Effects of a multiple health behavior change intervention for colorectal cancer survivors on psychosocial outcomes and quality of life: A randomized controlled trial

Background Multiple health behavior change can ameliorate adverse effects of cancer. Purpose The purpose of this study was to determine the effects of a multiple health behavior change intervention (CanChange) for colorectal cancer survivors on psychosocial outcomes and quality of life. Methods A total of 410 colorectal cancer survivors were randomized to a 6-month telephone-based health coaching intervention (11 sessions using acceptance and commitment therapy strategies focusing on physical activity, weight management, diet, alcohol, and smoking) or usual care. Posttraumatic growth, spirituality, acceptance, mindfulness, distress, and quality of life were assessed at baseline, 6 and 12 months. Results Significant intervention effects were observed for posttraumatic growth at 6 (7.5, p < 0.001) and 12 months (4.1, p = 0.033), spirituality at 6 months (1.8, p = 0.011), acceptance at 6 months (0.2, p = 0.005), and quality of life at 6 (0.8, p = 0.049) and 12 months (0.9, p = 0.037). Conclusions The intervention improved psychosocial outcomes and quality of life (physical well-being) at 6 months with most effects still present at 12 months. (Trial Registration Number: ACTRN12608000399392).

Short-term nutritional supplementation during management of pulmonary exacerbations in cystic fibosis: A controlled study, including effects of protein turnover

Effects of nutritional supplements on minimizing weight loss and abnormalities of protein turnover during pulmonary exacerbations in cystic fibrosis (CF) were studied by controlled trial. Patients received pulmonary therapy and either standard diet (n = 10) or adjunctive enteral supplements (n = 12). Initial protein turnover, measured by [15N]glycine kinetics, showed alterations of protein synthesis (P Syn) and catabolism (P Cat), which correlated with the degree of underweight, and negligible net protein deposition (P Dep). With treatment both groups had significant increases in mean body weight and forced expiratory volume in 1 s, expressed as percent predicted value for height (FEV1) by 3 wk, but a significant correlation between initial underweight and subsequent weight gain was observed only in supplemented patients. Mean P Syn and P Dep increased significantly (p < 0.001) only in the supplemented group. Pulmonary exacerbations in CF have important adverse effects on body-protein metabolism, similar to changes in protein-energy malnutrition and infection. These effects are reversed by short-term nutritional support. Strategic nutritional intervention should thus be considered in management, especially in malnourished patients.

Effects of providing prior experience of a feedlot environment on the performance of feedlot cattle

Cattle sourced for feedlots from extensive properties will generally have little experience of conditions to which they will be exposed in feedlots, eg close contact with humans, confinement, crowding and feed in troughs. Such conditions can result in stress (Fell 1994) which can have adverse effects on health and performance (Moberg 1985). This experiment determined the effect of prior exposure to aspects of a feedlot environment on the feedlot performance of Bos indicus steers. 21st Biennial Conference. 8 - 12 July 1996. University of Queensland. Brisbane.

Effects of severity of threshing damage on seed quality of Gatton panic Panicum maximum)

Different degrees of severity of threshing were imposed during combine-harvesting of seed of Gatton panic, a cultivar of Panicum maximum , to determine effects of degree of threshing damage on subsequent properties of seed. Threshing cylinder peripheral speeds and concave clearances covering the normal range employed commercially were varied experimentally in the harvest of 2 crops grown in north Queensland. Harvested seed was dried and cleaned, then stored under ambient conditions. The extent of physical damage was measured, and samples were tested at intervals for viability, germination, dormancy and seedling emergence from soil in a glasshouse and in the field over the 2 seasons following harvest. Physical damage increased as peripheral rotor speed rose and (though less markedly) as concave clearance was reduced. As the level of damage increased, viability was progressively reduced, life expectancy was shortened, and dormancy was broken. When the consequences were measured as seedling emergence from soil, the adverse effects on viability tended to cancel out the benefits of dormancy-breaking, leaving few net differences attributable to the degree of threshing severity. We concluded that there would be no value in trying to manipulate the quality of seed produced for normal commercial use through choice of cylinder settings, but that deliberate light or heavy threshing could benefit special-purpose seed, destined, respectively, for long-term storage or immediate use.

Timing of weaning and processing: effects on liveweight changes of weaner cattle

To reduce the number of musters and handling costs, calves in extensive cattle herds in northern Australia are processed (vaccinated, ear-marked, de-horned, branded and males castrated) shortly after they are weaned. As stress has adverse effects on health and growth, and weaning is a stressful time for calves, this experiment asked if calf health, welfare and performance were improved when calves had a period with their mothers post-processing, before they were weaned.

Ultraviolet radiation effects on fruit surface respiration and chlorophyll fluorescence

High-value fruit crops are exposed to a range of environmental conditions that can reduce fruit quality. Solar injury (SI) or sunburn is a common disorder in tropical, sub-tropical, and temperate climates and is related to: 1) high fruit surface temperature; 2) high visible light intensity; and, 3) ultraviolet radiation (UV). Positional changes in fruit that are caused by increased weight or abrupt changes that result from summer pruning, limb breakage, or other damage to the canopy can expose fruit to high solar radiation levels, increased fruit surface temperatures, and increased UV exposure that are higher than the conditions to which they are adapted. In our studies, we examined the effects of high fruit surface temperature, saturating photosynthetically-active radiation (PAR), and short-term UV exposure on chlorophyll fluorescence, respiration, and photosynthesis of fruit peel tissues from tropical and temperate fruit in a simulation of these acute environmental changes. All tropical fruits (citrus, macadamia, avocado, pineapple, and custard apple) and the apple cultivars 'Gala', 'Gold Rush', and 'Granny Smith' increased dark respiration (A0) when exposed to UV, suggesting that UV repair mechanisms were induced. The maximum quantum efficiency of photosystem II (Fv/Fm) and the quantum efficiency of photosystem II (ΦII) were unaffected, indicating no adverse effects on photosystem II (PSII). In contrast, 'Braeburn' apple had a reduced Fv/Fm with no increase in A0 on all sampling dates. There was a consistent pattern in all studies. When Fv/Fm was unaffected by UV treatment, A0 increased significantly. Conversely, when Fv/Fm was reduced by UV treatment, then A0 was unaffected. The pattern suggests that when UV repair mechanisms are effective, PSII is adequately protected, and that this protection occurs at the cost of higher respiration. However, when the UV repair mechanisms are ineffective, not only is PSII damaged, but there is additional short-term damage to the repair mechanisms, indicated by a lack of respiration to provide energy.

Row spacing and planting density effects on the growth and yield of sugarcane. 3. Responses with different cultivars.

The promotion of controlled traffic (matching wheel and row spacing) in the Australian sugar industry is necessitating a widening of row spacing beyond the standard 1.5 m. As all cultivars grown in the Australian industry have been selected under the standard row spacing there are concerns that at least some cultivars may not be suitable for wider rows. To address this issue, experiments were established in northern and southern Queensland in which cultivars, with different growth characteristics, recommended for each region, were grown under a range of different row configurations. In the northern Queensland experiment at Gordonvale, cultivars Q187((sic)), Q200((sic)), Q201((sic)), and Q218((sic)) were grown in 1.5-m single rows, 1.8-m single rows, 1.8-m dual rows (50 cm between duals), and 2.3-m dual rows (80 cm between duals). In the southern Queensland experiment at Farnsfield, cvv. Q138, Q205((sic)), Q222((sic)) and Q188((sic)) were also grown in 1.5-m single rows, 1.8-m single rows, 1.8-m dual rows (50 cm between duals), while 1.8-m-wide throat planted single row and 2.0-m dual row (80 cm between duals) configurations were also included. There was no difference in yield between the different row configurations at Farnsfield but there was a significant row configuration x cultivar interaction at Gordonvale due to good yields in 1.8-m single and dual rows with Q201((sic)) and poor yields with Q200((sic)) at the same row spacings. There was no significant difference between the two cultivars in 1.5-m single and 2.3-m dual rows. The experiments once again demonstrated the compensatory capacity that exists in sugarcane to manipulate stalk number and individual stalk weight as a means of producing similar yields across a range of row configurations and planting densities. There was evidence of different growth patterns between cultivars in response to different row configurations (viz. propensity to tiller, susceptibility to lodging, ability to compensate between stalk number and stalk weight), suggesting that there may be genetic differences in response to row configuration. It is argued that there is a need to evaluate potential cultivars under a wider range of row configurations than the standard 1.5-m single rows. Cultivars that perform well in row configurations ranging from 1.8 to 2.0 m are essential if the adverse effects of soil compaction are to be managed through the adoption of controlled traffic.

Blood pressure lowering effects of Lactobacillus helveticus fermented milk containing bioactive peptides Ile-Pro-Pro and Val-Pro-Pro; mechanistic, kinetic and clinical studies

The purpose of the present study was to evaluate the effects of Lactobacillus helveticus fermented milk (peptide milk) containing the casein-derived tripeptides Isoleucyl-prolyl-proline (Ile-Pro-Pro) and Valyl-prolyl-proline (Val-Pro-Pro) on blood pressure and vascular function in hypertensive subjects. The peptide milk lowered systolic and diastolic blood pressure in long-term use in hypertensive subjects when blood pressure was measured by using 24-hour ambulatory blood pressure measurement (ABPM). The blood pressure lowering effect was seen with the dose of 50 mg of tripeptides, and a tendency for lowering blood pressure was also observed when the dose was 5 mg. No adverse effects compared to the placebo group were reported or detected in laboratory analysis. The effect of the peptide milk on arterial stiffness was shown using two different methods, the ambulatory arterial stiffness index (AASI) and pulse wave analysis (PWA). According to the AASI, arterial stiffness was significantly reduced in the peptide milk group compared to the baseline level, but the difference was not significant compared to the placebo group. PWA showed that the peptide milk reduced arterial stiffness significantly compared to the placebo group. Endothelium-independent relaxation (nitroglycerin) and endothelium-dependent relaxation (salbutamol) did not differ between the groups. The blood pressure lowering mechanisms of the tripeptides and the kinetics of Ile-Pro-Pro were investigated using spontaneously hypertensive rats (SHR) and Sprague-Dawley rats. Previous studies have suggested that the blood pressure lowering effect of the tripeptides Ile-Pro-Pro and Val-Pro-Pro is based on angiotensin-converting enzyme inhibition, but the present findings did not agree with these previous studies. It was shown in SHR that calcium, potassium and magnesium may also have an important role in attenuating the development of hypertension as part of the peptide milk effect. In addition, the present study suggests indirectly that improved endothelial nitric oxide release capacity is not the mechanism by which peptide milk mediates its favourable circulatory effects. The kinetics of Ile-Pro-Pro were studied using adult Sprague-Dawley rats. The results showed that orally administered Ile-Pro-Pro is absorbed at least partly intact from the gastrointestinal tract. Radiolabelled Ile-Pro-Pro was distributed in different tissues and considerable radioactivity levels were found in tissues related to the renin-angiotensin system (RAS), adrenals, aorta and kidneys. Ile-Pro-Pro does not bind to plasma proteins, and therefore it is possible that its blood pressure lowering effect is mediated by free Ile-Pro-Pro. In conclusion, consumption of the peptide milk lowers blood pressure and reduces arterial stiffness in hypertensive subjects. Ile-Pro-Pro can be absorbed partly intact from the gastrointestinal tract and might accumulate in tissues related to the RAS. The precise blood pressure lowering mechanism of peptide milk remains to be studied.

Genetic variability in high temperature effects on seed-set in sorghum

Sorghum (Sorghum bicolor (L.) Moench) is grown as a dryland crop in semiarid subtropical and tropical environments where it is often exposed to high temperatures around flowering. Projected climate change is likely to increase the incidence of exposure to high temperature, with potential adverse effects on growth, development and grain yield. The objectives of this study were to explore genetic variability for the effects of high temperature on crop growth and development, in vitro pollen germination and seed-set. Eighteen diverse sorghum genotypes were grown at day : night temperatures of 32 : 21 degrees C (optimum temperature, OT) and 38 : 21 degrees C (high temperature, HT during the middle of the day) in controlled environment chambers. HT significantly accelerated development, and reduced plant height and individual leaf size. However, there was no consistent effect on leaf area per plant. HT significantly reduced pollen germination and seed-set percentage of all genotypes; under HT, genotypes differed significantly in pollen viability percentage (17-63%) and seed-set percentage (7-65%). The two traits were strongly and positively associated (R-2 = 0.93, n = 36, P < 0.001), suggesting a causal association. The observed genetic variation in pollen and seed-set traits should be able to be exploited through breeding to develop heat-tolerant varieties for future climates.

Postoperative Volume Therapy in Cardiac Surgery : Effects on Hemostatic and Circulatory Variables

Background: Patients may need massive volume-replacement therapy after cardiac surgery because of large fluid transfer perioperatively, and the use of cardiopulmonary bypass. Hemodynamic stability is better maintained with colloids than crystalloids but colloids have more adverse effects such as coagulation disturbances and impairment of renal function than do crystalloids. The present study examined the effects of modern hydroxyethyl starch (HES) and gelatin solutions on blood coagulation and hemodynamics. The mechanism by which colloids disturb blood coagulation was investigated by thromboelastometry (TEM) after cardiac surgery and in vitro by use of experimental hemodilution. Materials and methods: Ninety patients scheduled for elective primary cardiac surgery (Studies I, II, IV, V), and twelve healthy volunteers (Study III) were included in this study. After admission to the cardiac surgical intensive care unit (ICU), patients were randomized to receive different doses of HES 130/0.4, HES 200/0.5, or 4% albumin solutions. Ringer’s acetate or albumin solutions served as controls. Coagulation was assessed by TEM, and hemodynamic measurements were based on thermodilutionally measured cardiac index (CI). Results: HES and gelatin solutions impaired whole blood coagulation similarly as measured by TEM even at a small dose of 7 mL/kg. These solutions reduced clot strength and prolonged clot formation time. These effects were more pronounced with increasing doses of colloids. Neither albumin nor Ringer’s acetate solution disturbed blood coagulation significantly. Coagulation disturbances after infusion of HES or gelatin solutions were clinically slight, and postoperative blood loss was comparable with that of Ringer’s acetate or albumin solutions. Both single and multiple doses of all the colloids increased CI postoperatively, and this effect was dose-dependent. Ringer’s acetate had no effect on CI. At a small dose (7 mL/kg), the effect of gelatin on CI was comparable with that of Ringer’s acetate and significantly less than that of HES 130/0.4 (Study V). However, when the dose was increased to 14 and 21 mL/kg, the hemodynamic effect of gelatin rose and became comparable with that of HES 130/0.4. Conclusions: After cardiac surgery, HES and gelatin solutions impaired clot strength in a dose-dependent manner. The potential mechanisms were interaction with fibrinogen and fibrin formation, resulting in decreased clot strength, and hemodilution. Although the use of HES and gelatin inhibited coagulation, postoperative bleeding on the first postoperative morning in all the study groups was similar. A single dose of HES solutions improved CI postoperatively more than did gelatin, albumin, or Ringer’s acetate. However, when administered in a repeated fashion, (cumulative dose of 14 mL/kg or more), no differences were evident between HES 130/0.4 and gelatin.

Topical tacrolimus in atopic dermatitis : Effects of long-term treatment on skin and respiratory symptoms

Objective: Patients with atopic dermatitis often have a poor long-term response to conventional topical or systemic treatments. Staphylococcal superinfections, skin atrophy due to corticosteroid use, and asthma and allergic rhinitis are common. Only a few, usually short-term, studies have addressed the effects of different treatments on these problems. Tacrolimus ointment is the first topical compound suitable for long-term treatment. The aim of this thesis was to evaluate the effects of long-term topical tacrolimus treatment on cutaneous staphylococcal colonization, collagen synthesis, and symptoms and signs of asthma and allergic rhinitis. Methods: Patients with moderate-to-severe atopic dermatitis were treated with intermittent 0.1% tacrolimus ointment in prospective, open studies lasting for 6 to 48 months. In Study I, cutaneous staphylococcal colonization was followed for 6 to 12 months. In Study II, skin thickness and collagen synthesis were followed by skin ultrasound and procollagen I and III propeptide concentrations of suction blister fluid samples for 12 to 24 months and compared with a group of corticosteroid-treated atopic dermatitis patients and with a group of healthy subjects. Study III was a cross-sectional study of the occurrence of respiratory symptoms, bronchial hyper-responsiveness, and sputum eosinophilia in atopic dermatitis patients and healthy controls. In Study V, the same parameters as in Study III were assessed in atopic dermatitis patients before and after 12 to 48 months of topical tacrolimus treatment. Study IV was a retrospective follow-up of the effect of tacrolimus 0.03% ointment on severe atopic blepharoconjunctivitis and conjunctival cytology. Results: The clinical response to topical tacrolimus was very good in all studies (p≤0.008). Staphylococcal colonization decreased significantly, and the effect was sustained throughout the study (p=0.01). Skin thickness (p<0.001) and markers of collagen synthesis (p<0.001) increased in the tacrolimus-treated patients significantly, whereas they decreased or remained unchanged in the corticosteroid-treated controls. Symptoms of asthma and allergic rhinitis (p<0.0001), bronchial hyper-responsiveness (p<0.0001), and sputum eosinophilia (p<0.0001) were significantly more common in patients with atopic dermatitis than in healthy controls, especially in subjects with positive skin prick tests or elevated serum immunoglobulin E. During topical tacrolimus treatment the asthma and rhinitis (p=0.005 and p=0.002) symptoms and bronchial hyper-responsiveness (p=0.02) decreased significantly, and serum immunoglobulin E and sputum eosinophils showed a decreasing trend in patients with the best treatment response. Treatment of atopic blepharoconjunctivitis resulted in a marked clinical response and a significant decrease in eosinophils, lymphocytes, and neutrophils in the conjunctival cytology samples. No significant adverse effects or increase in skin infections occurred in any study. Conclusions: The studies included in this thesis, except the study showing an increase in skin collagen synthesis in tacrolimus-treated patients, were uncontrolled, warranting certain reservations. The results suggest, however, that tacrolimus ointment has several beneficial effects in the long-term intermittent treatment of atopic dermatitis. Tacrolimus ointment efficiently suppresses the T cell-induced inflammation of atopic dermatitis. It has a normalizing effect on the function of the skin measured by the decrease in staphylococcal colonization. It does not cause skin atrophy as do corticosteroids but restores the skin collagen synthesis in patients who have used corticosteroids. Tacrolimus ointment has no marked systemic effect, as the absorption of the drug is minimal and decreases along with skin improvement. The effects on the airway: decrease in bronchial hyper-responsiveness and respiratory symptoms, can be speculated to be caused by the decrease in T cell trafficking from the skin to the respiratory tissues as the skin inflammation resolves, as well as inhibition of epicutaneous invasion of various antigens causing systemic sensitization when the skin barrier is disrupted as in atopic dermatitis. Patients with moderate-to-severe atopic dermatitis seem to benefit from efficient long-term treatment with topical tacrolimus.

The effects of organic environmental toxicants on hard tissue formation in developing tooth : An in vitro study in mice

Dioxins are organic toxicants that are known to impair tooth development, especially dental hard tissue formation. The most toxic dioxin congener is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Further, clinical studies suggest that maternal smoking during pregnancy can affect child s tooth development. One of the main components of tobacco smoke is the group of non-halogenated polycyclic aromatic hydrocarbons (PAHs), a representative of which is 7,12-dimethylbenz[a]anthracene (DMBA). Tributyltin (TBT), an organic tin compound, has been shown to impair bone mineralization in experimental animals. In addition to exposure to organic toxicants, a well-established cause for enamel hypomineralization is excess fluoride intake. The principal aim of this thesis project was to examine in vitro if, in addition to dioxins, other organic environmental toxicants, like PAHs and organic tin compounds, have adverse effects on tooth development, specifically on formation and mineralization of the major dental hard tissues, the dentin and the enamel. The second aim was to investigate in vitro if fluoride could intensify the manifestation of the detrimental developmental dental effects elicited by TCDD. The study was conducted by culturing mandibular first and second molar tooth germs of E18 NMRI mouse embryos in a Trowell-type organ culture and exposing them to DMBA, TBT, and sodium fluoride (NaF) and/or TCDD at various concentrations during the secretory and mineralization stages of development. Specific methods used were HE-staining for studying cell and tissue morphology, BrdU-staining for cell proliferation, TUNEL-staining for apoptosis, and QPCR, in situ hybridization and immunohistochemistry for the expressions of selected genes associated with mineralization. This thesis work showed that DMBA, TBT, TCDD and NaF interfere with dentin and enamel formation of embryonic mouse tooth in vitro, and that fluoride can potentiate the harmful effect of TCDD. The results suggested that adverse effects of TBT involve altered expression of genes associated with mineralization, and that DMBA and TBT as well as NaF and TCDD together primarily affect dentin mineralization. Since amelogenesis does not start until mineralization of dentin begins, impaired enamel matrix secretion could be a secondary effect. Dioxins, PAHs and organotins are all liposoluble and can be transferred to the infant by breast-feeding. Since doses are usually very low, developmental toxicity on most of the organs is difficult to indentify clinically. However, tooth may act as an indicator of exposure, since the major dental hard tissues, the dentin and the enamel, are not replaced once they have been formed. Thus, disturbed dental hard tissue formation raises the question of more extensive developmental toxicity.

Effects of pot fishing on the physical condition of snow crab (Chionoecetes opilio) and southern Tanner crab (Chionoecetes bairdi)

The effects of commercial fishing with crab pots on the physical condition of the snow crab (Chionoecetes opilio) and southern Tanner crab (C. bairdi) were investigated in the Bering Sea and in Russian waters of the Sea of Okhotsk. In crabs that were subjected to pot hauling, the presence of gas embolism and the deformation of gill lamellae were found in histopathological investigations. Crab vitality, which was characterized subjectively through observation of behavioral responses, depended on not only the number of pot hauls but also the time between hauls. Immediately after repeated pot hauls at short time intervals (≤3 days), we observed a rapid decline in vitality of crabs. When hauling intervals were increased to >3 days, the condition of crabs did not significantly change. After repeated pot hauls, concentration of the respiratory pigment hemocyanin ([Hc]) was often lower in the hemolymph of crabs than in the hemolymph of freshly caught animals. Our research indicated that changes in [Hc] in crabs after repeated pot hauls were caused by the effects of decompression and not by starvation of crabs in pots or exposure of crabs to air. We suggest that the decrease in [Hc] in hemolymph of snow and southern Tanner crabs was a response to the adverse effects of decompression and air-bubble disease. The decrease in [Hc] in affected crabs may be a result of mechanisms that regulate internal pressure in damaged gills to optimize respiratory circulation.

Effects of tetrabrominated diphenyl ether and hexabromocyclododecanes in single and complex exposure to hepatoma HepG2 cells

This study was designed to determine cytotoxic effects of PBDE-47 and HBCDs individually or with a mixture of both compounds exposure to Hep G2 cells. The results showed PBDE-47 and HBCDs induced increase of nitric oxide synthase (NOS) activity, release of NO. dissipation of mitochondria membrane potential and cell apoptosis. Exposure to HBCDs induced ROS formation. Moreover, preincubation with PTIO (NO scavanger) and N-acetylcysteine (ROS scavanger) partially reversed cytotoxic effects of these compounds. The possible mechanism is that PBDE-47 and HBCDs could boost generation of NO and/or ROS, impact mitochondria, and result in start-ups of apoptosis program. Cells exposed to mixture of both compounds and each of them showed non-apoptotic rate significant difference, but the combination of them caused more adverse effects on cells. These results Suggest that PBDE-47 and HBCDs in single and complex exposure have the cytotoxic activity of anti-proliferation and induction of apoptosis in tumor cells in vitro. (C) 2008 Elsevier B.V. All rights reserved.

The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.