensemakr, [Several programs in our review provided benchmark values to aid interpretation of the QBA results. Note that, ion of U , 68. Seensemakr, , and [83U represents a linear combination of multiple unmeasured confounders, with the elementary scenario that U is a single unmeasured confounder. A drawback of this appealing assumption is that the QBA tends to be conservative for multiple unmeasured confounders [U unspecified and instead define its bias parameters as upper bounds . A drawOur review did not identify any publicly available software implementations of probabilistic QBAs published between 2011 and 2021 (inclusive). In part this may be due to the perception that probabilistic QBAs are more difficult to apply than deterministic QBAs  and the misconception that probabilistic QBAs require specialist software for Bayesian inference . Note thtreatSens, sensemakr and causalsens). Our comparative evaluation has illustrated the wide diversity in the types of QBA method that can be applied to the same substantive analysis of interest. Such diversity of QBA methods presents challenges in the widespread uptake of QBA methods. Guidelines are needed on the appropriate choice of QBA method, along with greater availability of software implementations of probabilistic QBAs and in platforms other than R.In summary, there have been several new software implementations of deterministic QBAs, most of which are available in R. Deterministic QBAs are often interpreted as tipping point analyses with statistical significance as one of the tipping points. Given the call to move away from reliance on statistical significance , we recoAdditional file 1.Additional file 2.Additional file 3.


The aim of this work is to shed light on the characteristics and relationship between customer loyalty and publications by the companies on social networks; it has been undertaken with the aid of an exhaustive review of previous studies from 1994 up to the present time. The purpose of the research is to generate a model that can tackle the practical characteristics of the publications on social networks to encourage loyalty. With a view to this, a model is developed that is an extension of the traditional “Four Stage Loyalty Model” based on other constructions of the same model, and combined with the characteristics of social networks publications defined in earlier literature. This reflexive approach is particularly important here due to the fact that companies have to be closer to customers’ requirements and customers have the option to choose from which type of communication they wish to be the object. According to As has been established in previous studies, loyalty implies, amongst other competitive advantages, that the customers are less sensitive to prices and, so, they stick to the brand for longer without taking any notice of the competition and its potential offers. This means that brand loyalty is also very useful for preventing customers from changing to the competition, given that the more loyal customers are, the less vulnerable they will be to the competitions’ activities.Furthermore, capturing new customers amounts to a financial cost and an investment in time that is up to six times greater than keeping existing customers loyal, according to Another direct benefit for companies, which also leads to a cost reduction, is the fact that it provides the company with more information about consumer behavior. The awareness and knowledge of loyal customers can be used to improve the effectiveness of marketing activities and negotiations with the customers .At present, most companies have understood that the service to the customer is essential, which means that this is no longer a differentiating action, so it is necessary to seek new ways of differentiation, such as focusing on the customer’s experience . It mustFirms find social networks to be a channel for reactivating their branding, listening, segmenting, talking, conversing, mobilizing, helping and involving potential customers to turn them into loyal users. In view of the major competition, current businesses have found themselves obliged to seek new social networks strategies for their loyalty programmes in order to attract and keep customers loyal so they can continue to be competitive .The aim of the brands where social networks are concerned has to be much more than merely being present, given that this relationship with its customers may offer them many more advantages, such as interacting with loyal customers, having an influence on the members of a community and their perceptions about the brand, disclose information and teach the customers, affecting their opinions and needs .This new environment means the need for a major reconversion of business strategies. In the market, changes take place in the way that one communicates, collaborates, consumes, and creates content and value. Digital marketing involves improvements in efficiency when compared to traditional marketing and adds the option of immediate response from the customers, this implies interesting advantages on multiple levels. Companies’ success currently depends, and increasingly so, on their presence on social networks and the creation of interesting and interactive communication, as well as the presentation of offers to the intern3.auts who are spending increasingly long periods of time on social networks to interact with other people, keeping up to date with the latest news, commenting on events and situations and sharing the posts of others .Several factors have been studied that affect brand loyalty on social networks, however, there are no studies that detect which specific characteristics of the publications on social networks have the greatest effect on consumers, which is therefore the main objective of this research.A review has been carried out of the empirical studies published so far concerning two subjects: loyalty and social networks. This review of past literature is carried out from 2020 until 2022, priority being given to the works published by Web of Sciences. The study methodology was based upon the principles of The following keywords associated with the subject matter of the study were used in order to access the greatest number of papers possible, and those words were utilized both individually and in association, when looking for the topic: loyalty, social media, and social networks. A large number of articles turned up as a result of this search, so it was necessary to filter them by content.With the keyword loyalty, a large volume of bibliography referring to fidelity programs was excluded, as they are not the subject of the study, together with specific countries and sectors. Papers are included that refer to how the term has evolved, definition, advantages, and the practical use of the term.With social networks, studies concerned with the use of one network in particular were excluded, because this intends to be generic. The subject matter from specific sectors and countries was also excluded. However, papers about the emergence of social networks, the way they have evolved, their characteristics and benefits to companies were included.Once the loyalty model that constituted the foundation for subsequent ones had been identified, , it was In the case of social networks, as it is a relatively recent subject, no explicit time segmentation is carried out for the previous studies, the segmentation merely being limited to the content itself.The articles that were found as a result of the research and filters described were used to define the background to the loyalty and social networks criteria. Moreover, the most representative models were identified and used to generate our own model with practical solutions.Companies’ success can be measured in terms of the loyalty of their customers . Brand lObviously, brand loyalty can only exist if customers have different brands to choose from, so there can be no such thing as brand loyalty in monopoly situations . A long-Customer loyalty was traditionally interpreted as meaning repurchasing the same brand. However, after numerous acts of research, a new tendency emerged that attributed a customer attitude component to loyalty. Admitting that repurchasing the product or service is an important aspect of customer loyalty, According to this trend, a distinction should be made between genuine loyalty and “spurious loyalty” or false loyalty, which merely involves buying the product again. It could be explained by contextual factors such as low prices, better exposure of the product or simply by the absence of other options at the moment of purchase . These aOn the basis of this dual perspective , the authors prepared a table of customer loyalty typologies in The Dick and Basu Model is a sound base for the highly studied model defended by •Cognitive loyalty: at this phase, loyalty is determined by the information that the consumer receives.•Affective loyalty: is the consumer’s attitude toward the brand.•Conative loyalty: implies the wish to carry out an action.•Action loyalty: is the effective action, normally the purchase.This four-stage loyalty model implies that the different aspects of loyalty do not emerge simultaneously, but consecutively. Numerous models will be based on this one in the future, because it encapsulates and simplifies most of both the past and future definitions in The same author, in Several authors base their studies on Oliver’s loyalty model creating other models from Oliver’s. This is the case with Another example of a model based on the Four Stage by Oliver is In the case of As can be observed, Oliver’s Four Stage Model has been used as the basis for developing different models such as those shown above thanks to the combination of their multi-dimensional simplicity expressed by other authors. That is why it will be utilized as the basis for the model presented in this study.According to There are two types of social networks according to •Horizontal social networks: with users of different profiles and a variety of interests. They do not focus on one particular topic. For example, Facebook.•Vertical social networks: with one specific and common objective for all the users. For example LinkedIn.Research work dating back more than 10 years, already indicated that social networks would be the ideal tool for orientating the customer . Manchan•construct a public or semi-public profile within a limited system,•articulate a list of other users with whom to share a connection and,•display and track a list of contacts and those prepared by other users within the environment of the social network.Nowadays, social networks have become a daily ritual for the majority of their users .The emergence of different social networks, the socialization of access to the new technologies and the diffusion of these networks, have ensured that the increase in the use of social networks has been constant. As can be seen, the use of social networks has clearly and increasingly been making major inroads.In the USA in 2022 the utilization of social networks had reached 90%. A total of 55% of the users are women .Different social network platforms have been appearing throughout the years, adapting to the users’ preferences and needs. Some of them are more focused on information, such as Twitter, whereas others offer mixture of information and images, such as Facebook or Instagram, and others, like YouTube and Pinterest, are more orientated to images or videos. At the present time, the most extensively used social network is Facebook  with 2.9According to The work by However, this model was not referenced or extended subsequently in other studies. Erdogmus and Çiçek’s model does not develop the loyalty dimension taking into account the different variables that make up the loyalty concept. Therefore, there is a gap in the current literature in this sense regarding a comparison between models that feature a combination of the two concepts.The model proposed in this work has two dimensions: customer loyalty and the characteristics that are most important in the publications in social networks to achieve customer loyalty.It is very easy for a large proportion of the publications made by companies to be ignored by social network users. If there is no steady flow of popular and interesting publications, it is highly likely that users will lose interest in the websites .This means that it is essential for the brand presence on social networks to be detectable, connected, opportune and perceptive  so that The first characteristic of brand communications on the social networks will be that the content of those publications is interesting and useful to the users who follow them, otherwise those followers will lose interest. Users deliberately select specific media and in the case of social networks, specific pages where there is content that satisfies their needs .Companies must inform themselves well about the type of content that interests their consumers and offer them it; this would be the way to get them interested and get them hooked on this brand on the social networks. To successfully achieve this aim, it is necessary to listen to the customers, understand them and offer them that interesting content that they are waiting for Products associated with the brand and interesting content generated by the brand itself can be accessed via the social networks, while at the same time the users are feeling the benefits of the consumers’ knowledge and experience . AchieviOne of the biggest advantages of social networks is that they can reach customers and offer them this relevant content without interrupting their browsing, in contrast to traditional advertising . Ros purchase, trust, and recommendation, as indicated in this study’s findings], aligns with previous research, as referenced in section “4.2. Customer loyalty” of However, it is important to note that while the current study builds upon previous research, it goes more in-depth than others in terms of practical application.This article aligns with the conclusions of In conclusion, this study delves deeper than previous literature into both the concepts of customer loyalty and the specific characteristics of social media posts, resulting in a more concrete, analytical, and applicable model for the practice of corporate marketing.This research reviews different loyalty models based upon Oliver’s Model (1997), and the various marketing tools applied to the social networks proposed whose ultimate aim is to achieve loyalty, leading to a simplified model that can be applied to the business sector and the marketing sector. So companies whose aim is make their followers on social networks become loyal customers, can apply that model to create suitable publications that meet the real needs where making their followers loyal is concerned.It is established that to achieve this goal, the four main characteristics for publications on social networks are: relevant content or content that generated added value, campaigns with advantages for the customer, content that is popular among friends and quality photographs, illustrations or animations (PQ).The publications with these characteristics will give rise to types of publications that generate trust in the brand, which will lead to it being recommended causing the product or service to be acquired by customers and potential customers, and thus, loyal customers.Based on the proposed model and the current situation in the use of social networks, a few lines of research are proposed below that could lead to new conclusions regarding this subject that may complete the proposals.To test the proposed model, hypotheses of an attitudinal nature could be established as well as finding out the opinions of the social network users about the effectiveness of these types of publications and how they affect the different customer loyalty stages.Furthermore, the reality of social network use (due mainly to the time they appeared and their access barriers) makes us think that it is highly likely that the effectiveness of this model could be affected by different sociodemographic variables that may affect the way users interact, not only with the brands but also with the social networks in general. That is why it would be of great interest to conduct an empirical study in which attitudinal differences are pinpointed based on such variables as age, generation, sex, education level, income bracket, geographical analysis: rural world vs. cities, etc.The relationships between customers and their favorite brands are established in very different ways on the basis of the sectors to which the brand belongs, which is why an analysis by sectors would also shed light on this subject.This model has been created on the basis of usability and on the social networks in general. However, each social network presents certain peculiarities: some enable users to include direct links in their publications, others do not. Some permit one type of image composition and others allow a very different type, etc. These peculiarities also give rise to differences in the publications that the brands can make when communicating with their customers. Therefore, by going more deeply into the matter, specific marketing action criteria could be established for loyalty in each one of the social networks.In view of the great potential that implementing effective communication in social networks and brand loyalty have in terms of efficiency for companies and users, there is a great challenge to be met when continuing to discover the best ways to optimize relations between the two fields.ND: Conceptualization, Data curation, Formal analysis, Investigation, Software, Writing – original draft. MR: Funding acquisition, Methodology, Methodology, Resources, Supervision, Validation, Visualization, Writing – review and editing. CS: Funding acquisition, Project administration, Resources, Supervision, Validation, Visualization, Writing – review and editing.


How has the 340B Drug Pricing Program affected the US health care system?This scoping review found evidence that the 340B program was associated with revenue to hospitals, clinics, and pharmacies; expanded services for patients; and costs to pharmaceutical manufacturers. The study found mixed evidence that 340B revenue funded health care specifically for low-income populations.The 340B program has benefited hospitals, clinics, pharmacies, and patients, but its expansion has led to calls for reform. This scoping review assesses the literature on the foundations of and outcomes associated with the 340B Drug Pricing Program in the US health care system. The 340B Drug Pricing Program requires manufacturers to offer discounted drug prices to support safety net hospitals and clinics (covered entities) providing care to low-income populations. Amid expansion, the program has received criticism and calls for reform.To assess the literature on the foundations of and outcomes associated with the 340B program.The databases searched in this scoping review included PubMed, Embase, EconLit, National Bureau of Economic Research (NBER), Westlaw, the Department of Health and Human Services Office of the Inspector General (HHS-OIG) website, the Government Accountability Office (GAO) website, and Google in February 2023 for peer-reviewed literature, legal publications, opinion pieces, and government agency and committee reports related to the 340B program.Among a collected 900 documents, 289 met inclusion criteria: 83 articles from PubMed, 12 articles from Embase, 2 articles from EconLit, 1 article from NBER, 28 articles from Westlaw, 23 legislative history documents, 103 documents from Google, 11 GAO reports, and 26 HHS-OIG reports. Included literature pertained to 4 stakeholders in the 340B program: covered entities, pharmacies, pharmaceutical manufacturers, and patients. This literature showed that hospitals, clinics, and pharmacies generated revenue and manufacturers have forgone revenue from 340B discounted drugs. Audits of covered entities found low rates of compliance with 340B program requirements, whereas mixed evidence was uncovered on how covered entities used their 340B revenue, with some studies suggesting use to expand health care services for low-income populations and others to acquire physician practices and open sites in higher-income neighborhoods. These studies were hampered by a lack of transparency and reporting on the use of 340B revenue. Studies revealed patient benefits from access to expanded health care services, but there was mixed evidence on patient cost savings. Although the review identified considerable research on 340B hospitals, pharmacies, and patients, less research was found evaluating the 340B program’s effect on nonhospital covered entities, drug pricing, and racial and ethnic minority groups.In this scoping review of the 340B program, we found that the 340B program was associated with financial benefits for hospitals, clinics, and pharmacies; improved access to health care services for patients; and substantial costs to manufacturers. Increased transparency regarding the use of 340B program revenue and strengthened rulemaking and enforcement authority for the Health Resources and Services Administration would support compliance and help ensure the 340B program achieves its intended purposes. These rebates include a best price discount to ensure that Medicaid pays no more than the lowest price paid by commercial insurers.6 and permits these entities to charge nondiscounted prices to all payers  and some insulins—are required to provide additional Medicaid rebates for price increases exceeding inflation.12The 340B program, enacted in response to these events, requires manufacturers participating in Medicaid to sell drugs at discounts to eligible clinics and hospitals, called “covered entities,”l payers , generatAuthority over the 340B program was vested with the Department of Health and Human Services (HHS), which delegated authority to the Health Resources and Services Administration (HRSA) . InitialBox. Disproportionate share hospitalsChildren’s hospitalsCritical access hospitalsFreestanding cancer hospitalsSole community hospitalsFederally qualified health centers and look-alikesHealth centers for residents of public housingFamily planning clinicsClinics receiving grants for outpatient early HIV/AIDS intervention servicesState AIDS drug purchasing assistance programsBlack lung clinicsComprehensive hemophilia diagnostic treatment centersNative Hawaiian health centersUrban Indian organizationsRyan White program granteesClinics receiving funds to treat sexually transmitted diseasesClinics receiving funds to treat tuberculosisRural referral centersThe 340B program places 2 key requirements on covered entities’ participation. First, it prohibits covered entities from duplicate discounting, or purchasing a drug at a 340B discount and submitting a claim to Medicaid for reimbursement that results in a rebate paid to the state Medicaid agency. Second, the 340B program bars covered entities from reselling 340B discounted drugs or providing them to patients not receiving care from the covered entity, a practice called “diversion.” Covered entities are subject to audits to ensure compliance with these provisions.13 We conducted a scoping review to assess the foundations of and outcomes associated with the 340B program.Critics of the 340B program, led by the pharmaceutical industry, have expressed concern about the program’s growth in recent years.14 and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.15Our study followed the scoping review methodology set forth by Arskey and O’Malley340B, 340B Drug Pricing Program, 340B Drug Discount Program, and 340B program  website, and the US Department of Health and Human Services Office of the Inspector General (HHS-OIG) website. Searches were updated iteratively from May 2022 to February 2023. Search terms included variations of Our search yielded 900 documents, of which 289 met our inclusion criteria: 83 articles from PubMed, 12 articles from Embase, 2 articles from EconLit, 1 article from NBER, 28 articles from Westlaw, 23 legislative history documents, 103 articles from Google, 11 GAO reports, and 26 HHS-OIG Reports . This li18 In 1992, there were approximately 1000 covered entities ; by 2021, there were over 50 000.19 In 2021, approximately 60% of covered entities were hospitals (including child sites), while 40% were federal grantee clinics.19 The 340B program now includes more than 40% of US hospitals.20Included articles and reports revealed the dramatic increase in covered entities participating in the 340B program since its inception.21 Another study estimated that covered entities’ collective profits doubled from $20.2 billion in 2015 to $40.5 billion in 2019.22The 340B program can be lucrative for hospitals. One study found that hospitals’ mean estimated 340B profits from Medicare Part B in 2016 were $2.5 million, whereas median profits were $0.8 million, equal to 0.3% of hospital operating budgets or 9.4% of uncompensated care costs.23 Another study similarly found that disproportionate share hospitals joining before 2004 were located in counties with lower income levels and higher uninsurance rates.24The locations of covered entities, particularly hospitals, have changed over time. One study found that disproportionate share hospitals joining the 340B program since 2004 served higher-income communities compared with disproportionate share hospitals joining before 2004.29 One study found that 340B participation of disproportionate share hospitals was associated with a 29% increase in charity care spending, a 4% increase in discounted care, and a 19% increase in the income eligibility limit for discounted care, but was not associated with the offering of low-profit medical services.30 Another study found that 340B hospitals provided more medication access services and outpatient treatment services for drugs, alcohol, and HIV/AIDS compared with non-340B hospitals.31Covered entities are not required to report how they use 340B revenue as a condition of participation, creating challenges in studying this spending. In spite of this limitation, 340B revenue appeared to fund a range of health care services and programs. However, study findings conflicted as to whether the revenue is primarily directed toward charity care and low-income populations. Surveys and self-reported data from covered entities indicated that 340B program revenue funded free or low-cost medications for patients and subsidized uncompensated care and specialty clinics for diabetes, cancer, stroke, and brain injuries.32 found no evidence that hospitals increased uncompensated care after joining the 340B program. The GAO found in a study of almost 3000 hospitals that, although most 340B hospitals provided more uncompensated care and charity care than nonparticipating hospitals, 14% of the 340B disproportionate share hospitals studied were among the bottom quarter of all hospitals studied in providing uncompensated care.20 Overall, 340B hospitals also increasingly purchased outpatient oncology clinics, moving oncology care from community-based practices to hospital outpatient sites.34 This consolidation may increase cost of care because outpatient sites often provide more expensive services not offered in physician’s offices.34 However, similar consolidation was observed among oncology practices and non-340B hospitals,35 making unclear the association with the 340B program.By contrast, 1 study36 One study37 concluded that the 340B program saved sexually transmitted disease clinics almost 100% on the cost of penicillin treatment for syphilis, whereas another found that 55% of rural hospitals used 340B revenue to be able to stay open.38 Similarly, a study39 found hepatitis C virus infection treatment programs would lose $370 per patient and not be financially sustainable without revenue from the 340B program.Fewer included articles and reports focused on nonhospital 340B covered entities. In a survey of 31 hemophilia treatment centers, all reported that salaries of staff  were supported by 340B revenue and almost half used 340B revenue to provide patients with financial assistance for transportation to access care.40 A 2020 GAO study41 of 1242 HRSA audits from 2012 through September 2020 found similarly high rates of noncompliance. Examples of noncompliance included recordkeeping flaws regarding 340B program eligibility, duplicate discounting, and diversion.Covered entities’ compliance with 340B program requirements has been closely scrutinized. The HRSA audits of covered entities between 2012 and 2016 found noncompliance rates (rates of 1 or more violations of 340B program requirements) between 63% and 82%.43 Contract pharmacies were essential to the program because most covered entities lacked in-house pharmacies42 and contract pharmacies made receiving prescription drugs more convenient for patients.43 Contract pharmacies dispense drugs purchased by covered entities at 340B discounts to patients of the covered entities. In return, the pharmacies are paid a fee per prescription filled and in some cases a percentage of the revenue from 340B prescriptions.26 One study22 estimated that in 2019, contract pharmacy arrangements generated $5 billion in profit from 340B sales.Included literature revealed that covered entities have contracted with external pharmacies to dispense discounted drugs since the start of the 340B program.42 HRSA advised in 2010 that covered entities could use an unlimited number of contract pharmacies.44 As a result, the number of contract pharmacies working with covered entities increased from approximately 1000 in 2010 to almost 28 000 in 2021.19 In 2017, approximately 25% of US pharmacies participated in the 340B program,45 with the 5 largest pharmacy chains accounting for 60% of contract pharmacies.26 As of July that year, the number of contract pharmacies employed by individual covered entities ranged from 0 to 439.26 The average among all covered entities using at least 1 contract pharmacy was 12, whereas the average among disproportionate share hospitals was 25.Investigations highlighted the dramatic increase in pharmacy participation since 2010. Although previous guidance only permitted a single contract pharmacy,26 found that 45% of disproportionate-share hospitals engaged a contract pharmacy more than 1000 miles away. One study45 of contract pharmacies found many stationed in higher-income, less diverse neighborhoods. Another study46 found that contract pharmacies for safety net clinics were opening in poorer communities, whereas the locations of contract pharmacies for 340B hospitals were uncorrelated with rates of poverty or uninsurance. A third study47 found that contract pharmacies were more prevalent in poorer communities but less prevalent in communities with high uninsurance rates.The location of contract pharmacies varied widely. Although many contract pharmacies were within 30 miles of the covered entity in 2017, a GAO report48 found that 340B prescriptions dispensed by contract pharmacies had a higher share of antivirals and specialty medicines and a lower share of generic drugs.The types of 340B discounted drugs dispensed by contract pharmacies differed from all prescriptions dispensed by pharmacies. For example, 1 study50 Manufacturers have tried to limit the scope of the program, and in turn the amount of their 340B discounted sales, by challenging regulations implemented by HRSA and placing restrictions on their participation with contract pharmacies.52Pharmaceutical manufacturers face high costs through participation in the 340B program because they are required to provide steep discounts on their drugs to levels far below private market prices. In 2020, manufacturers sold more than $80 billion in drugs  at 340B discounted prices of approximately $38 billion.53 A separate study54 calculated that a 60% reduction in the list prices of hepatitis C drugs may have actually saved manufacturers $182 million from lower 340B discounts, whereas another suggested that the 340B program may have contributed to a 10% annual increase in list prices of cancer drugs between 1995 and 2013.55 Still, to our knowledge, no study investigated the association between the 340B program and manufacturers’ drug pricing practices broadly.The 340B program’s effects on drug pricing remain unresolved. One study uncovered no data supporting an association between 340B discounts and related inflation penalties with manufacturer price increases in Medicare Part D.36 However, 1 study56 found no relationship between the 340B program and increased provision of such services to low-income patients. Little research was identified on the diversity of patients in the 340B program or the benefits of the program to racial and ethnic minority groups.Patients benefited from the 340B program through the programs and health care services that covered entities provided to them. Surveys revealed that some covered entities used 340B funds to open specialty clinics, dispense free or low-cost medications, offer patients transportation, and provide patient education services.26 A 2012 study57 comparing uninsured patients’ prescription drug costs and savings related to patient assistance programs and the 340B program at 2 community health centers found that patients receiving 340B medications had an average medication cost of $11.50 and average savings of $62.31 relative to list prices. However, in a GAO survey of 55 covered entities, 25 reported that they did not offer discounts at their contract pharmacies.26 Another study58 found that out-of-pocket costs increased for patients paying cash at 340B covered entities.There was mixed evidence on the association between the 340B program and patient cost savings. Some studies showed that some patients received free or low-cost medications from covered entities or contract pharmacies.59 found an association between the 340B program and increased medication adherence: 340B clinics had 5% higher medication adherence for patients with diabetes and 3% higher for patients with hyperlipidemia and hypertension compared with the general patient population, and 340B hospitals had 7% higher medication adherence for patients with diabetes, 6% higher for patients with hyperlipidemia, and 5% higher for patients with hypertension. However, a different study56 of 340B-eligible disproportionate share hospitals found no relationship between 340B program eligibility and mortality rates.The association of the 340B program with patient outcomes was also mixed. One studyOur scoping review revealed that the 340B program has grown substantially since it was launched and provided meaningful benefits to covered entities, pharmacies, and patients. Covered entities used revenue from the 340B program to expand health care services and programming, open specialty clinics, provide medications at reduced costs to patients, and subsidize uncompensated care and staff salaries. Patients of covered entities received greater access to health care services, but there was mixed evidence as to lower medication costs. However, covered entities—notably disproportionate share hospitals—also used 340B revenue for purposes seemingly unrelated to underserved patient care, including opening sites in higher-income neighborhoods and acquiring outpatient physician practices.52 District courts have reached different conclusions,63 and there has been only 1 appeals court ruling thus far, supporting manufacturer restrictions on 340B drug sales.64 Since then, at least 20 manufacturers have set conditions on their deliveries to contract pharmacies, although with other cases still pending, the propriety of these moves remains a source of legal uncertainty.65Pharmaceutical manufacturers, meanwhile, missed out on revenue as a result of the 340B program and pursued several legal challenges against it. Most recently, manufacturers challenged the HRSA mandate that manufacturers deliver 340B drugs to contract pharmacies.The findings of this study demonstrate that the 340B program offers value to many stakeholders in the US health care system. Studies have shown that many covered entities used 340B revenue to provide additional health services to patients, subsidize uncompensated and charity care, and provide free or low-cost medications to patients. These findings should be considered against the increasing criticism of the 340B program. The benefits from the 340B program may vary based on the category of the covered entity. In particular, federally-funded clinics and disproportionate share hospitals likely benefit in different ways, with clinics seeming more reliant on 340B revenue to stay open and disproportionate share hospitals using 340B revenue to expand health care services. Still, our findings show that the 340B program has been successful in aiding safety net hospitals and clinics serving low-income and underserved populations and that the consequences of eliminating or substantially restricting the program would be great.68 In 2017, the Centers for Medicare & Medicaid Services announced that it would decrease Medicare Part B reimbursement for 340B hospitals from average sales price plus 6% to average sales price minus 22.5% to account for discounts received under the 340B program. However, in 2022, the Supreme Court rescinded the rule,69 and a federal court required repayment to the hospitals at the higher reimbursement rate.70 Studies also conflict on the extent of patient financial benefits, particularly on whether 340B discounts are passed on to patients or are benefiting covered entities in unintended ways.59 These critiques are more concerning in the context of audits showing duplicate discounting and diversion.41 As the 340B program grows, involving more covered entities and contract pharmacies and reaching more patients, the need for additional data reporting and oversight is critical.Even with the strengths of the program, our review identified facets of the 340B program for potential reform. Covered entities are financially benefitting from the 340B program, yet some hospitals may be operating inconsistently with its goals. There are no requirements on how covered entities spend their 340B revenue, and it is difficult to study these activities and evaluate their effects. Covered entities’ use of 340B funds has been a controversial area that received pushback from the federal government.71 Of specific concern are disproportionate share hospitals, which have increasingly served higher-income communities and have been criticized for their practices.24 At a minimum, all covered entities should be required to report to HRSA data on 340B revenue and their spending to expand health care service offerings and programming. Additional requirements could be set for the proportion of 340B revenue that must be put toward community benefit spending. These rules will promote trust and accountability in the 340B program and support future evaluations of its successes and effectiveness. For example, data on use of 340B funds can inform rules on spending of 340B revenue or changes in the calculation of 340B discounts. Congress should also delegate HRSA additional rulemaking and enforcement authority to strengthen its administration and oversight of the 340B program. This authority would bolster the ability of HRSA to clarify program requirements and address compliance violations. It would additionally limit the need for Congressional intervention in the future.One avenue for reform would be new legislation requiring all covered entities to face greater transparency requirements. Federal grantees currently have some reporting conditions, including how they spend grant funds and data on the clients serviced and services provided.72 The study did not formally evaluate the quality of the evidence, identify potential biases in the individual or collective studies, or address the relative weight of the evidence in presenting the findings. Further, scoping reviews focus on breadth rather than depth on a particular topic. However, this method was most appropriate given our objectives to provide an overview of several aspects of the 340B program with analyses from several perspectives.This study was limited by a lack of critical information on the 340B program, such as pricing, savings, and revenue, which were confidential, proprietary, or unavailable. Most literature focused on 340B disproportionate share hospitals, with less research on federal grantees and nonhospital covered entities. Greater attention is needed on the effects of the 340B program on these 340B-covered entities. Inherent limitations in scoping review methodology should also be noted.In this scoping review of the 340B program, we found evidence that the 340B program benefited hospitals, clinics, pharmacies, and patients, with notable costs to pharmaceutical manufacturers. Increased transparency regarding the use of 340B program revenue and strengthened rulemaking and enforcement authority for HRSA would support compliance and help ensure the 340B program achieves its intended purposes.


Natural disasters cause long term psychological consequences, especially post-traumatic stress disorders. It has been regarded as the most prevalent of psychiatric disorders after a natural disaster. The purpose of this study is to estimate the prevalence of Post-Traumatic Stress Disorder (PTSD) and determine its associated factors in adult survivors three years after the 2015 Nepal earthquake.A cross-sectional descriptive design was used where 1076 adults within the age range of 19–65 were randomly selected and interviewed from four adversely affected districts due to the 2015 earthquake. Instruments included a demographic questionnaire, an earthquake exposure questionnaire, the Oslo Social Support Scale (OSSS), and the Post-traumatic Stress Disorder Checklist-Civilian Version (PCL-C). Descriptive and inferential statistics were applied using Statistical Package for Social Science (SPSS) Version 16 for data analysis.p < 0.001). Participants with medium and very high-level damage to personal property were more likely to have PTSD.The prevalence of PTSD among earthquake survivors was 18.9%. The multivariate logistic regression showed that gender, ethnicity, education, occupation, social support and severity of damage to house and property were significantly associated with PTSD. Odds of having PTSD was 1.6 times higher among females  and nearly 2 times higher amongst illiterate survivors . Participants from the Janajati ethnic group and those who had a business occupation had a 50% lower risk of having PTSD. Around 39% of the participants had moderate social support and had 60% lower odds of having PTSD compared to those with poor social support (AOR = 0.4, 95%CI: 0.2–0.5, Post-traumatic stress disorder remained prevalent amongst survivors three years after the 2015 Nepal Earthquake. It is important to provide psychological and social support for survivors to decrease the health burden from PTSD. Socio-demographic characteristics such as females, farmers, those survivors who endured significant personal property damage were at higher risk.The online version contains supplementary material available at 10.1186/s12888-023-04836-3. Nepal was hit by a devastating 7.8 magnitude earthquake with its epicenter in Barpak, Gorkha District, northwest of Kathmandu, at 11:55 a.m on April 25, 2015 . 17 days later, on May 12, 2015, another 6.8 magnitude aftershock caused further damage and suffering . AccordiEarthquakes are one of the world’s major calamities. With very little warning, it destroys personal property and lives . It may More than two-thirds of the world's populations have experienced an earthquake at some point in their lives, resulting in a wide range of mental and physical health consequences . ApproxiNumerous previous studies outside of Nepal have shown the prevalence rate of depression after earthquakes ranging from 16 to 28 percent, while PTSD prevalence rates range from 7 to 40 percent . SimilarPrevious mental health research in Nepal has focused on heightened rates of psychological distress among a substantial proportion of the population affected by the 2015 Nepal earthquakes, with a smaller proportion reporting more severe mental health and psychosocial difficulties . ResearcAccording to cross-sectional community-based research, 27.5 percent to 33.7 percent of individuals passed the Beck Depression Inventory criterion for depression, 22.9 percent to 27.7 percent for anxiety and 9.6 percent for PTSD , 16. AccIn a quantitative survey of 513 community members, those with symptom scores suggesting depression (34.2 percent), anxiety (33.8 percent), and alcohol-use issues (20.4%) were in greater proportions than those with PTSD symptoms (5.2 percent) .According to a study by S. Sherchan et al., following the earthquake, mental health services were offered in the form of hospital-based clinical services, mobile health camps, and health worker training workshops to deliver basic mental health services .Despite the fact that long-term psychological consequences of disasters are significant and common, little attention has been paid to the long-term psychological consequences of disasters . More reThe research was a descriptive cross-sectional study conducted in four earthquake-affected districts  in 2019, three years after the Nepal earthquake. The study population were young, middle and older adults who were the survivors of the devastating earthquake. Data was collected from 1076 randomly selected adults from the four adversely-affected districts. Participants aged between 19 and 65 years, who had experienced the earthquake, 2015 in Nepal and spoke Nepali were included in the study. Participants who had hearing problems, poor verbal communication, severe disease conditions, who were already identified or recorded in a health facility as intellectually disabled, dementia or any other major psychosis, and severe mental disorders under medication were excluded from the study.Sample size calculation was done Fig.  for the Multi-stage random sampling was done. At the first stage (firstly), three rural municipalities  and one urban municipality (Bhaktapur) were selected randomly. The list of the total number of administrative wards in each of the four municipalities and the total number of houses destroyed in each of the wards was obtained from the ward offices. The household destruction percentage of each ward was calculated. On the basis of the household destruction percentage, the wards with over 50 percent household destruction were considered as the most affected. Secondly, one of the most affected wards was selected through simple random sampling (lottery method) from each four municipalities. Thirdly, systematic random sampling was done to select households. Due to the earthquake and internal migration, it was difficult to determine the population size and the list of people (age 19–65 years) in selected wards.The total number of households and the sampling frame (list of households) in the selected wards were obtained from respective ward offices. The total number of present households in each ward was divided by the required sample size of the respective ward to determine the different kth intervals for each of the four wards.The first household was selected through a lottery method. Then, every kth household was selected for the study from the list of households in each ward accordingly until the required sample size was met. Only one participant of age 19 to 65 years within a household was recruited for interview through lottery method to ensure independence of study subjects.This study was approved by the Institutional Review Committee of Kathmandu University School of Medical Sciences at Dhulikhel, Nepal. All participants were informed about the purpose and procedures of the study. Participation in the study was voluntary. They were allowed to withdraw their consent and discontinue the research interview at any time. Before the interview began, written informed consent was taken from the participants. Anonymity and privacy of the participants were maintained during data collection.Face to face interview was conducted using a structured questionnaire. Before data collection, four enumerators with Bachelor’s degree in nursing were called together to review the questionnaire and each item was explained. They were also trained for face-to-face interview methods. The first part of the questionnaire included socio-demographic questionnaire such as age, gender, marital status, ethnicity, religion, occupation and literacy status. The second part included a questionnaire about earthquake exposure such as self-injury, loss of family or friends, loss of house and property, witness of burial, etc. Earthquake exposure was considered “Exposed” when participants answered “Yes” to any of these earthquake exposure related questionnaires.In the third part, post-traumatic stress symptoms were assessed using the subscale of PTSD Checklist-Civilian Version (PCL-C) to assess PTSD prevalence. The PCL-C version is a commonly used instrument to assess PTSD. It has 17 items which measures three clusters of symptoms that record into diagnostic Criteria B (re-experiencing), C (avoidance/ numbing), and D  for PTSD in the Diagnostic statistical manual for mental health (DSM-IV) was adopted  , 26. ThiThe social support scale was the fourth section of the questionnaire. The Oslo 3-items Social Support Scale (OSSS-3) is one of the best indicators of mental health since it is a brief measure of social functioning. It assesses the number of persons with whom the respondent feels close, as well as the level of attention and care provided by others and the ease with which they can seek practical assistance. The Oslo Social Support scale scores ranged from 3–14, with 3–8 indicating low (poor) support, 9–11 indicating moderate support, and 12–14 indicating strong support . InternaFinally, data was collected from 1076 total adult survivors (one in each house) selected from four different districts.All data were analyzed by statistical software SPSS 16.0. Descriptive analysis was done to report frequency, percentage, mean and standard deviation. Chi-square test was done to find association between PTSD and sociodemographic variables, earthquake exposure variables and social support. Binary logistic regression was used to determine the relationship between PTSD and socio-demographic variables, earthquake exposure variables and social support.P value of < 0.05 was considered to be statistically significant.p = 0.003), gender (p = 0.001), ethnicity (p < 0.001), education (p < 0.001), marital status (p = 0.010) and occupation (p < 0.001). Social support was also associated with PTSD (p < 0.001).Table In the study, most of the participants (88.4%) were young and middle adults where 17.6% of them had PTSD and 28.8% of older adults had PTSD. Again, more than half of the participants (56.3%) were females where 22.3% of females and 14.5% of males had PTSD. More than half of the participants (59.2) belonged to the Janajati ethnic group where 14.8% of them had PTSD. Majority (75.4%) of participants were Hindu and 18% of them had PTSD. Likewise, majority (79.6%) were literate and only 15% of them had PTSD. Most of the participants (82.3%) were married and among them 20% had PTSD. Agriculture was the most common (49.7%) occupation among the participants where 26% of them had PTSD.Regarding social support scale, nearly half of the participants (46%) had poor social support. Among participants with poor social support, 26.3% of them had PTSD. In participants who had moderate social support, only 9.8% had PTSD and in people with strong social support, 19% had PTSD.p = 0.006), self-injured (p < 0.001), witness of injured in earthquake (p = 0.001), witness of buried in earthquake (p = 0.001), witness of death in earthquake (p = 0.002), family members being handicapped (p = 0.005), death of family members (p = 0.012), loss of house and property (p < 0.001) and severity of damage to house and property (p < 0.001). Other exposure variables such as self-handicapped and relatives and friends being handicapped were not associated with PTSD.Majority (87%) of the respondents were exposed to the earthquake characteristics. Regarding earthquake exposure of the participants, most of the exposure variables were associated with PTSD such as self-buried (Majority of the participants (92.4%) had lost house or property in the earthquake. Among them, 20% had PTSD. Among the 82 participants who were self-buried, 30.5% had PTSD. Twenty two percent of the participants who had witnessed death in earthquake had PTSD. Again, among the participants who had death in their family, 26% of them had PTSD. The estimates related to earthquake exposure are not shown in tables.p = 0.008). The people in Janajati ethnicity have 40% lower odds of having PTSD compared to Brahmin/Chhetri . Participants who were illiterate are nearly 2 times more likely to have PTSD compared to literate . Participants who did business had 60% lower risk of having PTSD compared to farmers . The participants with moderate social support had 70% lower odds of having PTSD compared to those with poor social support . Participants who had medium to very high level damage to house and property were nearly 5 times more likely to have PTSD compared to those who did not have any damage to house and property or very less damage .Table Earthquakes cause significant stress and affect a substantial number of people in the world. The 2015 earthquake in Nepal was a dreadful disaster with a painful impact on many survivors. Three years after the disaster, affected people have yet to fully recover. This cross-sectional study emerged within the four selected most affected districts. The PTSD prevalence assessed using PCL-C (DSM-IV) criteria was remarkably high three years after the disaster.The present study found that the prevalence of PTSD three years after a devastating earthquake is 18.9% among earthquake-affected adult survivors, which is consistent with previous studies done in Nepal on mental health problems nine months after the 2015 Nepal earthquake [A study containing forty-six eligible articles showed the combined incidence of PTSD among survivors who were diagnosed, at no more than nine months after the earthquake, was 28.76%, while for survivors who were diagnosed at over nine months after earthquake the combined incidence was 19.48% . This reSimilarly, our prevalence rates are lower than the 40% rate three years after the Turkey earthquake. The epicenter was predominantly government-constructed housing. The study used the Traumatic Stress Symptom Checklist (TSSC), which included 17 DSM IV PTSD, 55.2% female, 33.4% male reported eighteen months after the Kashmir earthquake those people were living in tents, 28.5% reported 11 months after the 2015 Nepal earthquake, 23% reported 14 months after the epicenter of Turkey earthquake, 22.1% reported 8 months after the 2008 Wenchuan earthquake in China , 40–43.th year (2005) (p = 0.0001), using the same scale as ours [Most long-term studies of prevalence of PTSD in disaster exposed survivors show that the prevalence of PTSD decreases with time . In cont as ours .A literature review shows that most researchers who studied PTSD rates occurred around three months after the earthquake . Even afA study done in the Sichuan and Shaanxi provinces of China, 2 earthquake-stricken areas, showed that the 1 –year prevalence of PTSD amongst 2080 adult survivors was 40.1% . SimilarAfter an extensive literature review and comparing our results we conclude that many factors contribute to the prevalence of PTSD symptoms amongst earthquake survivors. Further comparison is limited due to lack of studies measuring the prevalence of PTSD among survivors three years after the earthquake in Nepal. We can also assume that variation may exist between magnitude of earthquake, assessment tools, type of study  and coping strategies adopted by individuals after a traumatic event.p = 0.003) with age group and PTSD. In the age group of 60 and above, participants had the highest prevalence of PTSD (28.8%). These findings were consistent with a study done in Dhading Nepal, 9 months after the earthquake where adolescents and the elderly were associated with a higher incidence of PTSD [In our study, there was a significant association  and other countries  , 61–66. 018 and oIn our study, illiterate survivors were nearly 2 times more likely to have PTSD compared to literate survivors. This is consistent with a study in Wenchuan (2012), where PTSD was found to be 52.6% among respondents with a low level of education (primary and secondary) compared with a university degree (master's and bachelor's degree). Another survey result revealed that in Nepal, the prevalence of PTSD was 13.9% among literate survivors, while illiterate accounted for 38.1% . A lowerThe results of the present study differs from a study conducted in Haiti and other countries  which showed that higher education increases levels of PTSD , 62, 65.Our study found that ethnicity also had an association with PTSD symptoms. In the current literature, ethnicity has not been consistently described as a risk factor associated with PTSD , 68.In our study, the profession of respondents was also found to have an association with PTSD. This is supported by a study conducted in China 5 years after the earthquake in 2013 . The majPeople engaged in other occupations where less likely to develop PTSD when compared with farmers or those engaged in agriculture. Our result was consistent with a study done by Mitsuaki Katayanagi et al. which revealed that after the Great East Japan Earthquake in 2011 nearly half of the farmers who were engaged in agriculture and fishery reported decreased income . It is pp < 0.001). In this study, participants with moderate social support had 70% lower odds of having PTSD compared to those with poor social support . These findings are similar to findings by Asnakew S. et al. who found that participants with poor social support were 3.6 times more likely to develop PTSD than those with strong social support  [In our study perceived social support was associated with PTSD in both univariate and multivariate analysis ( to 6.7) . Other r to 6.7) . Another to 6.7) . This vaThis study showed that there is a significant association between PTSD prevalence and factors such as getting buried after an earthquake, death of a family member, and witnessing others who have been buried, injured ordied. This finding is consistent with other previous studies , 74.ThesAnother factor that was associated with the PTSD prevalence was participant house and property damage. Those who had medium to very high level damage to house and property were 5 times more likely to have PTSD compared to those with no or very less damage. A study in Dhadhing showed participants who had house completely damaged and loss of property had between 4 and 9 times higher odds of having PTSD [Our study is consistent with numerous previous studies , 76, 77.According to Galea and colleagues’ studies, loss of private property (e.g. house) and experiencing economic loss (e.g. loss of job) are major stressors after a disaster .This is Similarly, consistent with our findings, a study  of PTSD concluded that female gender, being married, ethnicity, death of family members, and damaged personal property are associated risk factors , 64. GuoThe study included a large sample of communities most affected by the 2015 earthquake in 4 districts of Nepal. A standardized and validated PCL-C scale was used to assess PTSD symptoms. All interviews were conducted by trained researchers. There was, therefore, little missing data.Our study has some limitations. Our design is a cross-sectional study with data collected at a single time reference point. To better study the effects of time, additional time points would be helpful. This study is quantitative in nature. The findings would be stronger if it had been triangulated by qualitative (study) interviews. Similarly, we also could not assure that all participants properly disclosed their mental illness. Participants were asked if they were suffering from mental illness and/or if they were under medication as exclusion criteria. It is possible that some participants who responded no had an underlying mental illness. We also did not inquire about our respondents’ family income. Family history of psychiatric illness was also not asked.Ideally, the questionnaire should be completed by the respondents, but many of the respondents were illiterate. Researchers had to verbally ask questions and record their responses. This may have introduced bias into the study. Although the self-administration of the questionnaire would be more preferable, our data collector might have faced difficulties in explaining the PCL-C questionnaire during data collection due to its difficulty in comprehension. Recall bias may have also been a limitation. Although widely used around the world, PCL-C is a screening measure for PTSD, not a diagnostic tool. The current study participants with a score of 50 or above greater were classified as having probable PTSD without a clinical interview.Our findings conclude those three years after the 2015 earthquake, adverse mental health impact still. PTSD remains a common mental health problem among survivors. Multivariate logistic regression shows that associated risk factors of survivors with persistent PTSD include gender, ethnicity, educational status, occupation, social support and severity to loss of house and property. To reduce psychiatric problems such as PTSD and to improve overall mental health and wellbeing in earthquake-affected communities, a community-based mental health and psychosocial support program should be implemented. We also recommend further mix method studies for triangulation between quantitative and qualitative information.Additional file 1.


The literature is limited concerning the collaboration between pharmacists and promotoras in the delivery of medication therapy management (MTM) services. Yet, this information could help address a practice gap while improving MTM collaborative care approaches.To identify the knowledge, attitudes, and barriers of clinical call center health professionals  and promotoras towards MTM collaborative care in implementing the Rural Arizona Medication Therapy Management (RAzMTM) program.A descriptive, qualitative study using semistructured focus groups was conducted with call center health professionals and promotoras who participated in the RAzMTM program to improve pharmaceutical care for patients with diabetes and/or hypertension in rural Arizona. Recruitment and consent letters, a demographic questionnaire, and a focus group guide were designed specifically for this project. Three facilitators participated in each focus group—one guided the discussion while the others took notes. Focus groups were audio recorded to verify all responses and transcribed verbatim with omission of participant identifiers. Thematic analysis was conducted by 2 independent researchers who reviewed the transcripts to identify codes, seek consensus, and agree on themes, with negotiation from a third independent researcher.Nine participants took part in 2 focus groups. Participants were predominantly female (89%), college graduates and/or had postgraduate/professional degrees (78%), and were Hispanic or Latino (89%). Five themes were identified: (1) roles and responsibilities of RAzMTM participants; (2) benefits unique to the RAzMTM program; (3) interprofessional experience of RAzMTM participants; (4) professional growth for RAzMTM participants; and (5) opportunities for future improvement. Perceptions of the participants in the RAzMTM program were consistent—experiences of health professionals and promotoras were positive; they recognized the benefit of each other’s involvement in the program; and they learned how to work together to improve patient care. Future recommended program improvements include improving ease of scheduling .These focus group results suggest that provision of telephonic MTM services, using an academic-community partnership, was positively received by participating pharmacists and promotoras. However, future work is needed for continued improvement of strategies to enhance interprofessional relationships in patient chronic disease management. What is already known about this subjectPromotoras are Hispanic/Latino lay health workers who assist patients in their communities by serving as intermediaries between medical providers, pharmacists, and other clinical staff.In 2014, an academic-based medication management center began collaborating with community clinics and independent pharmacies to provide telephonic medication therapy management (MTM) services to patients in rural Arizona as part of the Rural Arizona Medication Therapy Management (RAzMTM) program.Limited data exist regarding the collaboration between pharmacist/pharmacy interns and promotoras in health care settings.What this study addsThis study provided insight into the perceptions and opinions of pharmacist/pharmacy interns and promotoras who participated in the RAzMTM program.This study adds to the body of literature on strategies to improve collaborative care using pharmacists/pharmacy interns, promotoras, and other health care providers.3 The Centers for Medicare & Medicaid Services mandate and oversee health plans to ensure that they provide MTM services to Medicare-eligible patients who meet these qualification criteria: having 2 or more chronic conditions, taking 2 or more chronic medications, and medication costs above an annually specified threshold. Plan sponsors may also offer services beyond these minimum criteria.4 To help patients manage their chronic conditions and medications, MTM encompasses comprehensive medication management services, which includes comprehensive medication reviews (CMRs), medication reconciliation, and adherence to national consensus guidelines.5The published literature is limited regarding collaborative relationships between pharmacists and community health workers, or promotoras, in today’s health care system and, more specifically, as it pertains to the provision of medication therapy management (MTM) services.3 Collaborations between pharmacists and other health professionals (such as promotoras) have been shown to increase benefits of MTM to patients.6A growing body of literature illustrates the efficacy of MTM in improving patient-related health measures and lowering health care costs.7 These individuals are sought out and highly respected because they understand the important situations and circumstances of their fellow community members, since they often live in the communities they serve.7 While these individuals have played an important role in their respective communities for some time, only more recently has their role and status in their communities become more fully recognized.9Promotoras, also commonly referred to as community (lay) health workers or advisors, outreach workers, patient navigators, or peer leaders, are trusted members of the Hispanic/Latino communities that are common in southern Arizona.9 To this end, the Centers for Disease Control and Prevention published a document providing guidance and resources for implementing recommendations for integrating promotoras into community-based efforts in chronic disease prevention.7 However, the evidence supporting this innovative practice does not include mention of the collaboration specifically between pharmacists and promotoras. Nevertheless, efforts are underway to establish standards to allow promotoras to serve as members of the interprofessional team in some health care settings.7Despite the recognition of the contributions of promotoras in the provision of health care services, their roles vary widely in different settings .6 Yet, a gap still exists regarding the role that promotoras can play in helping patients manage their chronic conditions and associated medications with the provision of pharmacist-delivered MTM services. Thus, the purpose of this qualitative study was to describe the perceptions and experiences of pharmacists, nurses, pharmacy interns, promotoras, and other professionals pertaining to their involvement in an academic-community partnership to deliver MTM services as part of the Rural Arizona MTM (RAzMTM) program.In Arizona, a novel program exists whereby promotoras engage patients in MTM services through patient recruitment, home visits, and ensuring patient understanding of recommendations.8In 2014, an academic medication management center began collaborating with community clinics and independent pharmacies to provide telephonic MTM services to eligible Medicare patients with diabetes and/or high blood pressure in rural Arizona, as part of the RAzMTM program. The partner clinic integrated promotoras into service delivery to assist patients with multiple chronic conditions. The role of the promotoras was to act as a patient advocate and serve as the link between the medication management center staff and patients.The current qualitative study used focus groups composed of call center health care professionals  and promotoras to obtain individual and collective perceptions and experiences regarding the RAzMTM pilot program. Separate focus groups were conducted for the pharmacists, interns, and nurse and the promotoras, along with the compliance manager. Thus, the focus groups provided an opportunity to allow participants to openly discuss their opinions, describe their understanding of each other’s roles, and identify facilitators and barriers. The University of Arizona Institutional Review Board approved this study, and it was deemed exempt, or not human subjects research.Individuals were eligible to participate in this focus group study if they were part of the RAzMTM health care professional or administrative staff  who participated in the RAzMTM program between 2014 and 2018. Eligible participants were identified via existing contacts provided by the lead pharmacist in the RAzMTM program. A recruitment letter was sent via email to eligible participants 4 weeks before the planned start date of the focus groups. All participants provided informed consent before the focus groups began.10 Four core questions, developed with prompts and probes to aid the discussion, included inquiries about participants’ work experiences during the RAzMTM program; the benefits or value they observed during the program; the knowledge of and improvements to the program; and the participants’ professional development during the RAzMTM program. The focus group guide questions were prepared in English and Spanish. See Focus group questions were developed specifically for this study by the research team, using previous focus group discussions that elicited perceptions and experiences of participants.A short, online demographic questionnaire was created using Survey-Monkey software . The questionnaire contained 6 items: age, gender, race, ethnicity, education, and postgraduate education. Participants were given the link to the questionnaire and asked to complete it at the end of the focus group session.One focus group was conducted at each of 2 different sites: an MTM call center and a community health clinic located in Arizona. The call center focus group included health care professionals , and the community health center focus group involved 2 promotoras and a quality assurance compliance manager . For both sessions, participants were given the option to join remotely via telephone; approximately half of participants in each group participated in person. Each focus group lasted approximately 60 minutes. Three facilitators attended each focus group: 1 facilitator guided the discussion (Guerra); the second and third facilitators  took notes and recorded the session while also helping to guide the discussion.https://www.rev.com/). Two independent reviewers  conducted thematic analysis of the transcripts via line-by-line coding, with individual codes aggregated into higher-level themes. A third reviewer (Axon) facilitated consensus among the reviewers for the final themes.Audio recordings of the focus groups were transcribed verbatim with omission of participant identifiers, using the online transcription service Rev , pharmacy interns (n = 3), nurses (n = 1), promotoras (n = 2), and a quality assurance compliance manager (n = 1). The sample was predominately female (89%), Hispanic or Latino (89%), and college graduates (78%). The high proportion of female and Hispanic/Latino participants was inclusive of the promotoras, an exclusively female group from the local Hispanic/Latino community. The high proportion of college graduates included the health care professionals providing the MTM services.11Thematic analysis yielded 5 major themes: (1) roles and responsibilities of RAzMTM participants; (2) benefits unique to the RAzMTM program; (3) RAzMTM participants’ interprofessional experience; (4) professional growth for RAzMTM participants; and (5) opportunities for future improvement. Participants provided specific examples of RAzMTM program benefits and opportunities for improvement. Representative quotes for each theme are presented in The pharmacist’s responsibilities were to conduct patient CMRs, contact the promotoras and patients, report their interventions to the clinic, follow up with patients, and serve as preceptor to the pharmacy interns. The interns reported having similar roles to the pharmacist, but they were under the supervision of the pharmacist.The nurse’s role was to handle scheduling and document outcomes following completion of the CMRs to track performance; they also sent out letters and facsimiles to the prescribers and followed up with telephone calls when warranted.The promotoras’ responsibilities were to identify/recruit patients, schedule the telephonic MTM appointments, assist during the appointments, and report findings to the provider.The role of the quality assurance compliance manager was to verify that appropriate documentation was present in the electronic medical records and that pharmacist calls/promotora visits were being scheduled for the patients who qualified for the program.Participants said that the RAzMTM program was beneficial; the call center health professionals  said that having promotoras at patients’ homes during the telephonic MTM appointments was valuable given that they were able to report how patients actually managed their medications at home.The promotoras also said the program benefited the patients; they said patients retained much of the information provided by the pharmacists/pharmacy interns during the telephone MTM appointments.Participants reported that their interprofessional experiences were instrumental in delivering telephonic MTM services to rural Arizonans. In particular, pharmacists commented that having a promotora present helped them communicate with patients from their remote location.Participants experienced professional growth during and after the pilot program. For example, 1 pharmacist commented that they were able to use their experiences from the RAzMTM program when applying to become a residency preceptor, while pharmacy interns gained clinical knowledge that they had not yet encountered in pharmacy school. As the pharmacists counseled patients about their medications, the promotoras were also able to learn about the medications that patients were using.One consistent comment among the participants pertained to appointment scheduling—patients were sometimes out when the pharmacist or pharmacy intern called or the pharmacists were unavailable when the patient was home.Another opportunity for improvement was to get providers involved initially. One pharmacist mentioned she had the opportunity to meet a provider at that clinic and was able to explain the program. She felt that after the conversation, the provider was more accepting of her recommendations.8 This evaluation investigated the views of those who participated in the RAzMTM program from a qualitative perspective.The findings of this focus group study offer important new insights into the value of collaborative, telephonic health care services. A previous evaluation of the RAzMTM program carried out in 2014 from a quantitative approach found that 237 medication-related problems were identified, and 1,1032 health promotion interventions were conducted by the interprofessional team for 517 patients.10 This project followed a similar methodology using focus groups to explore the perceptions of different health care workers who participated in the RAzMTM program.On the other hand, our focus group study looked at the perceptions of health professionals who were providing the MTM services. Previous work has looked at patient perspectives of the RAzMTM program using focus groups.12 Pharmacists and pharmacy interns in this study expressed a clear understanding of their role and responsibilities in this program through several examples, which demonstrated a greater focus on using their clinical knowledge to optimize medication therapy rather than just preparing and dispensing medications. They were also able to advance their professional careers as a result of participating in this program, for example, by learning new clinical knowledge or serving as a residency preceptor. The other professions represented in this study  also had a strong sense of their roles and identified opportunities for professional growth.The first key theme, roles and responsibilities of RAzMTM participants, was interesting from a professional practice perspective. Over the last decade or so, the pharmacy profession has sought to expand the role of pharmacists to make better use of their clinical skills.13 In 2018, Taylor et al. explored physician referral to telepharmacy MTM services using an in-person care coordinator (not a promotora) as an intermediary. The current study supports these findings and provides another example of effective interprofessional collaboration to improve health outcomes.Another important finding from this study was the emphasis placed on working collaboratively with other professions. Other recent studies of novel health care services have also highlighted the importance of interprofessional collaboration for a successful program to improve health outcomes.Perhaps most importantly, participants articulated several examples that demonstrated the benefits of the RAzMTM program for health professionals. This typically led to a greater understanding of each other’s roles and may have led to improved health outcomes for patients. For example, the pharmacist was able to work with a promotora to understand how patients are actually using medications and to identify any issues, and then communicate via the promotora to improve medication therapy and obtain better health outcomes.Along with the benefits of the program, participants suggested areas where the program could be improved. The first recommendation, to resolve scheduling issues, arose due to promotoras having to travel to patients’ homes and then finding that the patients and/or the pharmacist were unavailable. A system to improve the scheduling of appointments that works for all stakeholders, while being respectful of everyone’s time, is recommended. Offering out-of-hours  appointments may be a solution.7 yet conversely may cause additional challenges from a scheduling perspective. However, the findings from this study, including the benefits to both patients and professionals, as well as the opportunities to further improve the program, may be beneficial for others who are considering setting up a similar interprofessional, collaborative telehealth program for rural patients.A second recommendation was to involve more physicians and other primary care providers in the program. This may have benefits by improving the acceptance of pharmacist recommendations, which has previously been reported as a barrier to the value of such programs,Limitations of this study included susceptibility to recall bias given that data were self-reported, and a small sample size reflective of the small size of the RAzMTM program staff that limits the generalizability of these results. In addition, length of service in the program may have also influenced participant perceptions.These focus group results suggest that a telephonic MTM service for a Spanish-speaking rural population, using an academic-community partnership between health care professionals and promotoras, was positively received by the health care professionals who participated in the RAzMTM project. Future work is needed for continued improvement of strategies to enhance interprofessional relationships between pharmacy staff and promotoras in patient chronic disease management. Also, future studies should explore the connection between promotora-assisted MTM services and improved patient outcomes.