ADVERSE DRUG REACTION MONITORING AND REPORTING: KNOWLEDGE, ATTITUDE AND BELIEF OF PHYSICIANS & PHARMACISTS OF RAS AL KHAIMAH, UNITED ARAB EMIRATES (UAE)

Received on 11 July, 2013; received in revised form, 26 December, 2013; accepted, 09 January, 2014; published 01 February, 2014

ADVERSE DRUG REACTION MONITORING AND REPORTING: KNOWLEDGE, ATTITUDE AND BELIEF OF PHYSICIANS & PHARMACISTS OF RAS AL KHAIMAH, UNITED ARAB EMIRATES (UAE)

B.S. Sathvik*¹, Doha M. Osama Chukir ², Elaf Abo-Aldan ² and Madouna N. Soliman ²

Department of Clinical Pharmacy & Pharmacology ¹, Ras Al Khaima College of Pharmaceutical Sciences ²,  RAK Medical and Health Sciences University, Ras Al-Khaimah, United Arab Emirates

ABSTRACT: Adverse drug reactions (ADR) contribute significantly in health care cost through increased patient morbidity and mortality. Thus, there is an urgent need to create awareness among health care professionals towards ADR monitoring and reporting. The aim of our study is to assess the knowledge, attitude and belief of physicians and pharmacists towards ADR. This is a prospective cross-sectional survey based study. Questionnaire consists of 17 open ended and closed ended questions, was prepared and validated for its content and circulated to physicians and pharmacists from the selected hospitals and community pharmacies of Ras Al Khaimah, U.A.E. Majority of the physicians (n=50) were not aware of the ADR reporting system in UAE. Good number (n=19) of physicians did not know whom to report. The most common classes of medications associated with ADR were antibiotics. Great part of the physicians (n=45) have mentioned that only around 10% of their patients report their ADR. Only small number (n=15) of these physicians have reported the ADR to head of department or to drug manufacturer.  Many physicians (n=31) were interested in getting trained on ADR reporting. We conclude that the awareness of ADR Reporting system in Ras Al Khaimah, U.A.E was limited. One of the main reasons for under reporting of ADR was did not know “whom” and “how to report”. Hence, more ADR related awareness is needed to motivate the health care professionals to monitor, and report ADR for improving the health care quality.

Adverse Drug Reactions (ADR), Monitoring, Reporting, Pharmacists, Physicians, Pharmacovigilance

INTRODUCTION:Globally, adverse drug reactions (ADR) are the most important problem representing one of the leading causes of mortality and morbidity in health care facilities ¹. Studies have demonstrated the occurrence of ADR in hospitalized patients ^{2, 3}.

About 0.16% to 15.7% of hospital admissions occur due to ADR ⁴.  Studies conducted in developed countries have highlighted the need of reporting ADR to both local and international pharmacovigilance centers ⁵. Some of these studies have also investigated the reasons for underreporting of ADR ^5-7.

It is well known that both physicians and pharmacists play an important role in monitoring and reporting of ADR ^5-7. It is also evident from previous literatures that in developed countries community pharmacists contribute significantly in reporting of ADR6. Several studies conducted worldwide reveal that knowledge, attitude, belief and perceptions of healthcare professionals appear to be remarkably associated with reporting of ADR ^{5, 8}.

Not much published data is available regarding the ADR monitoring and reporting activities in United Arab Emirates (U.A.E). The regulatory bodies in UAE such as Ministry of Health (MOH), Dubai Health Authority (DHA) and Health Authority of Abu Dhabi (HAAD) are making continuous efforts to create awareness among healthcare professionals to monitor and report ADR in U.A.E ^{9, 10}. A study conducted on detection and preventability of ADR at Al Qassimi Hospital, Sharjah, U.A.E has highlighted the importance of active monitoring in ADR reporting ¹¹. Based on our literature review, no published data was available regarding U.A.E pharmacists’ involved ADR monitoring and reporting related studies.

Since ADR contribute for significant health care cost through increased patient morbidity and mortality ^{1, 3}, there is an urgent need to create awareness among health care professionals towards ADR monitoring and reporting. Identifying the attitude and beliefs of health care professionals towards ADR monitoring and reporting might help in developing and improving the ADR reporting system. With this background this study was designed to assess the knowledge, attitude and belief of physicians and pharmacists towards ADR reporting.

MATERIALS AND METHODS:

Study Design: A prospective cross-sectional survey based study was conducted during October 2011 to February 2012. The required data was collected through surveying physicians and pharmacists of public and private hospitals, primary health care centers and selected community pharmacies of Ras Al Khaimah, U.A.E. A convenient sampling technique was used to determine the sample size. The study was approved by the Ethics and Research committee of Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, U.A.E.

A self-administered knowledge, attitude and belief (KAB) questionnaire was prepared based on the extensive literature review of ADR related research studies and guidelines. The questionnaire consists of 17 open ended and closed ended type of questions. The questionnaire was a two part questionnaire, the first part comprised of demographics of the survey  participants, and the second part included KAB related questions,  which was designed to collect information about the survey participants' knowledge of ADR reporting system, their attitude towards  reporting, reasons for under-reporting  and their interest in getting trained on reporting ADR.

The questionnaire was validated for its content before it was finalized 12. It was then distributed to the participants by the study investigators upon visiting the different study sites. Survey questionnaires were distributed by the study investigators and were collected after a period of 1 – 2 days after distribution, based on respondent’s convenience and availability.

Data Analysis: The collected data was entered into Microsoft Excel worksheet (Microsoft office 2007) for analysis and then transferred to Statistical Package for Social Sciences (SPSS) software program version 18 for further statistical analysis. Data was presented in the form of frequency and percentages.

RESULTS AND DISCUSSION:

Demographics of the survey respondents: A total of 75 physicians and 50 community pharmacists of Ras Al Khaimah, U.A.E. have completed the KAB questionnaire. Ours was the first survey-based study conducted in Ras AL Khaimah, U.A.E which assesses the knowledge, attitude and belief of hospital physicians and community pharmacists towards ADR reporting. However, similar types of studies have been conducted in other parts of the world, which indicates a diverse range in knowledge, attitude and belief of health care professionals towards ADR monitoring and reporting ^13-18.

Responses to KAB Questionnaire Items:

Belief regarding safety of medications: A total of 39 (78%) community pharmacists and 61(81.3%) physicians believed that all the available medications were not safe.

Frequency of noticing ADR: Responses regarding how often the participants noticed ADR in their patients, a good number of the pharmacists 25 (50%) and physicians 43 (57.3%) mentioned it as "rarely" noticed.

Identification of ADR: A total of 27 (54%) pharmacists and 31 (41.3%) physicians mentioned that around 11 - 20% of their patients have reported ADR to them. Most of the pharmacists 34 (68%) mentioned that they confirmed occurrence of an ADR mainly by patient interview, whereas physicians 59 (78.7%) confirmed occurrence of ADR based on their clinical experience (Table 1).

The physicians who participated in the survey confirmed the occurrence of an ADR based on their clinical experience, which was similar to the findings of Kazeem et al., ¹⁹, whereas the pharmacists have mostly confirmed ADR by patient interview. Responses regarding how often the participants have noticed ADR in their patients, majority of the respondents mentioned it as "rarely” noticed. While good number of studies have reported higher rate of ADR observation by physicians and pharmacists. This difference in the observation could be due to the difference in the sample size of the referred studies and secondly, majority of these studies have been conducted in the countries or sites where there is an established ADR reporting system exists ^20-25.

ADR reporting: Only 14 (28%) pharmacists and 10 (13.3%) physicians were aware of the ADR reporting system in U.A.E. Only 9 (18%) pharmacists and 16 (21.3%) physicians mentioned that they have reported ADR to different set-ups.  Out of these, 3 (6%) pharmacists and 11 (14.7%) physicians have reported ADR “twice”. A total of 5 (10%) pharmacists have reported the ADR primarily to the physician, while 5 (6.7%) physicians have reported the ADR to the drug manufacturer.

In the present study, majority of the pharmacists and physicians were not aware of the ADR reporting system in UAE, hence only a small number of them have reported ADR. A similar response is given by participants in earlier studies ²⁶.   Findings of the present study is similar to that of other studies, which have reported limited awareness of health care professionals about the local or national ADR reporting system in their countries ^{27, 28}. This indicates the importance of creating awareness regarding the local reporting system among health care professionals. In our study most of the pharmacists who have reported ADR was to the physician, whereas physicians have reported the ADR mainly to the drug manufacturer.

Reasons for under reporting: The reasons for not reporting or under reporting of ADR, given by most of the pharmacists 23 (46%) and physicians 36 (48%) was that they didn't know whom to report ADR and 17 (34%) pharmacists and 21 (28%) physicians mentioned that the ADR noticed are very commonly observed and well documented in the literature hence they didn’t feel the importance of reporting (Figure 1).

The main reason for under-reporting of ADR quoted was “not aware of the method by which reporting can be done successfully”. Other reasons include that the ADR were very common to be reported and the unavailability of the ADR reporting forms. This was in comparison with a study done by Tabali M et al ²⁹. Some other responses given by the participants are lack of financial incentives and lack of awareness of the importance of ADR reporting or the worry about legal consequences of ADR reporting. This is highlighted in a study conducted by Vallano A et al ³⁰. While other studies indicate reasons such as unaware of ADR reporting process and identification of ADR does not influence the treatment ^{31, 32}.

Common class of medication(s) causing ADR: Pharmacists and physicians had a different point of view towards the most common class of medications causing ADR. In accordance to 45 (90%) pharmacists, “anti-diabetics” were the most common class of medication involved in causing ADR followed by “antibiotics” as quoted by 39 (78%) participants.  Antibiotics ranked the first category of medications to cause an ADR as specified by 18 (24%) physicians, followed by non-steroidal anti-Inflammatory drugs (NSAIDs) as mentioned by 14 (18.7%) physicians (Table 1). Amongst the most common class of medications causing ADR, anti-diabetics and antibiotics were the common ones as per the pharmacists’ and physicians’ opinion respectively.

Similar responses were identified by A Oshikoya et al ¹⁹. However, NSAIDs were the most common class of medications causing ADR in other studies ^33-35.

TABLE 1: KAB OF PHARMACISTS & PHYSICIANS REGARDING ADR REPORTING & MONITORING

Who should report ADR? Multiple responses were given by both physicians and pharmacists regarding who should report ADR. Majority of the pharmacists 40 (80%) and physicians 62 (82.7%) believed that ADR should be reported primarily by “physicians”. Subsequently 34 (68%) pharmacists mentioned it as it should be reported by “pharmacists”. Whereas 62 (82.7%) physicians thought “pharmacists” should have the priority to report ADR followed by “nurses” as mentioned by 38 (50.7%) physicians. Table 2 represents the responses of physicians and pharmacists on who should report ADR. In reference to who should report ADR, most of the participants believe that physicians followed by pharmacists are mainly responsible for ADR reporting. Approximately more than half of the participants did not anticipate the role of patients and nurses in reporting ADR, which is similar to the results of a study done in Desai C et al ³⁶.

When to report ADR? A total of 38 (76%) pharmacists and 54 (72%) physicians chose to report ADR only when they are “serious and life threatening” followed by 22 (44%) pharmacists and 39 (52%) physicians believed that rare ADR that may cause disability to the patient should also be reported (Table 1).

Most of the survey participants’ state that ADR should be reported only when they are “serious and life threatening” or “rare and when it has caused disability to patient”.  Whereas a study conducted by Khalili H et al., encouraged reporting adverse effects of newly marketed drugs in addition to reporting serious ADR 25. International guidelines on monitoring and reporting of ADR suggests to report all suspected ADR for newly marketed drugs and fatal, serious, life threatening or disabling ADR for all established drugs, vaccines, high risk drugs and those which occurs in high risk patients ^37-39.

FIGURE1: REASONS FOR UNDER REPORTING OF ADR

However, recommendations from health Canada suggest reporting all ADR regardless of   its type and severity ⁴⁰.

Training on ADR Monitoring and Reporting: The last part of our survey questionnaire included the interest of survey participants in getting trained in the area of ADR monitoring and reporting.

Training: A total number of 46 (92%) pharmacists and 64 (85.3%) physicians mentioned that they have not been trained to report ADR, but a good number of 43 (86%) pharmacists and 56 (74.7%) physicians were interested in getting trained. It is significant to emphasize that 41 (82%) pharmacists and 59 (78.7%) physicians preferred having a local pharmacovigilance center. In our study, most of the participants mentioned that they have not been trained on monitoring and reporting ADR and they pointed out that getting trained would inspire them to report an ADR. This was in support of a study highlighting the importance of training to motivate ADR monitoring and reporting activities ²⁶.

Reporting: Regarding whether ADR reporting would be beneficial to the patients, “Yes” response was given by 48 (96%) pharmacists and 68 (90.7%) physicians. While reporting ADR, 32 (64%) pharmacists and 52 (69.3%) physicians preferred to keep patient details confidential.

A significant number of pharmacists 36 (72%) and physicians 51 (68%) anticipated the role of information technology in order to facilitate ADR reporting. A vast number of pharmacists 48 (96%) and physicians 54 (72%) mentioned that they don’t have ADR reporting forms in their department (Table 2).

TABLE 2: KAB REGARDING ADR TRAINING & REPORTING

Vast majority of the participants prefer having local pharmacovigilance centers and they also anticipate the role of information technology like the use of frequent reminder massages and e-mails to facilitate the reporting activities in UAE.

The main limitations of our study were that our study was limited sample size and was circulated only to hospital physicians and community pharmacists. Since, it was a survey-based study; the results were only based on the responses given by the survey participants and were not supported by any evidence. Personal opinions given by the respondents were considered.

Not all the surveys were included for analysis due to the incomplete/missing data.

CONCLUSION: We conclude that the awareness of ADR Reporting system in Ras Al Khaimah, U.A.E was limited. One of the main reasons for under reporting of ADR was that the respondents did not know “how to report” and “whom to report”.

Hence, more ADR related awareness and training programs are required to continuously motivate the health care professionals to monitor, document and report ADR. Appointing clinical pharmacists in every hospital would be beneficial to enhance the ADR monitoring and reporting. We feel sending frequent reminders to health care professionals to report ADR through e-mails or short message service (SMS) to mobile phones could be beneficial in creating awareness & for further strengthening of pharmacovigilance activities.

Establishing a local pharmacovigilance center that would facilitate the reporting activities and would be more beneficial to help improve the ADR monitoring & reporting in UAE.

ACKNOWLEDGEMENTS: Our sincere thanks to Dr. Padma G.M Rao, Associate Dean and Chairperson, Department of Clinical Pharmacy & Pharmacology, RAK College of Pharmaceutical Sciences (RAKCOPS), RAK Medical and Health Sciences University (RAKMHSU)  for continuous support and encouragement during the study.

We are also grateful to Dr. B.G. Nagavi, Dean, and RAKCOPS for all the support and co-operation. Our heartfelt thanks to Dr. Gurumadhva Rao, Vice Chancellor of RAKMHSU for all the support, encouragement and motivation. We also extend our thanks to all the survey respondents for their kind help and support.

Conflict of interest: Nil

REFERENCES:

1. Patel KJ, Kedia MS, Bajpai D, Mehta SS, Kshirsagar NA, Gogtay NJ : Evaluation of the prevalence and economic burden of adverse drug reactions presenting to the medical emergency department of a tertiary referral centre: a prospective study. BMC Clinical Pharmacology2007; 7:8. 
2. Von Laue NC, Schwappach DLB and Koeck CM: The epidemiology of preventable adverse drug events: A review of the literature. BMC Medical Informatics and Decision Making2009; 9:11. 
3. Moore N, Lecointre D, Noblet C, Mabille M: Frequency and cost of serious adverse drug reactions in a department of general medicine. British Journal of Clinical Pharmacology 1998; 45(3):301-308.
4.  Kongkaew C, Noyce PR and Ashcroft DM: Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies.Annals of Pharmacotherapy 2008; 42(7):1017-1025.
5. Herdeiro MT, Figueiras A, Polónia J, Gestal-Otero JJ: Physicians' attitudes and adverse drug reaction reporting: a case-control study in Portugal. Drug Safety 2005; 28(9):825-833.
6. Irujo M, Beitia G, Bes-Rastrollo M, Figueiras A, Hernández-Díaz S, Lasheras B: Factors that influence under-reporting of suspected adverse drug reactions among community pharmacists in a Spanish region. Drug Safety 2007; 30(11):1073-1082.
7. Lopez-Gonzalez E, Herdeiro MT and Figueiras A: Determinants of under-reporting of adverse drug reactions: a systematic review. Drug Safety 2009;32(1):19-31
8. Christopher FG, David RM, Philip HR, and Pirmohamed M:  Attitudes and knowledge of hospital pharmacists to adverse drug reaction reporting. British Journal of Clinical Pharmacology 2001; 51(1): 81–86.
9. Jara-Puyod M: Ensuring drug safety for the population through pharmacovigilance. Available at http://gulftoday.ae/portal/2c3284bf-4dab-47f5-97df-2727f2f85e72.aspx. Accessed on 30-5- 2013.
10. Reporting adverse reactions. Available at http://www.haad.ae/haad/Portals/0/Reporting%20Adverse%20Reactions-updated24-june%20.pdf. Accessed on 2-7- 2012.
11. Al-Tajir GK, Kelly WN: Epidemiology, Comparative Methods of Detection, and Preventability of Adverse Drug Events. Annals of Pharmacotherapy 2005; 39 (7/8): 1169-1174.
12. Lynn MR: Determination and quantification of content validity. Nursing Research 1986; 35: 382-385.
13. Inman WH: Attitudes to adverse drug-reaction reporting. British Journal of Clinical Pharmacology 1996; 41:433–435.
14. Dos Santos Pernas SI, Herdeiro MT, Lopez-Gonzalez E, Da Cruz e Silva OA, Figueiras A: Attitudes of Portuguese health professionals toward adverse drug reaction reporting. International Journal of Clinical Pharmacology 2012; 34(5):693-698.
15. Bello SO, Umar MT: Knowledge and attitudes of physicians relating to reporting of adverse drug reactions in Sokoto, north-western Nigeria. Annals of African Medicine 2011; 10(1): 13-18.
16. Sencan N, Altınkaynak M, Ferah I, Özyıldırım A, Ceylan EM, Clark PM: The Knowledge and Attitudes of Physicians and Nurses towards Adverse Event Reporting and the Effect of Pharmacovigilance Training: A Hospital Experience. Hacettepe University Journal of the Faculty of Pharmacy 2010; 30(1): 25-40.
17. Rehan HS, Sah RK and Chopra D: Comparison of knowledge, attitude and practices of resident doctors and nurses on adverse drug reaction monitoring and reporting in a tertiary care hospital. Indian Journal of Pharmacology 2012; 44(6): 699–703.
18. Ozyildirim A: Analysis of awareness on adverse event reporting among physicians and nurses and contribution of pharmacovigilance training. European Journal of Hospital Pharmacy: Science and Practice 2012; 19:86-87.
19. Oshikoya KA and Awobusuyi JO:  Perceptions of doctors to adverse drug reaction reporting in a teaching hospital in Lagos, Nigeria. BMC Clinical Pharmacology 2009; 9:14.
20. Fadare JO, Enwere OO,  Afolabi AO, Chedi BAZ, Musa A:  Knowledge, Attitude and Practice of Adverse Drug Reaction Reporting among Healthcare Workers in a Tertiary Centre in Northern Nigeria. Tropical Journal of Pharmaceutical Research 2011; 10 (3): 235-242.
21. Eland IA, Belton KJ, Van Grootheest AC, Meiners AP, Rawlins MD and Ch Stricker BH: Attitudinal survey of voluntary reporting of adverse drug reactions. British Journal of Clinical Pharmacology 1999; 48(4): 623–627
22. Palaian S, Ibrahim MI and Mishra P: Health professionals' knowledge, attitude and practices towards pharmacovigilance in Nepal. Pharmacy Practice 2011; 9(4):228-235.
23. Sandeep A, Mamatha GT, Krishnagoudar B, Mahadevamma L, Venkappa RK, Begum SS, Girish HR: Adverse drug reaction: Community Pharmacists Knowledge, Attitude and Behavior. Mintage Journal of Pharmaceutical & Medical Sciences 2012; 1(1): 17-20.
24. Mes K, den Berg L. T. W. de Jong-van den, Van Grootheest CA: Attitudes of community pharmacists in the Netherlands towards adverse drug reaction reporting. International Journal of Pharmacy Practice 2002; 10(4): 267-272.
25. Khalili H, Mohebbi N, Hendoiee N, Keshtkar AA, Dashti-Khavidaki S:  Improvement of knowledge, attitude and perception of healthcare workers about ADR, a pre- and post-clinical pharmacists' interventional study. Biomedical Journal Open 2012; 13(2):e000367.
26. Li Q, Zhang SM, Chen HT, Fang SP, Yu X, Liu D, Shi LY, Zeng FD: Awareness and attitudes of healthcare professionals in Wuhan, China to the reporting of adverse drug reactions. Chinese Medical Journal 2004; 117(6):856-861.
27. Lee KK, Chan TY, Raymond K, Critchley JA: Pharmacists' attitudes toward adverse drug reaction reporting in Hong Kong. The Annals of Pharmacotherapy 1994; 28(12):1400-1403.
28. Al-Hazmi NN and Naylor IL: A Study of Community Pharmacists’ Awareness and Contributions to Adverse Drug Reactions (ADR) Reporting Systems in the Makkah, Kingdom of Saudi Arabia (KSA). Journal of Clinical Trials 2013; 3:1-5
29. Tabali M, Jeschke E, Bockelbrink A, Witt CM, Willich SN, Ostermann T et al.: Educational intervention to improve physician reporting of adverse drug reactions (ADR) in a primary care setting in complementary and alternative medicine. Biomed Central Public Health 2009; 31; 9:274.
30. Vallano A, Cereza G, Pedròs C, Agustí A, Danés I, Aguilera C, Arnau JM: Obstacles and solutions for spontaneous reporting of ADR in the hospital. British Journal of Clinical Pharmacology 2005; 60:653–658.
31. González-Rubio F, Calderón-Larrañaga A, Poblador-Plou B, Pemán CN, Cabañas AL, Torres AP: Underreporting of recognized adverse drug reactions by primary care physicians: an exploratory study. Pharmacoepidemiology and Drug Safety 2011; 20(12):1287–1294.
32. John LJ, Arifulla M, Cheriathu JJ and Sreedharan J: Reporting of adverse drug reactions: an exploratory study among nurses in a teaching hospital, Ajman, United Arab Emirates. DARU Journal of Pharmaceutical Sciences 2012; 20:44.
33. Pirmohamed M, James S, Meakin S, Green C, Scott A, Walley TJ, Farrar K, Park BK, Breckenridge AM: Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients. Biomedical Journal 2004; 329:15.
34. Gallagher RM, Mason JR, Bird KA, Kirkham JJ, Peak M, Williamson PR et al: Adverse Drug Reactions Causing Admission to a Paediatric Hospital. PLoS ONE 2012; 7(12): e50127.
35. Andrade RJ and Tulkens PM: Hepatic safety of antibiotics used in primary care, The Journal of Antimicrobial Chemotherapy 2011; 66(7): 1431–1446.
36. Desai CK, Iyer G, Panchal J, Shah S, and Dikshit RK: An evaluation of knowledge, attitude, and practice of adverse drug reaction reporting among prescribers at a tertiary care hospital. Perspectives in Clinical Research 2011; 2(4):129-136.
37. American Society of Health-System Pharmacists. ASHP guidelines on adverse drug reaction monitoring and reporting. American Journal of Health-System Pharmacy 1995; 52:417–419.
38. Reporting medicine and vaccine adverse events. Therapeutic Goods Administration. Available from: http://www.tga.gov.au/safety/problem-medicine.htm. Accessed on 11-7-2012.
39. What to monitor. Medicines and Healthcare Products Regulatory Agency Available from: http://www.mhra.gov.uk/Safetyinformation/Howwemonitorthesafetyofproducts. Accessed on 11-7-2012.
40. Osborne C: Adverse Drug Reactions: Investigating to Reporting, Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2010; 19(1): 46–47.
    

    ---

    How to cite this article:

    Sathvik BS, Chukir DMO, Abo-Aldan E and Soliman MN: Adverse drug reaction monitoring and reporting: Knowledge, attitude and belief of physicians & pharmacists of Ras Al Khaimah, United Arab Emirates (UAE). Int J Pharm Sci Res 2014; 5(2): 368-75.doi: 10.13040/IJPSR. 0975-8232.5(2).368-75

    ---

    All © 2013 are reserved by International Journal of Pharmaceutical Sciences and Research. This Journal licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

    ---