TYPE Original Research

PUBLISHED 21 June 2023

DOI 10.3389/fpubh.2023.1145016

Assessment of medication
OPEN ACCESS adherence among Lebanese adult
patients with non-communicable
EDITED BY
Joseph O. Fadare,
Ekiti State University, Nigeria

REVIEWED BY
Gerard Kennedy,
diseases during COVID-19
Federation University Australia, Australia
Ib Christian Bygbjerg,
University of Copenhagen, Denmark
lockdown: a cross-sectional study
*CORRESPONDENCE
Diana Malaeb Diana Malaeb 1,2*, Hala Sacre 3, Sara Mansour 2, Chadia Haddad 3,4,
[email protected] Abir Sarray El Dine 2, Tamara Fleihan 5, Souheil Hallit 6,7,8,
RECEIVED 15January 2023
ACCEPTED 25 May 2023
Pascale Salameh 3,9,10,11 and Hassan Hosseini 12,13
PUBLISHED 21 June 2023 1
College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates, 2 School of Pharmacy,
CITATION Lebanese International University, Beirut, Lebanon, 3 INSPECT-LB (Institut National de Santé Publique,
Malaeb D, Sacre H, Mansour S, Haddad C, d’Épidémiologie Clinique et de Toxicologie-Liban), Beirut, Lebanon, 4 School of Health Sciences,
Sarray El Dine A, Fleihan T, Hallit S, Modern University for Business and Science, Beirut, Lebanon, 5 Gilbert and Rose-Marie Chagoury School
Salameh P and Hosseini H (2023) Assessment of Medicine, Lebanese American University, Byblos, Lebanon, 6 School of Medicine and Medical
of medication adherence among Lebanese Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon, 7 Applied Science Research Center, Applied
adult patients with non-communicable Science Private University, Amman, Jordan, 8 Department of Research, Psychiatric Hospital of the Cross,
diseases during COVID-19 lockdown: a cross- Jal Eddib, Lebanon, 9 Faculty of Pharmacy, Lebanese University, Hadath, Lebanon, 10 Department of
sectional study. Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus, 11 School of
Front. Public Health 11:1145016. Medicine, Lebanese American University, Byblos, Lebanon, 12 INSERM U955-E01, IMRB, Henri Mondor
doi: 10.3389/fpubh.2023.1145016 Hospital, Créteil, France, 13 Department of Neurology, Henri Mondor Hospital, AP-HP, Créteil, France

COPYRIGHT
© 2023 Malaeb, Sacre, Mansour, Haddad,
Sarray El Dine, Fleihan, Hallit, Salameh and
Hosseini. This is an open-access article Background: Medical treatment is considered a cornerstone in non-communicable
distributed under the terms of the Creative diseases (NCDs) management, lack of adherence remains the main challenge that
Commons Attribution License (CC BY). The
use, distribution or reproduction in other may compromise optimal therapeutic outcome achievement.
forums is permitted, provided the original Purpose: This study aimed to evaluate treatment adherence levels and associated
author(s) and the copyright owner(s) are
credited and that the original publication in this factors among Lebanese adult patients with non-communicable diseases.
journal is cited, in accordance with accepted Materials and methods: A cross-sectional survey conducted during the COVID-19
academic practice. No use, distribution or
reproduction is permitted which does not lockdown imposed by the Lebanese Government (between September 2020
comply with these terms. and January 2021) enrolled 263 adult patients through an anonymous online
questionnaire to assess adherence to medications using the Lebanese Medication
Adherence Scale (LMAS-14).
Results: Of the total sample, 50.2% showed low adherence with a total mean
adherence score of 4.41±3.94. The results showed that depression (β =1.351)
and peptic ulcer (β =1.279) were significantly associated with higher LMAS scores
(lower adherence). However, age between 50 and 70 (β =−1.591, p =0.011),
practicing physical exercise (β =−1.397, p =0.006), having kidney disease
(β =−1.701, p =0.032), and an intermediate (β =−1.336, p =0.006) to high income
(β =−3.207, p <0.001) were significantly associated with lower LMAS scores
(higher adherence).
Conclusion: Our study shed light on the factors affecting medication adherence in
patients with non-communicable diseases. It showed that depression and peptic
ulcer were associated with lower adherence, contrary to older age, exercising,
having chronic kidney disease, and a higher socioeconomic status.

KEYWORDS

non-communicable, diseases, adherence, medications, Lebanon, COVID-19

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1. Introduction Therefore, since medication adherence in Lebanon is facing many

challenges during this period and since the burden of NCDs is
Non-communicable diseases (NCDs), also known as chronic continuously growing, this study aimed to assess medication
diseases, are responsible for significant premature mortality and adherence levels and factors that affect it among a sample of Lebanese
morbidity throughout the world. They account for more than one-half adult patients with chronic conditions, using the Lebanese Medication
of the global disease burden with a 71% mortality rate (1, 2). The rise Adherence Scale.
in the prevalence and encumbrance of NCDs has been partly linked
to the increased life expectancy that resulted from the decline in
premature deaths caused by communicable diseases (1). 2. Materials and methods
NCDs usually last 1 year or more and require ongoing
comprehensive medical care, including the assessment of daily life 2.1. Study design and procedure
activities. They are a consequence of several physiologic, genetic, and
behavioral factors (2), and encompass many diseases, such as This online cross-sectional survey, carried out between September
cardiovascular, cerebrovascular, cancer, endocrine, and respiratory 2020 and January 2021, enrolled 263 adult patients from all
conditions (2). The development of NCDs is strongly associated with Governorates (Beirut, Mount Lebanon, North, South, and Beqaa),
risk factors such as smoking, unhealthy diet, alcohol consumption, using the snowball sampling method because of the COVID-19
physical inactivity, obesity, hyperglycemia, and hyperlipidemia (3). In lockdown imposed by the Lebanese Government. The questionnaire
Lebanon, a developing middle-income country in the Middle East, was created on Google Forms and shared on social media (WhatsApp,
NCDs are ubiquitous, with hypertension affecting one-third of the LinkedIn, and Facebook). This study is part of a larger research project
Lebanese population and dyslipidemia is around 10 times higher than about knowledge of NCDs that included all individuals aged 18 years
in Western countries (4, 5). and above and excluded those with history of mental diseases that can
Although medical treatment is considered a cornerstone in NCD compromise the ability to read and understand the questionnaire.
management, lack of adherence remains the main challenge that may Participation was voluntary, and anonymity was guaranteed during
compromise optimal therapeutic outcome achievement. Adherence is the data collection process.
the extent to which behaviors meet the agreed recommendations of a
health care provider (e.g., taking medications, following a diet, or
changing lifestyle) (6). It is estimated that approximately 50% of the 2.2. Sample size calculation
patients diagnosed with NCD are non-adherent, leading to poor
outcomes and increased morbidity and mortality (6). The underlying According to the Epi Info software version 7.2 (population
reasons for lack of medication adherence are complex and include lack survey), the minimum sample size required to ensure a 95%
of access to medications, cultural sensitivity, relationship with confidence interval was 223 participants, based on medication
healthcare professionals, and patients’ beliefs (7). A study of Middle adherence of 82.4% in participants with hypertension and a 5% error
Eastern populations in 2011 found that non-adherence rates varied (10). The reason for oversampling is that this study is part of a larger
from 1.4 to 80%; the highest was among hypertensive patients (7), and research project necessitating a bigger sample size.
the two most reported barriers were forgetfulness and drug side effects
(7). In Lebanon, patients with hypertension (8), and diabetes (9)
showed low treatment adherence, mainly because of forgetfulness. 2.3. Questionnaire
One of the most influential factors that can affect adherence to
medications is the patient belief regarding his medications. Patient The self-administered questionnaire was in Arabic, the native
beliefs encompass individuals’ attitudes, perception, and expectations language in Lebanon, and required approximately 20 min to complete.
about medications. Patient beliefs and concerns about medications The first section of the questionnaire covered the sociodemographic
risks, side-effects, or long-term effects of medications are proposed to and socioeconomic factors, including age, smoking status, marital status
influence the degree to the adherence to the medications. (married versus others), employment status (employed versus
Following these results, a new scale, the Lebanese Medication unemployed), family income, residence (urban versus rural), education
Adherence Scale (LMAS-14), was developed to assess the level of level, past medical history (e.g., hypertension, diabetes mellitus,
medication adherence, considering Lebanese socioeconomic, dyslipidemia). Age was categorized into four groups (18–29, 30–49,
psychological, occupational, economic, annoyance, and cultural 50–70, and above 70 years) while family income was divided into three
factors, including forgetfulness, marital status, education level, and categories: low (<1,500,000 Lebanese Lira), intermediate (1,500,000–
monthly income (10). 3,000,000 Lebanese Lira), and high (>3,000,000 Lebanese Lira) (13).
In Lebanon, several factors hamper drug adherence due to the The second section consisted of the Lebanese Medication
combined economic, political, and sanitary crises of the past 2 years, Adherence Scale-14 (LMAS-14) used to assess medication adherence.
added to the Lebanese financial collapse and the Beirut port explosion This scale covers the occupational, psychological, annoyance, and
that led to severe drug shortages (11, 12). economic domains; it was previously validated among Lebanese
patients with hypertension and hypothyroidism (10, 14). The
dichotomous version of the LMAS-14 was used to make self-
assessment simpler and less problematic, with questions rated 0 (Yes)
Abbreviations: NCDs, non-communicable diseases; LMAS-14, Lebanese Medication and 1 (No), where lower scores would indicate higher adherence. The
Adherence Scale; COVID-19, coronavirus disease-2019. dichotomous format has some advantages, as it forces people to fall on

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TABLE 1 Sociodemographic characteristics of the study sample.

one side of a scale or the other and is quicker to answer than questions
that rely on a Likert scale, with no substantial loss of information, Frequency Percentage
reliability, or validity.
Gender
Male 75 28.5%

2.4. Ethics approval Female 188 71.5%

Age
The study was conducted based on the declaration of Helsinki and
18–29 121 46%
was approved by the ethics committee at the School of pharmacy of
30–49 93 35.4%
the Lebanese International University (202ORC-035-LIUSOP).
Written informed consent was obtained from participants before 50–70 45 17.1%
inclusion in the study. Above 70 years 4 1.5%

Living area
Beirut 125 47.5%
2.5. Statistical analysis
Bekaa 8 3%
Data collected were analyzed using the Statistical Package for Social Mount Lebanon 63 24%
Sciences (SPSS) version 25.0. Continuous variables were presented as North 22 8.4%
mean and standard deviation and 95% confidence interval. Categorical
South 45 17.1%
and ordinal variables were shown as frequencies (n) and percentages
(%). The LMAS score, taken as a continuous variable, was considered as Marital status
the outcome variable, whereas sociodemographic variables and past Single 132 50.2%
medical diseases were considered as explanatory variables. Married 131 49.8%
Non-parametric tests were used as LMAS-14 was not normally
Education level
distributed. The Mann–Whitney test and the Kruskal-Wallis test were
used to compare the means of two groups and three groups or more, Scholar level 25 9.5%
respectively. Stepwise linear regression was conducted, taking the LMAS University level 238 90.5%
total score as the dependent variable. Independent variables that showed
Employment status
a p < 0.2 in the bivariate analysis were entered in the final model to
Unemployed 107 40.7%
minimize confounding. A p < 0.05 was considered significant.
Employed 156 59.3%

Income level
3. Results Low 102 38.8%

Intermediate 137 52.1%

3.1. Sociodemographic characteristics
High 24 9.1%

Table 1 presents the sociodemographic features of the participants. Smoking status

The majority of the participants were females (71.5%), 18–49 years Yes 77 29.3%
(81.4%), had a university level of education (90.5%), and a low to
No 186 70.7%
intermediate monthly income (90.9%). More than half of them were
single (50.2%) and employed (59.3%); only 29.3% were smokers, and Exercise status
30% practiced physical exercise. Of the total sample, 50.2% had low Yes 79 30%
medication adherence, with a mean adherence score of 4.41 (SD = 3.94). No 184 70%

Mean SD

3.2. History of medical diseases LMAS scale 4.41 3.94

Table 2 presents the frequency and percentage of past medical

diseases. Of the total sample, 16.9% (n = 92) participants had do (4.76 vs. 3.58, p = 0.026), and those with a low monthly income vs.
dyslipidemia, followed by 16.1% (n = 88) with obesity, and 15% other groups. A higher mean LMAS-14 score was also found in
(n = 82) with peptic ulcer. participants who had arrhythmia (5.11 vs. 4.08, p = 0.05), peptic ulcer
(5.54 vs. 3.90, p = 0.002), and depression (5.69 vs. 3.90, p = 0.003)
compared to those who did not have these diseases.
3.3. Bivariate analysis

The results of the bivariate analysis are summarized in Table 3. A 3.4. Multivariable analysis
higher mean LMAS-14 score was found in females vs. males (4.89 vs.
3.20, p = 0.001), married vs. single participants (4.95 vs. 3.87, A first linear regression taking the LMAS-14 scale as the
p = 0.027), those who do not practice physical exercise vs. those who dependent variable and the sociodemographic characteristics as the

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TABLE 2 Description of history of medical disease. TABLE 3 Bivariate analysis of the LMAS scale as the dependent variable.

Count Percentage % LMAS scale p-value

Hypertension 65 12% Mean±SD
Diabetes 38 7% Gender
Dyslipidemia 92 16.9% Male 3.20 ± 3.34
0.001
Arrhythmias 83 15.2% Female 4.89 ± 4.06
Kidney disease 23 4.2% Age
Peptic ulcer 82 15% 18–29 4.75 ± 3.87
Depression 74 13.6% 30–49 4.63 ± 3.98
0.082
Obesity 88 16.1% 50–70 3.04 ± 3.66

Above 70 years 4.00 ± 6.05

independent variables showed that being married (β = 1.234, Marital status

p = 0.011) was significantly associated with higher LMAS-14 scores Single 3.87 ± 3.62
0.027
(lower adherence). However, being 50–70 years old (β = −1.906, Married 4.95 ± 4.17
p = 0.003), practicing physical exercise (β = −1.343, p = 0.010), and
Income level
having an intermediate (β = −1.336, p = 0.007) to high income
(β = −3.331, p < 0.001) were significantly associated with lower Low 5.39 ± 4.27

LMAS-14 scores (higher adherence) (Table 4, model 1). Intermediate 4.07 ± 3.68 <0.001
A second linear regression taking the LMAS-14 scale as the High 2.17 ± 2.40
dependent variable and the history of medical diseases as the
Exercise status
independent variable showed that being married (β = 1.193, p = 0.012),
having a depression (β = 1.351), and peptic ulcer (β = 1.279) were Yes 3.58 ± 3.77
0.026
significantly associated with higher LMAS-14 scores (lower No 4.76 ± 3.96
adherence). However, being 50–70 years old (β = −1.591, p = 0.011), Hypertension
practicing physical exercise (β = −1.397, p = 0.006), having kidney
Yes 3.80 ± 4.31
disease (β = −1.701, p = 0.032), and having an intermediate 0.152
(β = −1.336, p = 0.006) to high income (β = −3.207, p < 0.001) were No 4.61 ± 3.79

significantly associated with lower LMAS-14 scores (higher Diabetes

adherence) (Table 4, model 2). Yes 4.21 ± 4.13
0.740
No 4.44 ± 3.91

4. Discussion Cholesterol
Yes 4.24 ± 4.15
0.613
To our knowledge, no previous studies have explored medication No 4.50 ± 3.82
adherence among Lebanese patients with NCDs, a considerable
Arrhythmias
challenge in achieving therapeutic outcomes. Although poor
adherence is one of the principal causes of non-responsiveness to Yes 5.11 ± 3.98
0.05
medications, factors known to influence it have not been thoroughly No 4.08 ± 3.88
investigated yet. Hence, this study assessed the medication adherence Kidney disease
and associated factors in a sample of Lebanese adult patients with
Yes 3.30 ± 4.01
NCDs. It revealed that almost half of the patients were not adherent 0.160
to their medications, highlighting that married participants, those No 4.51 ± 3.92

depressed, and diagnosed with peptic ulcer had significantly lower Peptic ulcer
adherence. However, participants 50–70 years old, practicing physical Yes 5.54 ± 3.97
exercise, having a history of kidney disease, and an intermediate to 0.002
No 3.90 ± 3.82
high income had significantly higher adherence.
Depression
Yes 5.69 ± 4.60
0.003
4.1. The extent of medication adherence No 3.90 ± 3.53

Obesity
Our results showed that almost half of the patients were
Yes 4.10 ± 4.01
adherent to medications, similar to other findings among Lebanese 0.375
diabetic patients (15). The low adherence rate in our study can No 4.56 ± 3.89
be explained by the lack of structured healthcare systems, Bold values represent significant results.

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TABLE 4 Multivariable analysis.

Model 1: Linear regression taking the LMAS scale as the dependent variable and the sociodemographic as
independent variables

Unstandardized Confidence interval

Standardized beta p-value
beta Lower bound Upper bound
Exercise status (yes vs. no*) −1.343 −0.156 0.010 −2.359 −0.327

Marital status (married vs. single*) 1.234 0.158 0.011 0.282 2.185

Age (50–70 vs. 18–29*) −1.906 −0.186 0.003 −3.154 −0.659

High income vs. low* −3.331 −0.247 <0.001 −5.016 −1.646

Intermediate income vs. low* −1.336 −0.171 0.007 −2.311 −0.362

Model 2: Linear regression taking the LMAS scale as the dependent variable and the history of medical disease as
independent variables

Unstandardized Confidence interval

Standardized beta p-value
beta Lower bound Upper bound
Depression (yes vs. no*) 1.351 0.157 0.009 0.342 2.361

Peptic ulcer (yes vs. no*) 1.279 0.151 0.011 0.292 2.266

Kidney disease (yes vs. no*) −1.701 −0.126 0.032 −3.257 −0.145

Exercise status (yes vs. no*) −1.397 −0.163 0.006 −2.384 −0.410

Marital status (married vs. single*) 1.193 0.153 0.012 0.268 2.118

Age (50–70 vs. 18–29*) −1.591 −0.155 0.011 −2.814 −0.367

High income vs. low* −3.207 −0.238 <0.001 −4.844 −1.570

Intermediate income vs. low* −1.336 −0.171 0.006 −2.286 −0.386

Variables entered: age, gender, marital status, exercise status, income level, hypertension, diabetes, cholesterol, arrhythmias, kidney disease, peptic ulcer, depression, obesity.
*Stands for reference category.
Bold values represent significant results.

inappropriate medical coverages, and the low socioeconomic for our results could be low marital satisfaction, unhappy marriage,
status, forcing patients to be reluctant to adhere to their treatment. along with illness, depression, heavy drinking, and more isolation
This low adherence rate can also be due to the stressful events the (18, 19).
Lebanese population is witnessing, whether related to the economic
crisis or the COVID-19 pandemic, as described in previous
literature, showing that stress decreased medication adherence 4.3. Diseases and medication adherence
(12). Furthermore, this study was conducted during the COVID-19
imposed lockdown, where chronic patients were confined at home Our results highlighted that patients with depression had poor
and had limited access to healthcare services, thus decreasing medication adherence, consistent with the data from previous
adherence to medications. Another interpretation could be that literature showing that psychiatric conditions were frequently
this study was conducted among Lebanese patients with different associated with low adherence rates (20).
and multiple NCDs, thus having lower medication adherence than The reasons for the association between depressive symptoms and
those with a single disease (16). non-adherence to treatment might be the greater feelings of
hopelessness, social isolation, withdrawal from social networks, and a
possible decline in cognitive functioning that may affect memory, and
4.2. Marital status and medication reduce the energy to continue the medical treatment (21). In our
adherence study, patients with peptic ulcer disease had poor medication
adherence, in agreement with data from previous studies (22). A
Our study highlighted that married individuals had lower possible explanation could be the metallic taste of medications used
medication adherence contrary to previous findings (17). Our findings to eradicate Helicobacter pylori infection, as reported in previous
can be explained by the fact that sometimes marriage can create research (23). Another reason could be the frequency of drug
conflicts and tension, differences in health beliefs or attitudes can lead administration, the number of pills administered, and the complexity
to disagreements, and burden imposed on one partner to manage of eradication regimens, explaining the inverse relationship between
disease for a spouse with complex health needs can lead to caregiver the number of doses and adherence (24).
burden and stress which all can impact medication adherence. Our results revealed that patients with kidney disease had good
Although marital satisfaction was not explored, a possible explanation medication adherence, consistent with previous findings (25, 26). A

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possible interpretation could be the availability of memory aids, the social media, a selection bias might still exist as the majority
assisting devices, and support and care from family members of the study participants were of young age and educated which
facilitating medication adherence (25, 26). further hinders the generalizability of the results. Our study also
did not consider other cultural factors that affect adherence to
medication due to the nature of the study since it was conducted
4.4. Socioeconomic status and medication during COVID-19 lockdown and it was not conducted through
adherence face to face communication that impede the appropriate
assessment. The cultural factors include beliefs and traditions that
In our study, higher medication adherence was significantly can shape individuals’ perceptions of health and illness, language
associated with intermediate-high socioeconomic class, in barriers and health literacy that can impede effective
agreement with previous findings in other studies (27). These communication between healthcare providers and patients,
patients have greater provider/caregiver availability and regular religious and spiritual beliefs that play vital role in healthcare
medical follow-ups, enhancing medication adherence (28, 29). decision-making, and family and social support. An
They also have adequate medical/prescription coverage and thus overrepresentation of the Lebanese residing in Beirut and Mount
are more adherent (30). Lebanon was also noted. Thus, more studies are mandated to
assess adherence to medications among non communicable
diseases outside the lock downs since our study is not a
4.5. Age and medication adherence representative of adherence among all Lebanese population.

Older age was significantly associated with higher medication

adherence, consistent with the literature. Older patients have increased 4.8. Clinical implications
interaction with the healthcare system (more appointments and
interactions with physicians), a greater belief in the importance of Our findings suggest that educational programs for patients are
chronic medication management, or a higher experience with warranted to increase awareness about the importance of medication
managing medications (31). adherence. Furthermore, the doctor-patient relationship could
be improved to involve patients in their treatment, increasing the
likelihood of adherence. The community pharmacist has a prominent
4.6. Physical activity and medication role in patient adherence through counseling patients and educating
adherence them about drug–drug and drug-food interactions and the
detrimental consequences of non-adherence.
Our results showed a significant association between higher
medication adherence and patients who practice physical activity,
in line with those of other studies (32). Patients who perform 5. Conclusion
physical activity have lower depression, anxiety, and cognitive
impairment, which improves medication adherence. Moreover, Our study shed light on the factors affecting medication adherence
regular physical activity has favorable effects on reducing blood in patients with non-communicable diseases during COVID-19
pressure, heart rate, blood glucose, lipid profile, and weight, which lockdown. It showed that depression and peptic ulcer were associated
all decrease the risk of communicable diseases and minimize with lower adherence, contrary to older age, exercising, having
complications. Such benefits showed to increase chronic kidney disease, and a higher socioeconomic status. Further
medication compliance. studies are necessary to confirm our results.

4.7. Limitations Data availability statement

Our study has some limitations. Its cross-sectional design The raw data supporting the conclusions of this article will
prevents inferring the causality of the associations found. be made available by the authors, without undue reservation.
Information bias could exist since it was self-reported by the
participants; thus, adherence may be overestimated, mainly
because of social desirability. Dichotomizing the LMAS-14 scale Ethics statement
might have a consequence of losing information and validity of
the original scale. The LMAS-14 scale was not a sufficiently good The study protocol was approved by the ethics committee at the
tool to validly screen for patients with non-adherence to Lebanese International University (2020RC-041-LIUSOP). Online
medications; however, it was suggested as a practical, simple, and consent was obtained from all participants on the first page of the
non-expensive method. Although our sample was randomly questionnaire. The patients/participants provided their written
selected across Lebanon through snowball sampling method using informed consent to participate in this study.

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Author contributions Conflict of interest

DM designed the study. SM, CH, DM, and TF drafted the manuscript. The authors declare that the research was conducted in the
CH, SH, DM, and PS carried out the analysis and interpreted the results. absence of any commercial or financial relationships that could
AS contribute in data collection. DM, SH, PS, HH, and HS assisted in be construed as a potential conflict of interest.
drafting and reviewing the manuscript. DM, PS, and HH supervised the
course of the article. HS revised and edited the article for English language.
All authors reviewed and approved the final version of the manuscript. Publisher’s note
All claims expressed in this article are solely those of the authors
Acknowledgments and do not necessarily represent those of their affiliated organizations,
or those of the publisher, the editors and the reviewers. Any product
The authors would like to thank all those who participated in this that may be evaluated in this article, or claim that may be made by its
study by filling up and spreading the web-based online survey. manufacturer, is not guaranteed or endorsed by the publisher.

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