Patients' intention to consume prescribed and non-prescribed medicines: A study based on the theory of planned behaviour in selected 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. The aim 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, was to report on possible determinants of patient behaviour regarding the consumption of medicines, and particularly OTCs, in the context of primary care. 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. RESULTS AND DISCUSSION: 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. 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.

Eliciting general practitioners' salient beliefs towards prescribing: a qualitative study based on the Theory of Planned Behaviour in Greece.

WHAT IS KNOWN AND OBJECTIVE: Prescribing represents an important medical action especially in primary care. However, irrational prescribing is common and has an impact on clinical and economic outcomes. Therefore, there is a growing need to rationalize prescribing. Knowledge of influential factors is crucial for achieving this. The aim of the present study was to identify the behavioural, normative and control beliefs of GPs regarding prescribing in Greece. METHODS: Focus group sessions were conducted in three geographically defined areas in Greece. GPs working in the private and public sector in primary care settings were invited to participate. Transcripts from focus groups were content analysed using the Theory of Planned Behaviour (TPB) as the theoretical framework. RESULTS AND DISCUSSION: GPs acknowledged prescribing as the most important method for treating diseases in primary health care, with significant impact on patient's health and quality of life. The expectations of patients and their families were extremely influential during prescribing. Pharmaceutical sales representatives, other GPs and specialists, as well as public health authorities influenced prescribing. GPs admitted that factors such as the income of the patient, the limited time available and special situations such as prescribing through a third person or prescribing following patients' prescription requests for medicines that they have previously purchased over the counter through pharmacies may facilitate or hinder their prescribing decision. WHAT IS NEW AND CONCLUSION: This elicitation study shed light into GPs' beliefs regarding prescribing. Factors that are not common in the usual European setting were revealed, such as the influence of the patients' family and special situations during prescribing. Thus, various issues were highlighted that should inform the development of items for inclusion in a forthcoming TPB-based questionnaire. The results of this study revealed also certain issues that can affect the design of policies aiming at the rationalization of prescribing.

Are children from Crete abandoning a Mediterranean diet?

INTRODUCTION: Mediterranean countries such as Greece have experienced rapid social change in the last decade. These community changes affect nutritional habits and there is a tendency for the traditional healthy Mediterranean diet to be abandoned. METHODS: The parents of children from one rural Greek village on Crete (Neapolis), and one rural village in Sweden (Kisa) were invited to their primary health care centers for an interview and to fill in a validated nutrition questionnaire, KidMed. RESULTS: There were no differences (p = 0.48) in total KidMed score between the Cretan and Swedish children, adjusted for gender and age. However, there were some significant differences in scores on certain KidMed questions. Parents of the Cretan children reported significantly higher daily use of olive oil at home and more regular nut consumption, but also more commercially baked goods or pastries for breakfast. The parents of Swedish children reported significantly higher use of cereals, grains or bread for breakfast. The mean BMIs were similar for the Cretan (Neapolis mean 16.8, 95% CI 13.5-23.0) and for the Swedish children (Kisa mean 17.4, 95% CI 13.7-25.5) CONCLUSION: The results suggest the possibility of changing nutritional habits, measurable among young children in rural areas. The study raises the question of whether Cretan children may have abandoned some aspects of the traditional Mediterranean diet. It may also be that Swedish children have changed their diet in favor of a more Mediterranean food choice. The major limitation of the study is the small sample size, and further, larger studies are warranted.

Unwinding Ariadne's thread: some methodological and interpretative considerations on international hospital admission comparisons, with special reference to cancer.

Hospital utilisation rates comprise the main available source of information on morbidity patterns and the need for health care in a number of developing countries. On the basis of the findings of a Greek-Swedish comparison of somatic hospital admission (presented per the 18 principal head groups of the International Classification of Diseases) between two regional University hospitals, a number of important findings and methodological questions are considered. Factors that can explain the large variations of hospital admission found are examined; in particular those related to disease definition, classification and coding, hospital services supply, professional behavior and practices, illness behavior of patients, and demographic and socio-economic characteristics but especially a true difference in morbidity. An additional statistical elaboration of the hospitalization data in the form of a logistic regression analysis is suggested, in particular at the district or regional level. However, after rigorous scrutiny, our data point to persistent remarkable differences at the respective sites in the major "welfare-related" population diseases, notably, cancer and cardiovascular diseases.

Differential cancer morbidity towards year 2000 in a population disease outlook across Europe.I. The female gender.

Modern health system research emphasises the transition from mortality statistics via morbidity and risk factors observations to comparative site explorations in defined areas. The health of women from the perspective of their gender has become a priority in medical research over the last decade. Studies of morbidity have been called for as necessary intermediary stage for hypothesis generation, and the formulation and inception of epidemiological projects which are recognized as essential for attaining knowledge on the factors and circumstances that determine diseases and wellbeing in the general population. This applies especially to cancer, where the importance of seeing disease, from a ecological, cultural as well as gender context is evident. We made a comparative analysis of the hospitalization for somatic diseases during 1986-1987 at the Heraklion University Hospital on Crete, and the commensurable Linköping University Hospital in the country of Ostergötland, Sweden. They are representative of their complementary Europian situations and comprise the total hospital admissions in their regions. Large differences were found, notably regarding both cardiovascular diseases and cancer, with lower morbidity in the more 'arcadian', rural circumstances. The results provide unique data on traits and patterns intermediate to the pioneering observations of the Seven Countries survey on the rapidly changing European scene. In the field of cancer the data are effectively unmatched both as raw data and as a platform for further investigation, which we are presently pursuing under the emblem of 'Ariadne's thread'. From a salutogenetic point of view the elderly rural women on Crete, and from a pathogenetic point of view the elderly urban women in Linköping warrant particular attention.

Differential cancer morbidity towards year 2000 in a population disease outlook across Europe. II. The male gender.

The conception of new, 'avoidable' life style diseases in affluent Western societies is largely based upon observations in groups of middle-aged urban males with mortality as the major end-point. This applies to cancer, too, and studies of morbidity, where cancer is put within the overall disease spectrum, are called for as a necessary intermediary stage for hypothesis generation and initiation of evaluative and interventive epidemiological projects in the community. Here also the conditions and circumstances that determine health and well being, that is, salutogenetic factors, come increasingly into focus. We made a comparative analysis of the total hospitalization for somatic diseases during 1986-1987 at the Linköping University Hospital in the county of Ostergötland, Sweden and the both complementary and commensurable Heraklion University Hospital on Crete. They are representative of their respective European situations, and are the only somatic hospitals in their regions. Large differences were found with lower morbidity in the more 'Arcadian', rural settings. The results provide valuable data on traits and patterns between earlier surveys such as the Seven Countries study and today. We have earlier reported on the findings from the female group of the two populations, and here wish to concentrate on the males. In particular, cancer is compared with the both prominent and 'archetypical' forms of male ill-health that are comprised by cardiovascular diseases and accidents. We discuss some of the salutogenetic as well as pathogenetic factors that call for closer study in the next stage of our project, whose emblem of Ariadne's thread we feel also has a strong bearing on the masculine gender.

Hospital admissions for different cancer diagnosis: a comparison between two European landscapes.

Cancer frequency has been studied in a Department of Crete and a Department of Sweden, using in-patient data collected in the Departmental Hospitals, for a two-year period. The results of the study suggest that similar trends exist in the prevalence of different forms of cancer between the two areas studied, as well as some significant differences. The differences observed concern mainly the frequency of cancers of the lung, prostate, bladder and large bowel among men and breast and large bowel among women. These findings could to a great extent be explained by life-style and environmental differences between the two areas and are consistent with data concerning the cancer mortality in the two countries.

Managing Alzheimer's disease in primary care in Crete, Greece: room for improvement.

As Greece moves during the last two decades toward a national health care system, which gives emphasis to the development of a primary care system, many worry how to ensure that the quality of care is assessed. This is more apparent in the rural populations, in which health care is served to a large extent by physicians without formal training in general practice. This article explores the level of knowledge of primary care physicians in relation to Alzheimer's disease in geographically defined areas of Crete, Greece, in comparison with that of general practitioners in Ostergötland, Sweden, and in Iceland. It emphasizes the need for better education and training for primary care physicians in Crete in both the early diagnosis and management of Alzheimer's disease.

Costs of the treatment of leg ulcers: initiating a quality assurance process.

Reports on a study which aimed to initiate a quality assurance process among health care personnel in Sweden. An epidemiological survey concerning treatment of leg ulcers in a defined region in Sweden was conducted and the costs of treating leg ulcers at different levels of care were analysed. The epidemiological survey provided the data necessary to calculate the socio-economic costs for the treatment of leg ulcers. The weekly cost was found to be about 24 times higher for hospital inpatients than it was for patients treated at home. The quality assurance process has continued through an interdisciplinary regional consensus conference and the establishment of a consensus programme in the region, with targets and general suggestions for the care and treatment of leg ulcers. To maintain high quality in leg ulcer treatment in the region, an interdisciplinary reference group has been established with members from different clinics at the hospital and members from the primary health care.

[Asthma in children more and more common. A study of medical records shows a doubled increase during a 10-year period]. / Astma hos barn blir allt vanligare. Journalstudie visar en fördubbling under en tioårsperiod.

The number of children with asthma is rising. This is shown by a study of medically diagnosed asthma in a cohort of children born in 1990 in a well defined and limited region. The medical records from all of the health centres in primary health care, privately practising paediatricians and relevant child clinics in the region were examined when the children were 7 years old. The results showed that 10.9% of the children had been diagnosed with asthma. The percentage of children with asthma was highest (14.2%) among boys living in a city environment. Comparison with a similar follow-up study in the same region concerning children born in 1975 showed that the percentage of children with asthma doubled during a period of just over a decade.

Social environment and health--a social epidemiological frame of reference.

Growing interest in epidemiological studies and prevention has led to increased awareness of the importance of the social environment to health. In this field of research, which might be designated social epidemiology, there is today extensive research into the possible association between different types of social factors and ill-health in the population. This article presents a social epidemiological frame of reference and some social factors of importance when one is studying the relationships between the social environment and health. Important social factors in the model are social stratification, social network, social support and life-style factors. Two other main categories of social factors in the model are circumstances and events related to social stratification or occupation and social network respectively. These may be factors in the external or internal work environment and variables describing the general activity level of the individual or different types of stressful social network-related life events. Other important factors in the model are physiological and clinical factors and three different types of health indicator. In the field of social epidemiological research, there is an increasing need for the development of theoretical models and frameworks as support in the analysis of social factors and health. These could be based on experience and tradition in both epidemiological research and the social sciences.

The concept of status incongruence revisited: a 22-year follow-up of mortality for middle-aged men.

The purpose of this study was to analyse the relationships between status incongruency and mortality. From the concept of status incongruence two incongruent groups were defined, those with high education and low social position (socially downward drifters) and those with low education and high social position (socially upstarters). A cohort of middle-aged men (n = 855), all born in 1913 and living in the city of Gothenburg, Sweden were followed during a period of 22 years. The socially downward drifters had a significantly increased risk for: non-cause specific (overall) mortality, more potential years of life lost and mortality caused by coronary heart disease. These differences were still evident after taking other risk factors into account. The socially upstarters had, on the other hand, lower mortality risks and win years. Imbalance between educational level and attained social position appears to affect survival in a long term follow-up.

Social mobility and health in a prospective study of middle-aged men.

Many social factors and social phenomena and their influence on health are now of interest for epidemiological research and also for health policy. On social phenomenon of interest is mobility in the social structure of society. In this prospective study of a sample of 50-year-old men born in 1913 in Gothenburg, Sweden, it was possible to study intergenerational social mobility and different measures of ill-health, like health complaints, incidence of myocardial infarction and mortality. The results of the study indicate that individuals who find themselves in a lower social group than that of their father at the age of 50 exhibit a somewhat poorer subjective state of health and report more complaints and symptoms at the age of 60. They also tended to be slightly more at risk with regard to myocardial infarction, but there were no mortality differences in a long-term follow-up.

Relevance of social and behavioral factors in the evaluation of dental health care for school children.

An interdisciplinary strategy based on a theoretical model for studying dental health was used to analyze the relevance of social and behavioral factors in the evaluation of dental health care for school children. The study comprised pupils who, after a total period of 5 years, differed in their experience with preventive regimens applying different principles of dental prevention. In 1979-80 social and behavioral data were collected by means of a postal questionnaire from altogether 234 pupils, aged 15-16 years, from two school areas. Clinical data, comprising scores for prevalence of plaque, gingivitis, and caries, were available from examinations in 1974, 1978, and 1979. The analysis of factors influencing the subjects' oral status demonstrated that material factors--the parents' education and employment, type of housing, and line of education--and physical factors--sex and prevalence of plaque, gingivitis, and caries at base line--all were of significance for the results obtained. No significant influence of home care climate (social/political factors), dental knowledge and attitudes, general foresightedness or carelessness (mental factors), or tooth-cleaning and sweet-eating habits (action factors) was found. Social and behavioral factors of significance exerted their influence regardless of the type and scope of the dental health care provided. Gingival health was far more a consequence of the professional tooth-cleaning regimen than dependent on the social and behavioral factors tested. No superior effect on caries status was demonstrated for any of the preventive regimens tested.

The personal doctor reform in Sweden: perceived changes in working conditions.

BACKGROUND: In primary care in Sweden, several organizational changes have been implemented during the last decades in order to facilitate a shift from a high proportion of hospital care to a more primary-health-based care. The personal doctor reform has been one of the most important during recent years, for both personnel and patients. OBJECTIVES: We aimed to compare perceived changes in psychosocial working conditions for GP and district nurses in regions with traditional primary care and regions that have implemented a personal doctor system. METHODS: A questionnaire was mailed to 566 GPs and 554 district nurses in four selected county councils, two with traditional primary care and two with a personal doctor system. The overall response rate was 83%. A factor analysis of data concerning the experience of the organizational change revealed the following factors: fellowship at work, demands on the individual, influence and control, competence development and stimulation at work. RESULTS AND CONCLUSIONS: In the group as a whole, there was a general experience of deterioration of working conditions in all aspects except stimulation at work. This tendency was mostly marked in the regions with a personal doctor system. In these regions, GPs and district nurses reported significantly more impairments concerning demands on the individual and competence development. In addition, the district nurses also found themselves less able to exercise influence and control. These changes are neither desirable nor necessary consequences of an organizational development. It is important to follow continuously the personnel's experience in a changing primary health care system.

Assessment of psychosocial work environment in primary care--development of a questionnaire.

Recent studies have indicated deteriorated working conditions of health care personnel. To have an efficient health care organization requires good working conditions and the well-being of the personnel. Today there are no "gold-standard" assessment tools measuring psychosocial working conditions. The aim of this study was to develop two valid and reliable questionnaires, one generic and one specific, measuring psychosocial working conditions for general practitioners (GPs) and district nurses (DNs) in Sweden, with a special emphasis on organizational changes. The construction of the questionnaires were made after a stepwise developing phase including literature review, interviews, and a pilot study. The pilot study included GPs n = 42 and DNs n = 39. The questionnaires were later on used in a main study (GPs n = 465, DNs n = 465). A factor analysis was carried out and showed that there were fewer items in the main study that had factor loading > or = 0.40 in more than one factor, compared to the pilot study. The factors from the main study were easier to label and had good correspondence with other studies. After this stepwise development phase good construct validity and internal consistency were established for the questionnaire.

Community-based medical systems advancement in a hospital-primary health care centre in Crete, Greece: concepts, methods, and the new role of the general practitioner.

Modern health systems research and development emphasize the transition from hospital to primary health care. Importantly, this transition is projected to be coordinated and interactive, as facilitated, e.g., by improved information systems and collaboration between the involved parties, including Universities and health authorities. An ideal combination of this might accordingly be offered by a synthesis of a basic hospital and primary health care center in an area of suitable site, size, and structure. We believe that our institution, Nosokomion Neapolis, in; the moderate-size Cretan township of Neapolis (New-city) offers an interesting model example of this, because of its affiliation with the University of Heraklion and its international and EU-supported project status. In the present report we want to emphasize the elements that are particularly well suited and manageable and in many ways both opportunistic and conscientious "back to the future" instances of a successful Hospital/Primary Health Care integration. Specifically, we think that the advantages in local area epidemiology, prevention, and quality assurance are apparent, and nurture a--rather renewed that new-role of the general practitioner as both a holistic population doctor and a health systems researcher for the year 2,000 and beyond.