Prescription in primary health care in selected southern european countries

What is known and objective: Polypharmacy has a significant impact on patients’ health with overall expenditure on over-the- counter (OTC) medicines representing a substantial burden in terms of cost of treatment. Irrational prescribing of OTC medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the “OTC SOCIOMED”, conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. The aims of this study, which was conducted within the framework of a European Project funded by the European Union under the Seventh Framework Programme and was entitled OTC-SOCIOMED, firstly was to report on possible determinants of patient behavior regarding the consumption of medicines, and particularly OTCs, in the context of primary care. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region. Methods: A multicentre, cross-sectional study was designed and implemented in well-defined primary healthcare settings in Cyprus, the Czech Republic, France, Greece, Malta and Turkey. Patients completed a questionnaire constructed on the basis of the theory of planned behaviour (TPB), which was administered via face-to-face interviews. A feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to 21 the workplaces of participants. A pre- and post-test evaluation study design with quantitative and qualitative data was employed. The primary outcome of this feasibility pilot intervention was to reduce GPs’ intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs. Results and discussion: Results that emerged from the analysis were that the percentage of patients who had consumed prescribed medicines over a 6-month period was consistently high, ranging from 79% in the Czech Republic and 82% in Turkey to 97% in Malta and 100% in Cyprus. Reported non-prescribed medicine consumption ranged from 33% in Turkey to 92% in the Czech Republic and 97% in Cyprus. TPB behavioural antecedents explained 43% of the variability of patients’ intention to consume medicines in Malta and 24% in Greece, but only 3% in Turkey. Subjective norm was a significant predictor of the intention to consume medicines in all three countries (Greece, Malta and Turkey), whereas attitude towards consumption was a significant predictor of the expectation to consume medicines, if needed. Median intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale. What is new and conclusion: This study shows that parameters such as patients’ beliefs and influence from family and friends could be determining factors in explaining the high rates of medicine consumption. Factors that affect patients’ behavioural intention towards medicine consumption may assist in the formulation of evidence-based policy proposals and inform initiatives and interventions aimed at increasing the appropriate use of medicines. This study is also particularly timely, as certain European countries are currently facing a financial crisis, while at the same time physicians and pharmacists seem to provide medicines to a large number of patients often as a result of social pressure. This feasibility study, despite its limitations, could provide valuable insights for a largescale study. Qualitative studies and the analysis of empirical 22 data may prove valuable in highlighting areas of research, which should be taken into consideration when designing such trials. This intervention study also highlighted the GPs’ high expectation for guidance and training and this could be a key issue in health care reforms currently discussed and implemented in Southern European countries. Most importantly, the current intervention was tested in various settings and a proposed intervention frame has been evaluated as feasible, well-accepted and practical in the busy health care environment. The study further provides an operationalized structure to define and evaluate interventions targeting similar behaviours in health professions and other disciplines. It introduces common evaluation standards and tools translated in multiple European languages, appropriate for measuring the effectiveness of current interventions and their applicability in other settings. Researchers now have access to an educational intervention tool with relevant methodologies and instruments for a future large-scale implementation, to alter the existing situation at the regional and national levels, allowing for substantial curbing of pharmaceutical expenditures. Furthermore, the current study provides evidence to policy makers on future policy actions targeting physician skills and prescribing behaviours in primary health care. It can additionally provide guidance on how to manage physician behavioural change and how to prevent irrational prescribing of medicines at primary care settings, through borrowing theoretical constructs from behavioural sciences. These constructs could be used in undergraduate, postgraduate and continuous medical education, to improve medical practice. This study is further expected to enable multi-country, multi-stakeholder consultations regarding long-term planning for the provision and consumption of medicines