Investigating and Developing a Practical Domestic-Medication System of Public Health for Chinese Family
Round 1
Reviewer 1 Report
Particularly in light of the Chinese Zero Covid policy, the Reviewer finds the proffered manuscript both relevant and timely. The Authors astutely note that "...[D]ue to the lack of attention to scientific stockpiling of medications, most respondents do not have a clear plan of stockpiling medications at home and lack a general understanding, especially of the amount of stockpiling of different medications."
A similar line of thought appears to dovetail with the previously noted caveat; "....[A]t present, China has not yet established a mature, scientific, and perfect recycling system for expired drugs [3-5], and such a serious waste of drugs is not conducive to the green and sustainable development of the environment." -- however, unspoken but perhaps most alarming is the notion of hypoactive, inactive or potential toxicity. Here, one may reasonably wonder why the Authors failed to address perhaps the most relevant facet in the dynamic - which may be phrased as "what happens when these expired drugs are ingested (?)". In this case, a continuum of negative outcome might run from expired antacids, to antimicrobials to nitroglycerin. In this Reviewer's estimation, such questions lie precisely at the heart of the matter at hand - and the current draft Manuscript is poorer for their absence.
Author Response
We apologized that for “expired drugs” problems in this study was not described in particular, as it should have been in the manuscript. Thank you so much for the valuable suggestion. We do agree with it and we added more explanations about "what happens when these expired drugs are ingested (?)". It makes the research motivations stronger.
It was modified in the paper.
Reviewer 2 Report
Article with an interesting theme but that does not stimulate reading.
I notice that the presentation of data is not very careful, many tables and figures. The tables should have lines separating the items because it is difficult to understand what corresponds to each item between columns.
The methodology should be more explicit and well organized. It includes several steps, which does not facilitate the understanding of the work development.
I think that greater rigour is needed in the definition of the methods used: how were the families selected? Inclusion criteria; can all families be included or are there specific characteristics?
There is no reference to the request for informed consent, both for the application of the questionnaires and the interviews.
What is the data collection period?
Why the selection of 10 family members?
Figures 1-3 and 6-9 are written in Chinese, which makes them difficult to read;
The font of the figures (questionnaires) is too small to read.
What is the relevance of placing Figure 4? They don't present any analysis and so it doesn't make sense. There should be a connection between the figure and tables 3,4 and 5, highlighting the medicines most referred to by the family.
In table 6 I question how we have 11 answers if 10 family members were selected
I consider that in table 6, in Q8 the analysis is not very clear;
No ponto 3.2.1 - data sumaries you put table 1. Is it table 7?
The graphics exposed in tables 8, 9 and 10 are in very small print, which does not facilitate reading. On the other hand, the colours are not well perceived in relation to what is exposed in the legends. I wonder if it wouldn't make more sense to put a summary table with the most important data for the stockpile; frequency and rank.
In table 11, in the frequency they have 2.6 for others - wouldn't it be important to know which are the other drugs used?
Table 13 is not identified in the text.
You mention that you selected 4 doctors to analyse the questionnaire. What were the criteria for selecting these doctors? What translates clinical experience? What is the area in which they perform their duties? How many years of experience?
They should describe the acronyms - example OTC in Table 16.
I think that in point 4.3 the English is not very clear.
In the context of the introduction and rationale, I think that some information on the most common pathologies of the Chinese population is missing, so that we can then understand a little better the type of medicine that the Chinese have in stock at their homes.
In the conclusion, I would ask in what context do you intend to publicise and distribute the list?
What is the practical usefulness of the tool created?
In terms of bibliographic references, I question the relevance of reference number 15, which is dated 1986. On the other hand, it does not appear referenced in the text.
Author Response
Article with an interesting theme but that does not stimulate reading.
I notice that the presentation of data is not very careful, many tables and figures. The tables should have lines separating the items because it is difficult to understand what corresponds to each item between columns.
We apologized that for the layout problems and it was modified in the paper.
The methodology should be more explicit and well organized. It includes several steps, which does not facilitate the understanding of the work development.
The study is divided into three steps:
- Analysis of the existing drug list: Analyze the strengths and weaknesses of each list and aggregate them into a new list. This list is the original list of our system.
- Family actual drug reserve research: Based on our original list, we developed an interview outline. Through interviews, we verified the feasibility and credibility of our questions, and obtained the general importance of different drugs for a family. Then we drew up a questionnaire based on the results of the interview and collected answers from the public on the Internet. According to the frequency of use of different drugs by the respondents of different ages, regions and family members, we supplemented the inventory reserve quantity (ratio). In order to make all lists more uniform, we take the frequency of use of the first drug category in the original list as the benchmark. Set the use frequency of first aid drugs as 1 to calculate the quantity (ratio) of other types of drugs. We then regressed the actual amount of medications stocked by households and the perceived ranking of the importance of these medications to examine whether their perceptions and behaviors were aligned. The absence of a correlation between the two indicates that the public's perception of the importance of drugs and actual stockpiling behavior do not match, and that a list of drugs including the number of stockpiles is indeed needed as a guide.
- Finally, the built system is verified and reinspected according to the verification results.
Hope it could help you better understanding our plan. :)
I think that greater rigour is needed in the definition of the methods used: how were the families selected? Inclusion criteria; can all families be included or are there specific characteristics?
In principle, all Chinese families could be the subjects of the study. During the interview process, we selected 10 interviewees from different families, ages and regions. Also, there was no restriction on who could fill out the questionnaire, and the questionnaire results were relatively evenly distributed in terms of age, residence, and household status.
There is no reference to the request for informed consent, both for the application of the questionnaires and the interviews.
It was modified in the paper.
What is the data collection period?
The data collection took one week, from July 18 to July 24, 2022.
Why the selection of 10 family members?
The purpose of our interviews was mainly to verify the feasibility and credibility of the questions we asked, and to adjust and improve the questionnaire to increase the number of valid questionnaires based on the analysis of the interview content. Therefore, we believe that 10 interviewees from different families, ages and regions are sufficient to achieve our purpose.
Figures 1-3 and 6-9 are written in Chinese, which makes them difficult to read;
The font of the figures (questionnaires) is too small to read.
All the researches were carried out in China and employed Chinese participants, and Figure 1-3 is the Chinese version of the questionnaire when we collected data. We will attach the English version.
Figure 6-9 was replaced in English.
What is the relevance of placing Figure 4? They don't present any analysis and so it doesn't make sense. There should be a connection between the figure and tables 3,4 and 5, highlighting the medicines most referred to by the family.
Figure 4 shows the key words answered by the interviewees, especially Q3, 4 and 5. We showed the interviewees the contents of Tables 3, 4 and 5, and asked them to answer Q3, 4 and 5 according to these. This is mainly a visualization of the types and contents of medicines reserved by the interviewees. The frequency of interviewees' reference to these contents roughly shows the importance of these drugs to a family.
In table 6 I question how we have 11 answers if 10 family members were selected
It was an error and all data have now been second calibrated. It was modified in the paper.
I consider that in table 6, in Q8 the analysis is not very clear;
It was modified in the paper.
No ponto 3.2.1 - data sumaries you put table 1. Is it table 7?
Yes, and it was modified in the paper.
The graphics exposed in tables 8, 9 and 10 are in very small print, which does not facilitate reading. On the other hand, the colours are not well perceived in relation to what is exposed in the legends. I wonder if it wouldn't make more sense to put a summary table with the most important data for the stockpile; frequency and rank.
Different colours were carried out to represent different ages, locations and the number of families. To facilitate the comparison of different regions, ages, and cohabitants we stack the data we obtained on a graph in Tables 8, 9, and 10. The overlapping area, which means different influence factors indicated similar trends.
In table 11, in the frequency they have 2.6 for others - wouldn't it be important to know which are the other drugs used?
Combined with Table 11 on the stockpile of Others, the ratio was 0.003968 and there were no duplicate answers, so we did not see the need to list them in detail. The reason for the frequency of use score of 2.6 is that we used the Likert scale when investigating, and 2.6 is still a relatively infrequent use.
You mention that you selected 4 doctors to analyse the questionnaire. What were the criteria for selecting these doctors? What translates clinical experience? What is the area in which they perform their duties? How many years of experience?
We chose outpatient doctors because they have diagnosed a wide variety of cases and have some experience in treating various types of conditions. The hospital receives a large number of patients every day, but not all of them are serious enough to require hospitalization for observation and treatment, so patients are first given an initial diagnosis by the doctors in the outpatient department. For patients with mild or chronic conditions, these doctors can treat them directly, so they have a better understanding of the medicines that families can stock to treat mild and moderate conditions. The four doctors we interviewed were all outpatient doctors, differing only in their work experience: the first doctor was 39 years old and had 13 years of experience; the second doctor was 56 years old and had 30 years of experience; the third doctor was 45 years old and had 19 years of experience; and the fourth doctor was 47 years old and had 20 years of experience.
They should describe the acronyms - example OTC in Table 16.
It was modified in the paper.
I think that in point 4.3 the English is not very clear.
It was modified in the paper.
In the context of the introduction and rationale, I think that some information on the most common pathologies of the Chinese population is missing, so that we can then understand a little better the type of medicine that the Chinese have in stock at their homes. In the conclusion, I would ask in what context do you intend to publicise and distribute the list?
Our study is the first step which is a research project, we are going to follow up with more in-depth and professional validation and evaluation of the drug list before we try to recommend and propose to the relevant institutions for publication.
What is the practical usefulness of the tool created?
When a resident is familiar with the stockpile of a certain drug, he can quickly deduce the stock-pile of other unfamiliar drugs through this list according to his age and family situation. This study makes the household stockpile list more relevant and can provide some reference for the general population to stockpile drugs so that the list can realistically solve the problems about the type and quantity of drugs stockpiled by residents in different living environments. It also helps families to stock a reasonable amount of medicines, thus reducing the risk of expired medicines being consumed by family members and the impact of expired medicines on the environment.
In terms of bibliographic references, I question the relevance of reference number 15, which is dated 1986. On the other hand, it does not appear referenced in the text.
We refer to this literature in the section of the Introduction that elucidates the possible influence of region on the drug list because the research in this literature suggests that there are significant differences in the purchasing habits of people in different regions of Italy for psychotropic drugs. China is a very large country with different levels of medical care, different rates of participation in health insurance, and different levels of urbanization, so it is reasonable to assume that region is also important in influencing household medication lists. This literature divides Italy into different regions based on geographical location for the study, so we also divide China into three regions based on geographical location for the study.
Round 2
Reviewer 1 Report
The Reviewer appreciates the efforts Authors have made to address several of Reviewer's stated concerns. However, in Reviewer's estimation, weakness still remains, particularly in noting the severity of potential bad outcomes associated with the use of certain expired drugs.
Author Response
Sorry we didn't show the modified text directily. We added one paragraph (marked with red) in the background part which provides more explanations about "what happens when these expired drugs are ingested (?)". In the last conclusion section mentioned as well. Here it is:
In addition to this, many people tend to ignore the harmful effects of expired drugs on the body [4]. In fact, expired drugs are not only less effective or ineffective, but also may cause drug resistance, allergy, shock and other adverse reactions [22]. For example, expired sulfonamides and penicillins are prone to allergies and shock; expired tetracycline contains degradation products that are tens of times more toxic than tetracycline and can lead to damage to kidney tubular function; nitroglycerin, which is used for angina first aid, is highly volatile and can easily fail due to improper storage, which will reduce its role in first aid, etc. If the storage method is changed, such as put in high temperature environment, humid environment, open the cap, etc., it will lead to moisture absorption, dehydration, mold, changes in the chemical composition or structure of the drug, resulting in some decomposition products of unknown effect, in this case the expiration date of the drug can only be used as a reference. If patients continue to take such expired drugs will not only delay the treatment of diseases, but also produce acute (slow) toxicity and side effects, which may cause unnecessary damage to the human body. (Introduction, Page 1)
