Understanding community level influences on the prevalence of SARS-CoV-2 infection in England: new insights from comparison over time and space

Understanding and monitoring the major influences on SARS-CoV-2 prevalence is essential to inform policy making and devise appropriate packages of non-pharmaceutical interventions. Through evaluating community level influences on the prevalence of SARS-CoV-2 infection and their spatio-temporal variations in England, this study aims to provide some insights into the most important risk parameters. We used spatial clusters developed in Jahanshahi and Jin (2021 Transportation 48, 1329-1359 (doi:10.1007/s11116-020-10098-9)) as geographical areas with distinct land use and travel patterns. We also segmented our data by time periods to control for changes in policies or development of the disease over the course of the pandemic. We then used multivariate linear regression to identify influences driving infections within the clusters and to compare the variations of those between the clusters. Our findings demonstrate the key roles that workplace and commuting modes have had on some of the sections of the working population after accounting for several interrelated influences including mobility and vaccination. We found communities of workers in care homes and warehouses and to a lesser extent textile and ready meal industries and those who rely more on public transport for commuting tend to carry a higher risk of infection across all residential area types and time periods.

Motivation and Hesitancies in Obtaining the COVID-19 Vaccine-A Cross-Sectional Study in Norway, USA, UK, and Australia

BACKGROUND

Vaccinations protect the public against serious diseases or death; however, some individuals are hesitant in obtaining them. We aim to contribute to the understanding of the challenges of vaccination roll-out by examining the motivations, hesitancies, and their associated factors, in obtaining the COVID-19 vaccines two years into the pandemic.

METHODS

Cross-sectional online surveys were conducted in Norway, the USA, the UK, and Australia (N = 1649). The participants self-reported whether they had obtained one of the COVID-19 vaccines. Those who had obtained a vaccine reported the reason for their motivation, and those who had not obtained a vaccine reported the reason for their hesitancies.

RESULTS

More than 80% of the total sample obtained a COVID-19 vaccine because of public health recommendations and trusted that it was safe. Among those who had not obtained one, the most frequent reason was concerns about side effects. Most who obtained the vaccine reported that they believed in science, but many of those who had not obtained one reported distrust. Among those who had not obtained a vaccine, reports of distrust in policies and science were frequent. Concerns about side effects were more common in males and those with lower education, and those living in rural or remote areas.

CONCLUSION

People who endorsed the vaccine believed that the vaccine reduces the risk of illness, protects the health of others, and had trust in scientific vaccination research. Conversely, the most frequent reason for vaccine hesitancy was concerns about side effects, followed by distrust in healthcare and science. These findings could inform public health strategies that aim to increase vaccination rates.

The Association of Junk Food Consumption with Preadolescents' Environmental Influences: A School-Based Epidemiological Study in Greece

The aim of the present study was to evaluate the impact of environmental influences on Greek preadolescents' junk food consumption. A cross-sectional study, was conducted among 1718 preadolescents (mean (standard deviation(SD)) age: 11.2(0.8) years old; 54% girls) and their parents, during the school years 2014-2016. Parental and child characteristics were collected anonymously, through self-administered and validated questionnaires. Among others, junk food consumption was recorded, classifying children as low, moderate, and high consumers. The majority of the preadolescents were classified as at least moderate junk food consumers, while almost 3/10 children were classified as high junk food consumers. A significantly lower junk food consumption was observed among preadolescents with a healthier family environment, consisting of normal-weight parents who consume junk foods less frequently, prefer home-cooked meals and adhere more to the Mediterranean diet, while more frequent family meals were also associated with lower junk food consumption. In addition, influence from teachers and participation in extracurricular sports activities were significantly associated with lower junk food consumption, while advertisements were found to have a significant negative impact on preadolescents' eating habits. Notwithstanding, peers were not found to influence their dietary choices in terms of junk food consumption. Both parents and teachers seem to be positive influencers on preadolescents' low junk food consumption. The detrimental role of advertisements on junk food consumption is reconfirmed, while peers' influence is not significant on junk food consumption. The need for urgent public health initiatives for the promotion of healthy dietary habits among preadolescents is warranted.

Changes in Physical Fitness during the COVID-19 Pandemic in German Children

With the beginning of the COVID-19 pandemic in December 2019, each country has developed strategies to try to control the virus. The restrictions and subsequent consequences also limited the possibilities and structures for being physically active. Therefore, the aim of this study was to examine changes in physical fitness in a cohort that was investigated over an extended period. Physical fitness testing was conducted with the IPPTP-R in a primary school from a small rural community annually since 2012. Mean values of test items were calculated for each cohort. We conducted an ANCOVA to examine the differences between cohorts PreCOVID and 2020 as the first year of the COVID-19 pandemic, and between PreCOVID and 2021 as the second year of the COVID-19 pandemic. Overall, no evidence for a negative effect of the COVID-19 pandemic on physical fitness in children between the ages of 7 and 9 years was found. In strength tests, performances increased when comparing the PreCOVID cohort and COVID-19 cohorts (Push-Ups: p < 0.001, ηp2 = 0.032; p = 0.017, ηp2 = 0.006). No evidence for a change was found for endurance (6-min Run: p = 0.341, ηp2 = 0.001; p = 0.267, ηp2 = 0.001. The rural community maintained physical fitness despite restrictions and limitations through the environmental circumstances. Considering this, it is a positive example of how adequate long-term efforts promoting physical fitness make an impact and an active friendly environment helps to overcome COVID-19 pandemics limiting the structures for being physically active.

Influences on single-use and reusable cup use: a multidisciplinary mixed-methods approach to designing interventions reducing plastic waste

An estimated 2.5-5 billion single-use coffee cups are disposed of annually in the UK, most of which consist of paper with a plastic lining. Due to the difficulty of recycling poly-coated material, most of these cups end up incinerated or put in landfills. As drinking (take-away) hot beverages is a behaviour, behaviour change interventions are necessary to reduce the environmental impacts of single-use coffee cup waste. Basing the design of interventions on a theoretical understanding of behaviour increases the transparency of the development process, the likelihood that the desired changes in behaviour will occur and the potential to synthesise findings across studies. The present paper presents a methodology for identifying influences on using single-use and reusable cups as a basis for designing intervention strategies. Two behaviour change frameworks: The Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COMB) model of behaviour, were used to develop an online survey and follow-up interviews. Research findings can inform the selection of intervention strategies using a third framework, the Behaviour Change Wheel (BCW). The application of the methodology is illustrated in relation to understanding barriers and enablers to single-use and reusable cup use across the setting of a London university campus. We have developed a detailed method for identifying behavioural influences relevant to pro-environmental behaviours, together with practical guidance for each step and a worked example. Benefits of this work include it providing guidance on developing study materials and collecting and analysing data. We offer this methodology to the intervention development and implementation community to assist in the application of behaviour change theory to interventions.

Condom use in young women using long-acting reversible contraception (LARC): a qualitative study

Young women in Australia disproportionately experience unintended pregnancy and sexually transmissible infections (STIs). As the promotion of highly effective pregnancy prevention methods such as long-acting reversible contraception (LARC) increases, concurrent use of condoms with LARC remains optimal for pregnancy and STI prevention. There is little data exploring condom use behaviour in young Australian women using LARC. In this qualitative study we interviewed twenty women using LARC about their experiences of making decisions regarding condom use. We used inductive thematic analysis to identify factors influencing participant decision-making. We found that while LARC had an impact on condom use and sexual practices, decisions regarding condom use were influenced by multiple factors including mood, menstrual changes related to LARC, and relationship dynamics. Participants' views of 'safe sex' extended beyond pregnancy and STI protection, to include desired outcomes such as pleasure, consent and communication. Access to STI testing and treatment was key to how participants managed STI risk. Findings highlight the need for a more comprehensive approach to safer sex health promotion, and the importance of ensuring STI testing and treatment services continue to be available and accessible to all young people.

Influences of Jieyu Ruanjian Huoxue prescription on hepatic fibrosis indices and APRI in patients with hepatitis B cirrhosis

OBJECTIVE

To investigate the influences of Jieyu Ruanjian Huoxue prescription on hepatic fibrosis indices and aspartate aminotransferase to platelet ratio index (APRI) in patients with hepatitis B cirrhosis (HBC).

METHODS

A total of 140 patients with hepatitis B complicated with cirrhosis who received treatment in our hospital from January 2019 to December 2019 were selected as the research subjects. and Accoridng to the difference of intervention methods, the patients were divided into the study group (n=80, conventional treatment combined with Jieyu Ruanjian Huoxue prescription) and the control group (n=60, conventional treatment). The clinical intervention effects, changes in hepatic fibrosis indices and hepatic function indices, and levels of inflammatory factors before and after intervention were analyzed. In addition, Pearson correlation analysis was conducted to analyze the correlation between fibrosis indices and hepatic function indices in patients with HBC.

RESULTS

The overall response rate in the study group was markedly higher than that in the control group (98.75% vs. 91.67%, P < 0.05). The levels of hyaluronic acid (HA), Type IV collagen (IV-C), aspartate aminotransferase (AST), alanine aminotransferase (ALT), APRI, interleukin-2 (IL-2) and tumor necrosis factor-alpha (TNF-α) in the study group were lower than those in the control group (P < 0.05) during the 1-6 months of follow-up treatment. Pearson correlation analysis exhibited that hepatic fibrosis indices (HA and IV-C) were positively correlated with liver function indices (AST and ALT) (P < 0.05).

CONCLUSION

Jieyu Ruanjian Huoxue prescription can remarkably improve the hepatic fibrosis, abnormal hepatic function, and the level of inflammatory factors in patients with HBC, exhibiting a satisfactory efficacy. Therefore, Jieyu Ruanjian Huoxue prescription is worthy of clinical promotion and implementation.

The influences of behavioral and psychological interventions on the neurological function and MMSE scores in Parkinson's disease patients

OBJECTIVE

To analyze the effects of behavioral and psychological interventions on the neurological function in Parkinson's disease (PD) patients.

METHODS

A total of 103 patients with PD admitted to our hospital were randomly divided into the observation group (OG, n=52) or the control group (CNG, n=51). The CNG was treated with routine nursing, while the OG was treated with behavioral and psychological interventions.

RESULTS

At 1, 2, and 3 months after the nursing, the National Institutes of Health Stroke Scale (NIHSS) scores, the unified PD disease rating scale III (UPDRS-III) scores, and the Pittsburgh Sleep Quality Index (PSQI) scores in both groups were lower than they were before the nursing, the NIHSS, UPDRS-III, and PSQI scores in the OG were lower than they were in the CNG, the General Self-efficacy Scale (GSES) and Mini-Mental State Examination (MMSE) scores and the Barthel scores in both groups were higher than they were before the nursing, and the GSES, MMSE, and Barthel scores in the OG were higher than they were in the CNG (P < 0.05).

CONCLUSION

Behavioral and psychological interventions can improve PD patients' impaired neurological function, self-efficacy, cognitive function, motor dysfunction, sleep quality, and quality of life.

A Qualitative Study of Barriers and Enablers of Physical Activity among Female Emirati University Students

Interventions to promote physical activity participation should reflect social and culturally relevant influences of the target demographic. The aim of this study was to explore perceptions of barriers to and enablers of physical activity participation among female Emirati university students. Five semi-structured focus groups were conducted (n = 25). Participants were asked open-ended questions about benefits, barriers and enablers of physical activity, and recommendations to promote participation. Emergent themes were identified using Nvivo software. Commonly identified benefits included improved health, weight management, improved mood, and stress reduction. The main barriers were low family support, competing time demands from domestic and academic activities, lack of convenient access to women-only facilities, and hot weather. The main enablers and recommendations related to social support from family and friends, accessible and low-cost women-only facilities, and structured supervised sessions. Findings suggest that there are specific social-cultural influences of physical activity among female Emirati university students. Approaches to promote participation could include identifying benefits consistent with family and cultural values, using social media for education, support and modelling, on campus supervised physical activity sessions integrated with the academic timetable, low-cost women-only opportunities in the local residential area, and support for home-based activities.

The Influence of Normal Tissue Objective in the Treatment of Prostate Cancer

PURPOSE

The normal tissue objective (NTO) is a tool used in inverse-planned intensity-modulated radiation therapy to reduce dose spreading to the surrounding tissues. Only a few studies in the present literature are dedicated to understanding the influence of the NTO in radiation therapy planning in patients with prostate cancer or its consequences in the reduction of the dose in the surrounding healthy tissues.

MATERIAL AND METHODS

Our sample consists of 25 patients submitted to different treatment doses. Averages of plans with and without the NTO were obtained from the dose-volume histogram, and behaviours, comparisons, and quality were assessed considering homogeneity, conformity, and radiation plan indexes.

RESULTS

We were not able to find significant differences in the conformity index, homogeneity index, and radiation planning index between groups with and without the NTO or between treatment times. We observed a small advantage in NTO plans regarding hot spots in the central region of the planning target volume.

CONCLUSION

The NTO is an important tool used in the optimization of plans; however, possibly due to the anatomical location of the prostate, we failed to find a significant contribution of its use in the treatment of prostate cancer. Further studies, using a larger sample and different NTO parameters, are needed to confirm our results.

Factors Influencing Food Choice for Independently Living Older People-A Systematic Literature Review

Unyielding, disproportionate growth in the 65 years and older age group has precipitated serious concern about the propensity of health and aged-care services to cope in the very near future. Preservation of health and independence for as long as possible into later life will be necessary to attenuate demand for such services. Maintenance of nutritional status is acknowledged as fundamental for achievement of this aim. Determinants of food choice within this age group need to be identified and better understood to facilitate the development of pertinent strategies for encouraging nutritional intakes supportive of optimal health. A systematic review of the literature consistent with PRISMA guidelines was performed to identify articles investigating influences on food choice among older people. Articles were limited to those published between 1996 and 2014 and to studies conducted within countries where the dominant cultural, political and economic situations were comparable to those in Australia. Twenty-four articles were identified and subjected to qualitative analysis. Several themes were revealed and grouped into three broad domains: (i) changes associated with ageing; (ii) psychosocial aspects; and (iii) personal resources. Food choice among older people is determined by a complex interaction between multiple factors. Findings suggest the need for further investigations involving larger, more demographically diverse samples of participants, with the inclusion of a direct observational component in the study design.

Parental Views of Promoting Fruit and Vegetable Intake Among Overweight Preschoolers and School-Aged Children

Given the importance of parental influence on children’s eating habits, we explored perceptions of parents of overweight (body mass index–for-age percentile ≥85%) preschoolers (3-5 years) and overweight school-aged children (6-12 years) regarding challenges in promoting fruit and vegetable intake and how they and other family members influence their overweight children’s dietary habits. Focus groups were conducted with 13 parents of overweight preschoolers and 14 parents of overweight school-aged children. Codes and themes were developed by inductive data analysis. Four common themes were identified: short shelf life of fresh fruits and vegetables prohibiting parents from purchasing, children’s taste changes in fruits and vegetables, parents having the primary influence on children’s dietary intake, and wanting fruits and vegetables “ready to go.” Parents of school-aged children were more concerned about their children’s weight, and extended family members negatively influenced children’s dietary intake compared with parents of preschoolers. Our findings provide valuable insight for nutrition/health educators when developing family-based interventions for weight management.

Nonmedical prescribing: where are we now?

Nonmedical prescribing has been allowed in the United Kingdom (UK) since 1992. Its development over the past 24 years has been marked by changes in legislation, enabling the progression towards independent prescribing for nurses, pharmacists and a range of allied health professionals. Although the UK has led the way regarding the introduction of nonmedical prescribing, it is now seen in a number of other Western-European and Anglophone countries although the models of application vary widely between countries. The programme of study to become a nonmedical prescriber (NMP) within the UK is rigorous, and involves a combination of taught curricula and practice-based learning. Prescribing is a complex skill that is high risk and error prone, with many influencing factors. Literature reports regarding the impact of nonmedical prescribing are sparse, with the majority of prescribing research tending to focus instead on prescribing by doctors. The impact of nonmedical prescribing however is important to evaluate, and can be carried out from several perspectives. This review takes a brief look back at the history of nonmedical prescribing, and compares this with the international situation. It also describes the processes required to qualify as a NMP in the UK, potential influences on nonmedical prescribing and the impact of nonmedical prescribing on patient opinions and outcomes and the opinions of doctors and other healthcare professionals.

Career expectations and influences among dental students in Malaysia

INTRODUCTION

It is important to understand career expectations of emerging dental graduates if human resources are to be harnessed in support of oral health. The aims of this study were to explore students' career expectations and their perceived influences, and to examine variation according to student and school characteristics.

METHODS

All final-year students registered for 2013/2014 across 11 dental schools in Malaysia were invited to participate in a self-administered questionnaire (n = 530). The instrument explored short- and long-term career expectations, influences and students' background using a mix of open- and closed-ended questions. The chi-square test was used for comparison according to student and school characteristics.

RESULTS

Three-hundred and fifty-six (83%) students, across eight schools, completed the questionnaire. In the short term, undertaking specialist training (46%) was the most commonly cited career goal, and achieving financial stability (79%) was the greatest influence. In the long term, 59% planned to specialise (with a significant difference found according to ethnic group), and 67% considered working full-time, with men significantly more likely to do so than women (P = 0.036). More Malay students (90%) ranked childcare commitments as an important influence on the number of sessions they planned to work per week compared with Chinese students (75%) and Others (74%; P = 0.001). Work-life balance (95%) and high income/financial security (95%) were the main influences on respondents' long-term goals.

CONCLUSION

There was a high level of interest in specialisation and a desire to achieve financial stability and work-life balance in the group of dental students who responded to the survey. Long-term career expectations varied according to student but not according to school characteristics.

Supervisor perspectives on the summative in-training assessment

BACKGROUND

Assessment is a fundamental component of medical education and exists in many formats. In-training assessments are one such example and they serve to provide feedback to learners about their performance during a period of clinical attachment. However, in addition to trainee knowledge and performance, many factors influence the assessment given to a trainee.

METHOD

This study used an anonymous survey to investigate the perceptions of supervisors of the influences on their assessments of Australian dermatology trainees, focusing on the summative in-training assessment (SITA) format.

RESULTS

A response rate of 41% was achieved. The importance of reporting underperformance and providing feedback to trainees was agreed on, but current limitations in the ability of the tool to do this were noted. Implications for practice are discussed including the education and support of supervisors, consideration of logistical issues, the process of SITA completion and supervisor appointment. Further research into the impact of supervisor concerns about potential challenges to a judgement and hesitations about making negative comments about a trainee are required. Examination of the trainee perspective is also required.

CONCLUSION

Quality feedback is essential for learners to guide and improve their performance. Supervisors face many potential influences on their assessments and if these are too great, they may jeopardise the quality of the assessment given. Attention to highlighted areas may serve to improve the process, so allowing trainees to develop into the best clinicians they can be.

Modifiable barriers to leisure-time physical activity during pregnancy: a qualitative study investigating first time mother's views and experiences

BACKGROUND

Evidence suggests physical activity often declines during pregnancy, however explanations for the decline are not well understood. The aim of this study was to identify modifiable barriers to leisure-time physical activity among women who did not meet physical activity guidelines during pregnancy.

METHODS

Analyses were based on data from 133 mothers (~3-months postpartum) who were recruited from the Melbourne InFANT Extend study (2012/2013). Women completed a self-report survey at baseline in which they reported their leisure-time physical activity levels during pregnancy as well provided an open-ended written response regarding the key barriers that they perceived prevented them from meeting the physical activity guidelines during their pregnancy. Thematic analyses were conducted to identify key themes.

RESULTS

The qualitative data revealed six themes relating to the barriers of leisure-time physical activity during pregnancy. These included work-related factors (most commonly reported), tiredness, pregnancy-related symptoms, being active but not meeting the guidelines, lack of motivation, and a lack of knowledge of recommendations.

CONCLUSION

Considering work-related barriers were suggested to be key factors to preventing women from meeting the physical activity guidelines during pregnancy, workplace interventions aimed at providing time management skills along with supporting physical activity programs for pregnant workers should be considered. Such interventions should also incorporate knowledge and education components, providing advice for undertaking leisure-time physical activity during pregnancy.

The load and release characteristics on a strong cationic ion-exchange fiber: kinetics, thermodynamics, and influences

Ion-exchange fibers were different from conventional ion-exchange resins in their non-cross-linked structure. The exchange was located on the surface of the framework, and the transport resistance reduced significantly, which might mean that the exchange is controlled by an ionic reaction instead of diffusion. Therefore, this work aimed to investigate the load and release characteristics of five model drugs with the strong cationic ion-exchange fiber ZB-1. Drugs were loaded using a batch process and released in United States Pharmacopoeia (USP) dissolution apparatus 2. Opposing exchange kinetics, suitable for the special structure of the fiber, were developed for describing the exchange process with the help of thermodynamics, which illustrated that the load was controlled by an ionic reaction. The molecular weight was the most important factor to influence the drug load and release rate. Strong alkalinity and rings in the molecular structures made the affinity between the drug and fiber strong, while logP did not cause any profound differences. The drug-fiber complexes exhibited sustained release. Different kinds and concentrations of counter ions or different amounts of drug-fiber complexes in the release medium affected the release behavior, while the pH value was independent of it. The groundwork for in-depth exploration and further application of ion-exchange fibers has been laid.

Alcohol Use and Related Behaviors among Late Adolescent Urban Youth: Peer and Parent Influences

Peer and parent influences on alcohol use and related risky behaviors were examined in a sample of late adolescent (M = 17.3 years; SD = 1.11 years) urban youth. Participants (N = 400) completed an online measure assessing peer influences of alcohol use and alcohol offers, and parent influences of rules against alcohol use and perceived levels of emotional family support, relative to youths' alcohol use, binge drinking, alcohol-related consequences, and intentions to drink. Hierarchical regression analyses revealed that increased peer alcohol use and alcohol offers were associated with youths' increased drinking, binge drinking, alcohol-related consequences, and intentions to drink. Controlling for peer influences, parental rules against alcohol use were associated with decreased drinking, binge drinking, and intentions to drink; increased levels of family support was associated with decreased alcohol-related consequences and intentions to drink. These findings suggest that parental influences, albeit small relative to peer influences, are associated with fewer instances of monthly alcohol use and related risky behaviors among late adolescent urban youth.

Pediatric self-management: a framework for research, practice, and policy

Self-management of chronic pediatric conditions is a formidable challenge for patients, families, and clinicians, with research demonstrating a high prevalence of poor self-management and nonadherence across pediatric conditions. Nevertheless, effective self-management is necessary to maximize treatment efficacy and clinical outcomes and to reduce unnecessary health care utilization and costs. However, this complex behavior is poorly understood as a result of insufficient definitions, reliance on condition-specific and/or adult models of self-management, failure to consider the multitude of factors that influence patient self-management behavior, and lack of synthesis of research, clinical practice, and policy implications. To address this need, we present a comprehensive conceptual model of pediatric self-management that articulates the individual, family, community, and health care system level influences that impact self-management behavior through cognitive, emotional, and social processes. This model further describes the relationship among self-management, adherence, and outcomes at both the patient and system level. Implications for research, clinical practice, and health care policy concerning pediatric chronic care are emphasized with a particular focus on modifiable influences, evidence-based targets for intervention, and the role of clinicians in the provision of self-management support. We anticipate that this unified conceptual approach will equip stakeholders in pediatric health care to (1) develop evidence-based interventions to improve self-management, (2) design programs aimed at preventing the development of poor self-management behaviors, and (3) inform health care policy that will ultimately improve the health and psychosocial outcomes of children with chronic conditions.

Factors influencing adherence to ART: new insights from a center providing free ART under the national program in Delhi, India

BACKGROUND

Adherence to therapy is central to the success of antiretroviral treatment (ART). With the availability of free ART under the national program in India, cost of ART is no longer the primary determinant of adherence. This study evaluated the adherence and factors influencing it among patients receiving free ART in a public health ART center in India.

METHODS

The adherence and its influences among 250 HIV-positive patients on first line ART for at least 3 months from the ART Center of Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India were analyzed. The adherence was assessed by patients' self report using the adult AIDS Clinical Trial Group (ACTG) questionnaire and counter checked with pharmacy records. The association of various parameters affecting adherence levels was analyzed by using SPSS package and Epiinfo software.

RESULTS

Of the 250 patients, 242 (96.8%) had optimum adherence (>95%) and 8 (3.2%) were "non-adherent." CD4 counts (P = 0.05), high level of belief among patients, patients' knowledge about importance of adherence (P = 0.04), and sound mental health were positively influencing adherence. The main barriers to adherence were poor mental health and negative psychological states in the patients (0.001). The presence of adverse reactions to ART also resulted in poorer adherence.

CONCLUSIONS

The modifiable factors most strongly associated with good adherence rates were higher current CD4 counts, patients' beliefs in ART, and positive mental health. These factors can be targeted by simple, practical interventions to improve and maintain high adherence levels.