Cultural Issues in Medication Adherence: Disparities and Directions

Perspective

Abstract

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient’s family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

KEY WORDS

medication adherence healthcare delivery cultural competence disparities 

Notes

Acknowledgements

Dr. McQuaid is supported by the Hassenfeld Child Health Innovation Institute of Brown University. Dr. Landier is supported by grant R01 CA174683 (PIs: Bhatia/Landier). The authors would like to thank the University of Alabama at Birmingham (UAB) “Understanding and Improving Treatment Adherence: An Interdisciplinary Approach” conference leaders, and Elizabeth Rahn, PhD, for their review and input in the preparation of this manuscript, and Stacey C. Tobin, PhD, for providing editorial support.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Anderson G. Chronic care: Making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation; 2010.Google Scholar
  2. 2.
    Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-75.CrossRefPubMedGoogle Scholar
  3. 3.
    Thille PH, Russell GM. Giving patients responsibility or fostering mutual response-ability: family physicians’ constructions of effective chronic illness management. Qual Health Res. 2010;20(10):1343-52. https://doi.org/10.1177/1049732310372376.CrossRefPubMedGoogle Scholar
  4. 4.
    Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015(3):CD010523. https://doi.org/10.1002/14651858.CD010523.pub2.Google Scholar
  5. 5.
    Colby SL, Ortman JM. Projections of the size and composition of the U.S. population: 2014 to 2060. Washington, DC: U.S. Census Bureau; 2015.Google Scholar
  6. 6.
    MacArthur Foundation. Projections of the U.S. 2010-2040, by immigrant generation and foreign born duration in the U.S. 2012. www.macfound.org/media/article-pdfs/FULL_REPORT.PDF. Accessed April 19 2017.
  7. 7.
    Statistics Canada. Canada at a glance. 2007. www.statcan.gc.ca. Accessed April 19 2017.
  8. 8.
    Sackett DL. Introduction. In: Sackett DL, Haynes RB, editors. Compliance with therapeutic regimens. Baltimore: The Johns Hopkins University Press; 1979. p. 1-6.Google Scholar
  9. 9.
    Chakrabarti S. What’s in a name? Compliance, adherence and concordance in chronic psychiatric disorders. World J Psychiatry. 2014;4(2):30-6. https://doi.org/10.5498/wjp.v4.i2.30.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Vrijens B, De Geest S, Hughes DA, Przemyslaw K, Demonceau J, Ruppar T, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol. 2012;73(5):691-705. https://doi.org/10.1111/j.1365-2125.2012.04167.x.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Shi L, Liu J, Fonseca V, Walker P, Kalsekar A, Pawaskar M. Correlation between adherence rates measured by MEMS and self-reported questionnaires: a meta-analysis. Health Qual Life Outcomes. 2010;8:99. https://doi.org/10.1186/1477-7525-8-99.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Bonner K, Mezochow A, Roberts T, Ford N, Cohn J. Viral load monitoring as a tool to reinforce adherence: a systematic review. J Acquir Immune Defic Syndr. 2013;64(1):74-8. https://doi.org/10.1097/QAI.0b013e31829f05ac.CrossRefPubMedGoogle Scholar
  13. 13.
    Stirratt, MJ, Curtis, JR, Danila, MI, Hansen, R, Miller, MJ, Gakumo, CA. Advancing the science and practice of medication adherence.Google Scholar
  14. 14.
    DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200-9.CrossRefPubMedGoogle Scholar
  15. 15.
    Salt E, Frazier SK. Predictors of Medication Adherence in Patients with Rheumatoid Arthritis. Drug Dev Res. 2011;72(8):756-63. https://doi.org/10.1002/ddr.20484.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Simoni JM, Huh D, Wilson IB, Shen J, Goggin K, Reynolds NR, et al. Racial/Ethnic disparities in ART adherence in the United States: findings from the MACH14 study. J Acquir Immune Defic Syndr. 2012;60(5):466-72. https://doi.org/10.1097/QAI.0b013e31825db0bd.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Oh DL, Sarafian F, Silvestre A, Brown T, Jacobson L, Badri S, et al. Evaluation of adherence and factors affecting adherence to combination antiretroviral therapy among White, Hispanic, and Black men in the MACS Cohort. J Acquir Immune Defic Syndr. 2009;52(2):290-3. https://doi.org/10.1097/QAI.0b013e3181ab6d48.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kressin NR, Orner MB, Manze M, Glickman ME, Berlowitz D. Understanding contributors to racial disparities in blood pressure control. Circ Cardiovasc Qual Outcomes. 2010;3(2):173-80. https://doi.org/10.1161/CIRCOUTCOMES.109.860841.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Adeyemi AO, Rascati KL, Lawson KA, Strassels SA. Adherence to oral antidiabetic medications in the pediatric population with type 2 diabetes: a retrospective database analysis. Clin Ther. 2012;34(3):712-9. https://doi.org/10.1016/j.clinthera.2012.01.028.CrossRefPubMedGoogle Scholar
  20. 20.
    Apter AJ, Boston RC, George M, Norfleet AL, Tenhave T, Coyne JC, et al. Modifiable barriers to adherence to inhaled steroids among adults with asthma: it’s not just black and white. J Allergy Clin Immunol. 2003;111(6):1219-26.CrossRefPubMedGoogle Scholar
  21. 21.
    Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report - United States, 2011. MMWR Suppl. 2011;60(1):1-114.Google Scholar
  22. 22.
    McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage. Ann Intern Med. 2009;150(8):505-15.CrossRefPubMedGoogle Scholar
  23. 23.
    Redmond N, Baer HJ, Hicks LS. Health behaviors and racial disparity in blood pressure control in the national health and nutrition examination survey. Hypertension. 2011;57(3):383-9. https://doi.org/10.1161/HYPERTENSIONAHA.110.161950.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Dubay LC, Lebrun LA. Health, behavior, and health care disparities: disentangling the effects of income and race in the United States. Int J Health Serv. 2012;42(4):607-25.CrossRefPubMedGoogle Scholar
  25. 25.
    Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D. C.: National Academy Press; 2003.Google Scholar
  26. 26.
    Kronish IM, Diefenbach MA, Edmondson DE, Phillips LA, Fei K, Horowitz CR. Key barriers to medication adherence in survivors of strokes and transient ischemic attacks. J Gen Intern Med. 2013;28(5):675-82. https://doi.org/10.1007/s11606-012-2308-x.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Haywood C, Jr., Lanzkron S, Bediako S, Strouse JJ, Haythornthwaite J, Carroll CP, et al. Perceived discrimination, patient trust, and adherence to medical recommendations among persons with sickle cell disease. J Gen Intern Med. 2014;29(12):1657-62. https://doi.org/10.1007/s11606-014-2986-7.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Boarts JM, Bogart LM, Tabak MA, Armelie AP, Delahanty DL. Relationship of race-, sexual orientation-, and HIV-related discrimination with adherence to HIV treatment: a pilot study. J Behav Med. 2008;31(5):445-51. https://doi.org/10.1007/s10865-008-9169-0.CrossRefPubMedGoogle Scholar
  29. 29.
    Capoccia K, Odegard PS, Letassy N. Medication Adherence With Diabetes Medication: A Systematic Review of the Literature. Diabetes Educ. 2016;42(1):34-71. https://doi.org/10.1177/0145721715619038.CrossRefPubMedGoogle Scholar
  30. 30.
    Berry DL, Blonquist TM, Hong F, Halpenny B, Partridge AH. Self-reported adherence to oral cancer therapy: relationships with symptom distress, depression, and personal characteristics. Patient Prefer Adherence. 2015;9:1587-92. https://doi.org/10.2147/PPA.S91534.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Krauskopf KA, Sofianou A, Goel MS, Wolf MS, Wilson EA, Martynenko ME, et al. Depressive symptoms, low adherence, and poor asthma outcomes in the elderly. J Asthma. 2013;50(3):260-6. https://doi.org/10.3109/02770903.2012.757779.CrossRefPubMedGoogle Scholar
  32. 32.
    Shallcross AJ, Becker DA, Singh A, Friedman D, Jurd R, French JA, et al. Psychosocial factors associated with medication adherence in ethnically and socioeconomically diverse patients with epilepsy. Epilepsy Behav. 2015;46:242-5. https://doi.org/10.1016/j.yebeh.2015.01.034.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Briesacher BA, Gurwitz JH, Soumerai SB. Patients at-risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med. 2007;22(6):864-71. https://doi.org/10.1007/s11606-007-0180-x.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Frankenfield DL, Wei, II, Anderson KK, Howell BL, Waldo D, Sekscenski E. Prescription medication cost-related non-adherence among Medicare CAHPS respondents: disparity by Hispanic ethnicity. J Health Care Poor Underserved. 2010;21(2):518-43. https://doi.org/10.1353/hpu.0.0314.CrossRefPubMedGoogle Scholar
  35. 35.
    Lee M, Salloum RG. Racial and ethnic disparities in cost-related medication non-adherence among cancer survivors. J Cancer Surviv. 2016;10(3):534-44. https://doi.org/10.1007/s11764-015-0499-y.CrossRefPubMedGoogle Scholar
  36. 36.
    Forsyth J, Schoenthaler A, Chaplin WF, Ogedegbe G, Ravenell J. Perceived discrimination and medication adherence in black hypertensive patients: the role of stress and depression. Psychosom Med. 2014;76(3):229-36. https://doi.org/10.1097/PSY.0000000000000043.CrossRefPubMedGoogle Scholar
  37. 37.
    Adams AS, Uratsu C, Dyer W, Magid D, O’Connor P, Beck A, et al. Health system factors and antihypertensive adherence in a racially and ethnically diverse cohort of new users. JAMA Intern Med. 2013;173(1):54-61. https://doi.org/10.1001/2013.jamainternmed.955.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Egede LE, Lynch CP, Gebregziabher M, Hunt KJ, Echols C, Gilbert GE, et al. Differential impact of longitudinal medication non-adherence on mortality by race/ethnicity among veterans with diabetes. J Gen Intern Med. 2013;28(2):208-15. https://doi.org/10.1007/s11606-012-2200-8.CrossRefPubMedGoogle Scholar
  39. 39.
    Shavers VL, Lynch CF, Burmeister LF. Racial differences in factors that influence the willingness to participate in medical research studies. Ann Epidemiol. 2002;12(4):248-56.CrossRefPubMedGoogle Scholar
  40. 40.
    Bogart LM, Bird ST. Exploring the relationship of conspiracy beliefs about HIV/AIDS to sexual behaviors and attitudes among African-American adults. J Natl Med Assoc. 2003;95(11):1057-65.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Bogart LM, Wagner G, Galvan FH, Banks D. Conspiracy beliefs about HIV are related to antiretroviral treatment nonadherence among African American men with HIV. J Acquir Immune Defic Syndr. 2010;53(5):648-55. https://doi.org/10.1097/QAI.0b013e3181c57dbc.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Dale SK, Bogart LM, Wagner GJ, Galvan FH, Klein DJ. Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV. J Health Psychol. 2016;21(7):1311-21. https://doi.org/10.1177/1359105314551950.CrossRefPubMedGoogle Scholar
  43. 43.
    National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name. National Institutes of Health. 2016. https://nccih.nih.gov/health/integrative-health#cvsa. Accessed April 19 2017.
  44. 44.
    Adams SK, Koinis-Mitchell D. Perspectives on complementary and alternative therapies in asthma. Expert Rev Clin Immunol. 2008;4(6):703-11. https://doi.org/10.1586/1744666X.4.6.703.CrossRefPubMedGoogle Scholar
  45. 45.
    Nguyen H, Sorkin DH, Billimek J, Kaplan SH, Greenfield S, Ngo-Metzger Q. Complementary and alternative medicine (CAM) use among non-Hispanic white, Mexican American, and Vietnamese American patients with type 2 diabetes. J Health Care Poor Underserved. 2014;25(4):1941-55. https://doi.org/10.1353/hpu.2014.0178.CrossRefPubMedGoogle Scholar
  46. 46.
    Chao MT, Wade C, Kronenberg F. Disclosure of complementary and alternative medicine to conventional medical providers: variation by race/ethnicity and type of CAM. J Natl Med Assoc. 2008;100(11):1341-9.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies. Complement Ther Med. 2004;12(2-3):90-8. https://doi.org/10.1016/j.ctim.2004.09.006.CrossRefPubMedGoogle Scholar
  48. 48.
    McQuaid EL, Fedele DA, Adams SK, Koinis-Mitchell D, Mitchell J, Kopel SJ, et al. Complementary and alternative medicine use and adherence to asthma medications among Latino and non-Latino white families. Acad Pediatr. 2014;14(2):192-9. https://doi.org/10.1016/j.acap.2013.09.006.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Littlewood RA, Vanable PA. The relationship between CAM use and adherence to antiretroviral therapies among persons living with HIV. Health Psychol. 2014;33(7):660-7. https://doi.org/10.1037/a0033519.CrossRefPubMedGoogle Scholar
  50. 50.
    Ekwunife OI, Oreh C, Ubaka CM. Concurrent use of complementary and alternative medicine with antiretroviral therapy reduces adherence to HIV medications. Int J Pharm Pract. 2012;20(5):340-3. https://doi.org/10.1111/j.2042-7174.2012.00204.x.CrossRefPubMedGoogle Scholar
  51. 51.
    Pagan JA, Pauly MV. Access to conventional medical care and the use of complementary and alternative medicine. Health Aff (Millwood). 2005;24(1):255-62. https://doi.org/10.1377/hlthaff.24.1.255.CrossRefPubMedGoogle Scholar
  52. 52.
    Thornton JD, Pham K, Engelberg RA, Jackson JC, Curtis JR. Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences. Crit Care Med. 2009;37(1):89-95. https://doi.org/10.1097/CCM.0b013e3181926430.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Wisnivesky JP, Krauskopf K, Wolf MS, Wilson EA, Sofianou A, Martynenko M, et al. The association between language proficiency and outcomes of elderly patients with asthma. Ann Allergy Asthma Immunol. 2012;109(3):179-84. https://doi.org/10.1016/j.anai.2012.06.016.CrossRefPubMedGoogle Scholar
  54. 54.
    Jandasek B, Ortega AN, McQuaid EL, Koinis-Mitchell D, Fritz GK, Kopel SJ, et al. Access to and use of asthma health services among Latino children: the Rhode Island-Puerto Rico asthma center study. Med Care Res Rev. 2011;68(6):683-98. https://doi.org/10.1177/1077558711404434.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med. 2014;29(2):364-87. https://doi.org/10.1007/s11606-013-2583-1.CrossRefPubMedGoogle Scholar
  56. 56.
    Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084-90.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-15.CrossRefPubMedGoogle Scholar
  58. 58.
    Devine PG. Stereotypes and prejudice: their automatic and controlled components. J Pers Soc Psychol. 1989;56(1):5-18.CrossRefGoogle Scholar
  59. 59.
    Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-8. https://doi.org/10.1007/s11606-007-0258-5.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):e60-76. https://doi.org/10.2105/AJPH.2015.302903.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-10. https://doi.org/10.1007/s11606-013-2441-1.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Williams DR, Wyatt R. Racial Bias in Health Care and Health: Challenges and Opportunities. JAMA. 2015;314(6):555-6. https://doi.org/10.1001/jama.2015.9260.CrossRefPubMedGoogle Scholar
  63. 63.
    Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol. 1998;74(6):1464-80.CrossRefPubMedGoogle Scholar
  64. 64.
    van Ryn M, Hardeman R, Phelan SM, Burgess DJ, Dovidio JF, Herrin J, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30(12):1748-56. https://doi.org/10.1007/s11606-015-3447-7.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Amico, KR, Mugavero, M, Krousel-Wood, MA, Bosworth, HB, Merlin, JS. Advantages to using socialbehavioral models of medication adherence in research and practice.Google Scholar
  66. 66.
    Office of Minority Health. National standards for culturally and linguistically appropriate services (CLAS) in health and health care. U.S. Department of Health and Human Services, Washington, D.C. 2013. https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf. Accessed April 19 2017.
  67. 67.
    Saha S, Korthuis PT, Cohn JA, Sharp VL, Moore RD, Beach MC. Primary care provider cultural competence and racial disparities in HIV care and outcomes. J Gen Intern Med. 2013;28(5):622-9. https://doi.org/10.1007/s11606-012-2298-8.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-34. https://doi.org/10.1097/MLR.0b013e31819a5acc.CrossRefPubMedGoogle Scholar
  69. 69.
    Bosworth HB, Fortmann SP, Kuntz J, Zullig LL, Mendys P, Safford M, et al. Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence. J Gen Intern Med. 2017;32(1):93-100. https://doi.org/10.1007/s11606-016-3851-7.CrossRefPubMedGoogle Scholar
  70. 70.
    DeKoekkoek T, Given B, Given CW, Ridenour K, Schueller M, Spoelstra SL. mHealth SMS text messaging interventions and to promote medication adherence: An integrative review. Journal of Clinical Nursing. 2015;24(19-20):2722-35.CrossRefPubMedGoogle Scholar
  71. 71.
    Mosnaim G, Li H, Martin M, Richardson D, Belice PJ, Avery E, et al. The impact of peer support and mp3 messaging on adherence to inhaled corticosteroids in minority adolescents with asthma: A randomized, controlled trial. J Allergy Clin Immunol Pract. 2013;1(5):485-93.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Barrera M, Castro FG, Strycker LA, Toobert DJ. Cultural Adaptations of Behavioral Health Interventions: A Progress Report. J Consult Clin Psychol. 2013;81(2):196-205. https://doi.org/10.1037/a0027085.CrossRefPubMedGoogle Scholar
  73. 73.
    Zeh P, Sandhu HK, Cannaby AM, Sturt JA. The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review. Diabet Med. 2012;29(10):1237-52.CrossRefPubMedGoogle Scholar
  74. 74.
    Association of American Medical Colleges. Assessing change: Evaluating cultural competence education and training. Washington, D.C.: Association of American Medical Colleges; 2015.Google Scholar
  75. 75.
    Center for Child and Human Development. National Center for Cultural Competence. Georgetown University. 2017. https://nccc.georgetown.edu/. Accessed April 19 2017.
  76. 76.
    Horne R, Chapman SC, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework. PLoS One. 2013;8(12):e80633. https://doi.org/10.1371/journal.pone.0080633 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  1. 1.Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceUSA
  2. 2.Department of Pediatrics, Alpert Medical SchoolBrown UniversityProvidenceUSA
  3. 3.Bradley/Hasbro Children’s Research CenterProvidenceUSA
  4. 4.Department of Pediatrics, School of MedicineUniversity of Alabama at BirminghamBirminghamUSA

Personalised recommendations