What can we learn from general practitioners who left Spain? A mixed methods international study.

BACKGROUND: International mobility of health workforce affects the performance of health systems and has major relevance in human resources for health policy and planning. To date, there has been little research exploring the reasons why general practitioners (GPs) migrate. This mixed methods study aimed to investigate the reasons why Spain-trained GPs migrate and develop GP retention and recruitment health policy recommendations relevant to Spanish primary care. METHODS: The study followed an explanatory sequential mixed methods study design combining surveys with semi-structured interviews and focus groups with GPs who qualified in Spain and were living overseas at the time of the study. The survey data examined the reasons why GPs left Spain and their intention to return and were analysed using quantitative methods. The transcripts from interviews and focus groups centred on GPs' insights to enhance retention and recruitment in Spain and were analysed thematically. RESULTS: The survey had 158 respondents with an estimated 25.4% response rate. Insufficient salary (75.3%), job insecurity and temporality (67.7%), excessive workload (67.7%), poor primary care governance (55.7%), lack of flexibility in the workplace (43.7%) and personal circumstances (43.7%) were the main reasons for leaving Spain. Almost half of the respondents (48.7%) would consider returning to Spanish general practice if their working conditions improved. Interviews and focus groups with respondents (n = 24) pointed towards the need to improve the quality of employment contracts, working conditions, opportunities for professional development, and governance in primary care for effective retention and recruitment. CONCLUSION: Efforts to improve GP retention and recruitment in Spain should focus on salary, job security, flexibility, protected workload, professional development, and governance. We draw ten GP retention and recruitment recommendations expected to inform urgent policy action to tackle existing and predicted GP shortages in Spanish primary care.

Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation.

BACKGROUND: Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D). METHODS: Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods. RESULTS: People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17-4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27-1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients' wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness. CONCLUSIONS: Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

What does the literature mean by social prescribing? A critical review using discourse analysis.

Social prescribing (SP) seeks to enhance the role of the voluntary and community sector in addressing patients' complex needs in primary care. Using discourse analysis, this review investigates how SP is framed in the scientific literature and explores its consequences for service delivery. Theory driven searches identified 89 academic articles and grey literature that included both qualitative and quantitative evidence. Across the literature three main discourses were identified. The first one emphasised increasing social inequalities behind escalating health problems and presented SP as a response to the social determinants of health. The second one problematised people's increasing use of health services and depicted SP as a means of enhancing self-care. The third one stressed the dearth of human and relational dimensions in general practice and claimed that SP could restore personalised care. Discourses circulated unevenly in the scientific literature, conditioned by a wider political rationality which emphasised individual responsibility and framed SP as 'solution' to complex and contentious problems. Critically, this contributed to an oversimplification of the realities of the problems being addressed and the delivery of SP. We propose an alternative 'care-based' framing of SP which prioritises (and evaluates) holistic, sustained and accessible practices within strengthened primary care systems.

[Primary Care and oral health promotion: Assessment of an educational intervention in school children]. / Atención Primaria y promoción de la salud bucodental: evaluación de una intervención educativa en población infantil.

OBJECTIVE: To evaluate the short and medium term effectiveness of a Primary Care-driven oral health promotion intervention. DESIGN: A non-randomised community intervention trial. SETTING: Three socio-demographically similar primary schools of a deprived neighborhood in Granada, Spain. PARTICIPANTS: Eighty-two intervention and 109 control students aged 5 to 6, as well as the teachers and the parent's association of the intervention school (IS) participated in the study. INTERVENTION: School-based health promotion activities aimed at students, and regular meetings with the teachers and parents of the IS during 2 consecutive years. MAIN MEASUREMENTS: Students' oral health-related knowledge and behavior, assessed via questionnaires distributed before the intervention, and 6 and 18 months afterwards. RESULTS: Compared to the control groups at 18 months, students belonging to the IS reported enhanced oral health knowledge (OR 3.54; 95% CI 1.46-8.58), and an increased consumption of healthy food at breakfast (OR 2.95; 95% CI 1.26-6.89) and during mid-afternoon snack (OR 3.67; 95% CI 1.49-9.05). A significant decrease was seen in the intake of pastries (OR 4.05; 95% CI 1.68-9.81) and sweetened soft drinks and juices (OR 3.79; 95% CI 1.57-9.12) amongst intervention compared to control students in the medium term (18 months). No significant improvements were observed concerning oral hygiene in the IS. CONCLUSIONS: School-based educational interventions, when developed through an intersectoral and participative approach and considering the socio-economic context, appear to be effective in improving students' diet-related knowledge and behaviors.

[Medical students and drug marketing]. / Estudiantes de medicina y marketing farmacéutico.

OBJECTIVE: To determine the exposure of medical students to the marketing activities of the pharmaceutical industry, and identify their opinions and attitudes, and also the possible effects this exposure on their training and future professional practice. DESIGN: Descriptive cross-sectional. SETTING: University of Zaragoza Faculty of Medicine. PARTICIPANTS: Third, fourth, fifth and sixth year medical students. METHODS: The information was obtained using a previously adapted, self-report questionnaire on the exposure, attitudes and perceived suitability of drug marketing activities. Percentages were calculated for the categorical variables, applying the chi squared test for the comparison between the groups. A logistic regression was performed to determine the factors associated with their attitudes towards these activities. RESULTS: A total of 369 questionnaires were returned (93% of those attending classes). The exposure to marketing activities is high, particularly in the clinical stage (78.6% said to have received a gift non-educational gift). The students recognised the possible biases and repercussions in professional practice, although with ambiguity and contradictions. The most accepted activities are those associated with training, and the most critical attitudes appear in the clinical stage, particularly in the sixth year. CONCLUSIONS: Exposure to drug marketing by medical students and its possible training and professional effects is frequent and significant. The training environment is particularly open to promotional activities. The differences observed in the later years suggest the need for a specific curriculum subject and development of reflective attitudes by the students themselves.

What does social prescribing look like in practice? A qualitative case study informed by practice theory.

Social prescribing (SP) typically involves linking patients in primary care with a range of local, community-based, non-clinical services. While there is a growing body of literature investigating the effectiveness of SP in improving healthcare outcomes, questions remain about how such outcomes are achieved within the everyday complexity of community health systems. This qualitative case study, informed by practice theory, aimed to investigate how SP practices relevant to people at high risk of type 2 diabetes (T2D) were enacted in a primary care and community setting serving a multi-ethnic, socioeconomically deprived population. We collected different types of qualitative data, including 35 semi-structured interviews with primary care clinicians, link workers and SP organisations; 30 hours of ethnographic observations of community-based SP activities and meetings; and relevant documents. Data analysis drew on theories of social practice, including Feldman's (2000) notion of the organisational routine, which emphasises the creative and emergent nature of routines in practice. We identified different, overlapping ways of practising SP: from highly creative, reflective and adaptive ('I do what it takes'), to more constrained ('I do what I can') or compliant ('I do as I'm told') approaches. Different types of practices were in tension and showed varying degrees of potential to support patients at high risk of T2D. Opportunities to adapt, try, negotiate, and ultimately reinvent SP to suit patients' own needs facilitated successful SP adoption and implementation, but required specific individual, relational, organisational, and institutional resources and conditions. Feldman, M.S., 2000. Organizational Routines as a Source of Continuous Change. Organ. Sci. 11, 611-629.

Lack of sex-related analysis and reporting in Cochrane Reviews: a cross-sectional study.

BACKGROUND: Sex-specific analysis and reporting may allow a better understanding of intervention effects and can support the decision-making process. Well-conducted systematic reviews (SRs), like those carried out by the Cochrane Collaboration, provide clinical responses transparently and stress gaps of knowledge. This study aimed to describe the extent to which sex is analysed and reported in a cross-section of Cochrane SRs of interventions, and assess the association with the gender of main authorships. METHODS: We searched SRs published during 2018 within the Cochrane Database of Systematic Reviews. An investigator appraised the sex-related analysis and reporting across sections of SRs and collected data on gender and country of affiliation of the review first and last authors, and a second checked for accuracy. We conducted descriptive statistics and bivariate logistic regression to explore the association between the gender of the authors and sex-related analysis and reporting. RESULTS: Six hundred and ten Cochrane SRs were identified. After removing those that met no eligibility criteria, 516 reviews of interventions were included. Fifty-six reviews included sex-related reporting in the abstract, 90 considered sex in their design, 380 provided sex-disaggregated descriptive data, 142 reported main outcomes or performed subgroup analyses by sex, and 76 discussed the potential impact of sex or the lack of such on the interpretations of findings. Women represented 53.1 and 42.2% of first and last authorships, respectively. Women authors (in first and last position) had a higher possibility to report sex in at least one of the review sections (OR 2.05; CI 95% 1.12-3.75, P=0.020) than having none. CONCLUSIONS: Sex consideration amongst Cochrane SRs was frequently missing. Structured guidance to sex-related analysis and reporting is needed to enhance the external validity of findings. Likewise, including gender diversity within the research workforce and relevant authorship positions may foster equity in the evidence generated.

Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review.

BACKGROUND: Social prescribing (SP) involves linking patients in primary care with services provided by the voluntary and community sector (VCS). Despite growing interest within NHS primary care, it remains unclear how and under what circumstances SP might contribute to good practice. AIM: To define 'good' practice in SP by identifying context-specific enablers and tensions. To contribute to the development of an evidence-based framework for theorising and evaluating SP within primary care. DESIGN & SETTING: Realist review of secondary data from primary care-based SP schemes. METHOD: Academic articles and grey literature were searched for qualitative and quantitative evidence following the Realist And Meta-narrative Evidence Syntheses - Evolving Standards (RAMESES). Common SP practices were characterised in three settings (general practice, link workers, and community sector) using archetypes that ranged from best to worst practice. RESULTS: A total of 140 studies were included for analysis. Resources were identified influencing the type and potential impact of SP practices and four dimensions were outlined in which opportunities for good practice arise: 1) individual characteristics (stakeholder's buy-in, vocation, and knowledge); 2) interpersonal relations (trustful, bidirectional, informed, supportive, and transparent and convenient interactions within and across sectors); 3) organisational contingencies (the availability of a predisposed practice culture, leadership, training opportunities, supervision, information governance, resource adequacy, accessibility, and continuity of care within organisations); and 4) policy structures (bottom-up and coherent policymaking, stable funding, and suitable monitoring strategies). Findings were synthesised in a multilevel, dynamic, and usable SP framework. CONCLUSION: The realist review and resulting framework revealed that SP is not inherently advantageous. Specific individual, interpersonal, organisational, and policy resources are needed to ensure SP best practice in primary care.

Development and evaluation of a training programme on asset-based community development aimed at general practice trainees: protocol for a mixed-method multilevel and multicentric action research study.

INTRODUCTION: Asset-based community development (ABCD) is a strategy aimed at strengthening communities of interest through the identification and enhancement of those protective resources (also called 'health assets') that contribute to improve population health. Although primary care is specially well placed to contribute to ABCD by facilitating patients' access to community health assets, the implementation of ABCD approaches is limited, in part due to training deficiencies amongst general practitioners. In this study, we will develop a training programme on ABCD aimed at general practice trainees and evaluate its implementation and scale-up in Andalusia, Spain. We will also investigate whether the programme may contribute to strengthen the community orientation of the primary care practices involved in the study. METHODS AND ANALYSIS: We will undertake a mixed methods, multilevel and multicentric action research study drawing on theoretical frameworks relevant to learning (pedagogy) and community health promotion. The intervention will be implemented and evaluated in eight different study areas over 48 months. It will comprise a classroom-based session and a practical exercise, which will involve general practice trainees producing a map of community health assets relevant to common health conditions. In each study area, we will set up a stakeholder group to guide our study. We will run the intervention sequentially across the eight study areas, and modify and refine it iteratively by incorporating the findings from the evaluation. We will employ qualitative (interviews and focus groups with general practice trainees, primary care workers, members of the teaching units and policymakers) and quantitative methods (self-administered questionnaires with an approximate sample of 157 general practice trainees and 502 primary care workers). ETHICS AND DISSEMINATION: Ethics approval from the Andalusian Regional Health Council has been granted (6/2020). It is envisaged that this research will provide relevant, evidence-based guidance on how best to incorporate learning on ABCD into the general practice training curriculum. Findings will be disseminated in an ongoing manner and will target the following audiences: (1) general practice trainees, primary care workers and members of the teaching units, (2) policymakers and strategic decision makers and (3) the academic community.

Could social prescribing contribute to type 2 diabetes prevention in people at high risk? Protocol for a realist, multilevel, mixed methods review and evaluation.

INTRODUCTION: Social prescribing is an innovation being widely adopted within the UK National Health Service policy as a way of improving the management of people with long-term conditions, such as type 2 diabetes (T2D). It generally involves linking patients in primary care with non-medical community-based interventions. Despite widespread national support, evidence for the effectiveness of social prescribing is both insufficient and contested. In this study, we will investigate whether social prescribing can contribute to T2D prevention and, if so, when, how and in what circumstances it might best be introduced. METHODS AND ANALYSIS: We will draw on realist evaluation to investigate the complex interpersonal, organisational, social and policy contexts in which social prescribing relevant to T2D prevention is implemented. We will set up a stakeholder group to advise us throughout the study, which will be conducted over three interconnected stages. In stage 1, we will undertake a realist review to synthesise the current evidence base for social prescribing. In stage 2, we will investigate how social prescribing relevant to people at high risk of T2D 'works' in a multiethnic, socioeconomically diverse community and any interactions with existing T2D prevention services using qualitative, quantitative and realist methods. In stage 3 and building on previous stages, we will synthesise a 'transferable framework' that will guide implementation and evaluation of social prescribing relevant to T2D prevention at scale. ETHICS AND DISSEMINATION: National Health Service ethics approval has been granted (reference 20/LO/0713). This project will potentially inform the adaptation of social prescribing services to better meet the needs of people at high risk of T2D in socioeconomically deprived areas. Findings may also be transferable to other long-term conditions. Dissemination will be undertaken as a continuous process, supported by the stakeholder group. Tailored outputs will target the following audiences: (1) service providers and commissioners; (2) people at high risk of T2D and community stakeholders; and (3) policy and strategic decision makers. PROSPERO REGISTRATION NUMBER: CRD42020196259.

Comparative anti-fracture effectiveness of different oral anti-osteoporosis therapies based on "real-world" data: a meta-analysis of propensity-matched cohort findings from the UK Clinical Practice Research Database and the Catalan SIDIAP Database.

PURPOSE: This paper aims to compare the clinical effectiveness of oral anti-osteoporosis drugs based on the observed risk of fracture while on treatment in primary care actual practice. MATERIALS AND METHODS: We investigated two primary care records databases covering UK National Health Service (Clinical Practice Research Datalink, CPRD) and Catalan healthcare (Information System for Research in Primary Care, SIDIAP) patients during 1995-2014 and 2006-2014, respectivey. Treatment-naive incident users of anti-osteoporosis drugs were included and followed until treatment cessation, switching, death, transfer out, or study completion. We considered hip fracture while on treatment as main outcome and major osteoporotic fractures (hip, clinical spine, wrist, and proximal humerus) as secondary outcome. Users of alendronate (reference group) were compared to those of (1) OBP, (2) strontium ranelate (SR), and (3) selective estrogen receptor modulators (SERMs), after matching on baseline characteristics using propensity scores. Multiple imputation was used to handle missing data on confounders and competing risk modelling for the calculation of relative risk according to therapy. Country-specific data were analyzed separately and meta-analyzed. RESULTS: A total of 163,950 UK and 145,236 Catalan patients were identified. Hip (sub-hazard ratio [SHR] [95% CI] 1.04 [0.77-1.40]) and major osteoporotic (SHR [95% CI] 1 [0.78-1.27]) fracture risks were similar among OBP compared to alendronate users. Both hip (SHR [95% CI] 1.26 [1.14-1.39]) and major osteoporotic (SHR [95% CI] 1.06 [1.02-1.12]) fracture risk were higher in SR compared to alendronate users. SERM users had a reduced hip (SHR [95% CI] 0.75 [0.60-0.94]) and major osteoporotic (SHR [95% CI] 0.77 [0.72-0.83]) fracture risk compared to alendronate users. CONCLUSION: We found a 26% excess hip fracture risk among SR compared to matched alendronate users, in line with placebo-controlled RCT findings. Conversely, in a lower risk population, SERM users had a 25% reduced hip fracture risk compared to alendronate users. Head-to-head RCTs are needed to confirm these findings.

[Training in community health: challenges, threats and opportunities. SESPAS Report 2018]. / Formación en salud comunitaria: retos, amenazas y oportunidades. Informe SESPAS 2018.

Incorporating community health teaching in the undergraduate nursing and medicine curriculum and postgraduate training programmes contributes to enhance the quality, rigour and sustainability of health-promoting community interventions. In this article, we discuss the failure of Spanish Medical Universities to include family and community medicine and primary health care as integrated and cross-cutting disciplines on the undergraduate curriculum. During specialized medical and nursing training, community health teaching varies widely depending on the qualification, priorities and motivation of the primary health care workers, teaching units and trainees. Growing job instability and current nurse and medical recruitment systems, are hindering learning being put into practice, as well as the development of health-promoting community activities and the strengthening of training networks and facilities. Amid such adversity, there are initiatives that provide quality training on community health and should, accordingly, be fostered and acknowledged.

Atención Primaria y promoción de la salud bucodental: evaluación de una intervención educativa en población infantil / Primary Care and oral health promotion: Assessment of an educational intervention in school children

Objetivo: Evaluar a corto y medio plazo la efectividad de una intervención de promoción de la salud bucodental impulsada desde Atención Primaria. Diseño: Ensayo comunitario de intervención no aleatorizado. Emplazamiento: Tres centros educativos de características sociodemográficas similares de un barrio empobrecido de Granada. Participantes: Participaron en el estudio 82 alumnos de entre 5 y 6 años del colegio intervención (CI) y 109 de los colegios control (CC), así como los profesores y padres/madres de los alumnos del CI. Intervención: Actividades escolares de promoción de la salud bucodental dirigidas a los alumnos, y reuniones periódicas con los profesores y padres/madres del CI durante 2 cursos consecutivos. Mediciones principales: Conocimientos sobre salud bucodental y hábitos higiénico-dietéticos de los alumnos, valorados mediante cuestionarios distribuidos antes de la intervención y transcurridos 6 y 18 meses. Resultados: Transcurridos 18 meses, los conocimientos adquiridos fueron significativamente superiores en el CI (OR 3,54; IC 95% 1,46-8,58) en comparación con los CC. El consumo de alimentos saludables aumentó significativamente en el desayuno (OR 2,95; IC 95% 1,26-6,89) y la merienda (OR 3,67; IC 95% 1,49-9,05) y disminuyó el consumo de bollería (OR 4,05; IC 95% 1,68-9,81) y refrescos azucarados (OR 3,79; IC 95% 1,57-9,12) respecto a los CC. No se observaron mejoras en relación con la higiene bucodental en el CI. Conclusiones: Las intervenciones escolares de educación sanitaria, desarrolladas de forma intersectorial, participativa y considerando los contextos socioeconómicos particulares, resultan eficaces en la mejora del conocimiento y los hábitos dietéticos de los alumnos

Objective: To evaluate the short and medium term effectiveness of a Primary Care-driven oral health promotion intervention. Design: A non-randomised community intervention trial. Setting: Three socio-demographically similar primary schools of a deprived neighborhood in Granada, Spain. Participants: Eighty-two intervention and 109 control students aged 5 to 6, as well as the teachers and the parent's association of the intervention school (IS) participated in the study. Intervention: School-based health promotion activities aimed at students, and regular meetings with the teachers and parents of the IS during 2 consecutive years. Main measurements: Students' oral health-related knowledge and behavior, assessed via questionnaires distributed before the intervention, and 6 and 18 months afterwards. Results: Compared to the control groups at 18 months, students belonging to the IS reported enhanced oral health knowledge (OR 3.54; 95% CI 1.46-8.58), and an increased consumption of healthy food at breakfast (OR 2.95; 95% CI 1.26-6.89) and during mid-afternoon snack (OR 3.67; 95% CI 1.49-9.05). A significant decrease was seen in the intake of pastries (OR 4.05; 95% CI 1.68-9.81) and sweetened soft drinks and juices (OR 3.79; 95% CI 1.57-9.12) amongst intervention compared to control students in the medium term (18 months). No significant improvements were observed concerning oral hygiene in the IS. Conclusions: School-based educational interventions, when developed through an intersectoral and participative approach and considering the socio-economic context, appear to be effective in improving students’ diet-related knowledge and behaviors

Formación en salud comunitaria: retos, amenazas y oportunidades. Informe SESPAS 2018 / Training in community health: challenges, threats and opportunities. SESPAS Report 2018

La incorporación de contenidos docentes relativos a la salud comunitaria en los programas formativos de enfermería y medicina contribuye a acrecentar la calidad, el rigor y la sostenibilidad de las intervenciones comunitarias. En este artículo dialogamos sobre cómo la medicina familiar y comunitaria y la atención primaria siguen sin ser consideradas disciplinas nucleares y transversales en las facultades de medicina españolas. Durante la formación especializada médica y enfermera existe una gran variabilidad en el aprendizaje sobre salud comunitaria, dependiendo de la capacitación, las prioridades y la motivación de los profesionales de atención primaria, las unidades docentes y sus residentes. La creciente inestabilidad laboral y los actuales sistemas de contratación dificultan la puesta en práctica de las competencias adquiridas, el desarrollo de actividades comunitarias y la consolidación de espacios y redes para la formación. A pesar de las adversidades, existen iniciativas que potencian con ilusión una formación de calidad en salud comunitaria, y que merecen ser impulsadas y visibilizadas

Incorporating community health teaching in the undergraduate nursing and medicine curriculum and postgraduate training programmes contributes to enhance the quality, rigour and sustainability of health-promoting community interventions. In this article, we discuss the failure of Spanish Medical Universities to include family and community medicine and primary health care as integrated and cross-cutting disciplines on the undergraduate curriculum. During specialized medical and nursing training, community health teaching varies widely depending on the qualification, priorities and motivation of the primary health care workers, teaching units and trainees. Growing job instability and current nurse and medical recruitment systems, are hindering learning being put into practice, as well as the development of health-promoting community activities and the strengthening of training networks and facilities. Amid such adversity, there are initiatives that provide quality training on community health and should, accordingly, be fostered and acknowledged

Estudiantes de medicina y marketing farmacéutico / Medical students and drug marketing

OBJETIVO: Conocer la exposición de los estudiantes de medicina a las actividades promocionales de la industria farmacéutica, e identificar sus opiniones y actitudes, así como los posibles efectos de esta exposición en su formación y futura práctica profesional. DISEÑO: Estudio descriptivo transversal. Emplazamiento: Facultad de Medicina de la Universidad de Zaragoza. Participantes: Estudiantes de medicina de los cursos tercero, cuarto, quinto y sexto. MÉTODOS: La información se obtuvo mediante un cuestionario autoaplicado, previamente adaptado, sobre exposición, actitudes e idoneidad percibida de las actividades de marketing farmacéutico. Se estimaron porcentajes para las variables categóricas, aplicando el test de ji al cuadrado para la comparación entre grupos. Regresión logística para determinar los factores asociados a actitudes proclives a dichas actividades. RESULTADOS: Se obtuvieron 369 encuestas (93% de los asistentes a clase). La exposición a las actividades promocionales es elevada, sobre todo en la etapa clínica (el 78,6% declara haber recibido un regalo no formativo). Los estudiantes reconocen los sesgos y posibles repercusiones en la práctica profesional, aunque con ambigüedad y contradicciones. Las actividades mejor aceptadas son las relacionadas con la formación y las actitudes más críticas aparecen en la etapa clínica, sobre todo en el sexto curso. CONCLUSIONES: La exposición de los estudiantes al marketing farmacéutico y sus posibles repercusiones formativas y profesionales son frecuentes e importantes. El ámbito de la formación resulta especialmente permeable a las actividades promocionales. Las diferencias observadas en los últimos cursos señalan la necesidad de formación específica curricular y desarrollo de actitudes reflexivas por los propios estudiantes

OBJECTIVE: To determine the exposure of medical students to the marketing activities of the pharmaceutical industry, and identify their opinions and attitudes, and also the possible effects this exposure on their training and future professional practice. DESIGN: Descriptive cross-sectional. Setting: University of Zaragoza Faculty of Medicine. Participants: Third, fourth, fifth and sixth year medical students. METHODS: The information was obtained using a previously adapted, self-report questionnaire on the exposure, attitudes and perceived suitability of drug marketing activities. Percentages were calculated for the categorical variables, applying the chi squared test for the comparison between the groups. A logistic regression was performed to determine the factors associated with their attitudes towards these activities. RESULTS: A total of 369 questionnaires were returned (93% of those attending classes). The exposure to marketing activities is high, particularly in the clinical stage (78.6% said to have received a gift non-educational gift). The students recognised the possible biases and repercussions in professional practice, although with ambiguity and contradictions. The most accepted activities are those associated with training, and the most critical attitudes appear in the clinical stage, particularly in the sixth year. CONCLUSIONS: Exposure to drug marketing by medical students and its possible training and professional effects is frequent and significant. The training environment is particularly open to promotional activities. The differences observed in the later years suggest the need for a specific curriculum subject and development of reflective attitudes by the students themselves