Exploring pharmacists' perspectives about substandard and falsified medical products through interviews.

Background: The problem with substandard and falsified (SF) medical products may grow in high-income countries when e-commerce of medicines increases. Unauthorized websites offer medicines of insufficient quality. This underscores the importance of evaluating how the problem with SF medical products can be prevented from escalating. However, little is known about what knowledge and experience professionals working primarily with medicines have about the phenomenon. Objective: This study was conducted to explore purposively selected pharmacists' experience and knowledge about SF medical products. Methods: Twelve individual interviews were conducted with purposively selected pharmacists between May 2021 and September 2021. An interview guide was used with specific questions about e-commerce, which focused on exploring pharmacists' experience and knowledge about SF medical products. The interviews lasted, on average, 49 min and were analyzed using inductive qualitative content analysis. Results: A main theme 'Pharmacists as guardians of safe medicines' emerged. This theme consisted of three categories pinpointing 'risk factors', 'protective factors', and 'opportunities for improvement' regarding SF medical products. Findings suggest that pharmacists can play a role in preventing the problem with SF medical products from escalating. Participants emphasized they were in this line of work to help patients and increase patient safety. Conclusions: Pharmacists have the opportunity to empower the public with knowledge about SF medical products since they discuss medicines with many people every day. Awareness of risk factors for SF medical products enables pharmacists to guide patients to avoid risky purchases from unauthorized websites. To do this, better communication, and cooperation with patients and other healthcare professionals are needed.

Swedish community pharmacy employees' knowledge and experience of substandard and falsified medical products: a cross-sectional descriptive survey.

OBJECTIVES: Substandard and falsified medical products are, according to the World Health Organization, a global threat to public health. To evaluate if community pharmacy employees can guide the public to safer medication purchases, their knowledge and experience about SF medical products was examined. METHODS: A digital questionnaire was distributed to the five dominating pharmacy companies in Sweden, representing 97% of the community pharmacies (1391/1433), giving the theoretical possibility of reaching 6200 employees. Three companies published a link to the questionnaire on their intranets, one distributed the link via e-mail to the responsible pharmacist for quality and knowledge, respectively. The fifth company did not pass on, due to technical problems. Employees aged 18 years or older with customer contact were invited to participate. KEY FINDINGS: The questionnaire was available for 74% of all community pharmacies (1067/1433), having approximately 4900 employees with customer contact. The response rate was 5% (228/4900). Of the respondents, 89% were pharmacists (203/228), 84% were women (191/228) and 43% were 35-49 years (98/228). The respondents worked in pharmacies of different size, located both in rural and urban areas. The definition of substandard and falsified medical products was known by 182 of the 228 respondents (80%) and the main source of knowledge was media (61%, 111/228). The common European logo for authorized online pharmacies was not recognized by 74% (169/228). CONCLUSIONS: For pharmacy employees to guide the public to safer medication purchases, knowledge about substandard and falsified medical products needs to be enhanced specially about legal international e-commerce.

Substandard and falsified medical products are a global public health threat. A pilot survey of awareness among physicians in Sweden.

BACKGROUND: Substandard and falsified medical products are a public health threat, primarily associated with low- and middle-income countries. Today, the phenomenon also exists in high-income countries. Increased Internet access has opened a global market. Self-diagnosis and self-prescription have boosted the market for unregulated websites with access to falsified medicines. AIM: To describe the state of knowledge and experience on SF medical products among emergency physicians (EPs) and general practitioners (GPs) in Sweden. METHODS: An online survey with anonymous answers from 100 EPs and 100 GPs. Physicians were recruited from TNS SIFO's medical database. The term in the survey was 'illegal and falsified medicines' which was common in Sweden at that time. It corresponds well with the term 'substandard and falsified medical products' that the WHO launched shortly after our data collection. We report our results with this term. RESULTS: In Sweden, 78.5% of the physicians had heard the term 'illegal and falsified medicines' and 36.5% had met patients they suspected had taken it. Physicians lacked awareness of the use of the reporting system and wanted more knowledge about how to deal with patients who have possibly used falsified medicines. CONCLUSIONS: To meet the public health threat of SF medical products, physicians need more knowledge.

Conceptions of depressive disorder and its treatment among 17 Swedish GPs. A qualitative interview study.

BACKGROUND: Making clinical decisions for psychiatric patients in general practice is a complicated issue. A marked variation in the prescribing rates for antidepressant drugs in general as well as between geographical regions has been reported. Also, GPs tend to underestimate and undertreat depressive disorders. OBJECTIVES: The aim of this study was to explore GPs' conceptions of depressive disorder and its treatment. METHOD: A qualitative semi-structured interview was carried out on 17 GPs, selected to ensure variation of pre-conditions, in the county of Orebro, Sweden. Informants' conceptions about four depression-related issues were determined: the depressive disorder, antidepressant drugs, the treatment decision and psychotherapy. RESULTS: Conceptions of the four themes varied widely among informants in the interviews. However, the informants shared certain conceptions concerning the selection of drugs and drug treatment of major depression as well as the patient's role in deciding whether or not to treat pharmacologically. CONCLUSIONS: The study adds knowledge of GPs' thoughts about depressive disorder and their diagnostic and treatment preferences. Utilizing the concepts discussed herein, a quantitative study will be conducted to analyse how GPs' conceptions of depression are inter-related.

Awareness and treatment of cardiovascular disease risk factors among middle-aged Swedish men and women.

OBJECTIVE: To study awareness and treatment of risk factors for cardiovascular disease in a primary care district where a screening program for hypercholesterolaemia involving one third of the population had been conducted 7 years earlier. DESIGN: A semi-structured telephone survey on four risk factors; blood pressure, serum cholesterol, blood sugar, and smoking habits. SETTING: The study was performed in a defined area in Blekinge county in Sweden. SUBJECTS: A random sample of the general population aged 40-49 years, in total 356 people. MAIN OUTCOME MEASURES: Awareness of individual risk factors, for cardiovascular diseases, on-going medication, and lifestyle changes in order to lower individual risks. RESULTS: A total of 95% had had their blood pressure measured at least once, compared with 69% for serum cholesterol. Twenty-two per cent had at some time been told that they had high blood pressure, and, of these, almost half (44%) received pharmacological treatment. Among the 62 subjects who were informed about hyperlipidaemia only 5% were taking a lipid-reducing drug. Among present smokers, 38% had had at least one quitting episode during the previous 2 years with a median duration of 60 days. CONCLUSION: In a general population there is a difference between blood pressure and cholesterol check-up and medicalization. Screening activities seem to raise the awareness of cardiovascular risk factors in a population, but when evaluating the tendency to change lifestyle the contagious effects of screening activities might be taken into account. Finding quick-relapsing former smokers among current non-smokers may be of importance when planning smoking cessation activities.

Guidelines and reported practice for the treatment of hypertension and hypercholesterolaemia.

OBJECTIVE: To monitor changes in family physicians' reported practice on hypertension and hypercholesterolaemia. DESIGN: Random samples of physicians were selected for telephone interviews on their practice regarding cut-off levels and pharmacological treatment of hypertension and hypercholesterolaemia, related to a case scenario of a 48-year-old man, in 1989, 1991 and 1993. SETTING: Primary care facilities in southern Sweden. SUBJECTS: Specialists in family medicine, employed in public primary health care. Participation rates were in 187/201 (93%) in 1989, 236/264 (89%) in 1991 and 257/298 (86%) in 1993. MAIN OUTCOME MEASURES: Cut-off levels and drug treatment preferences for hypertension and hypercholesterolaemia. RESULTS: During the period 1989-1993, decreasing mean cut-off levels for pharmacological treatment of hypertension (P < 0.001) were reported, below the levels of the guidelines. Although betablockers were first choice drug in all three surveys, the proportion preferring this has diminished (P < 0.001), whilst the proportions preferring ACE-inhibitors and calcium channel blockers have increased (P < 0.001 and P = 0.02, respectively). For drug treatment of hypercholesterolaemia, the mean cut-off level remained close to guidelines in all three surveys. The proportion of physicians suggesting resins and nicotinic acid as first choice drug had decreased (P < 0.001 and P = 0.03, respectively), whilst the proportion preferring statins and fibrates had increased (P < 0.001 and P = 0.048, respectively). CONCLUSION: Practice guidelines on hypertension and hypercholesterolaemia have not had the desired impact on physicians' reported practice. The reason for this might be that physicians did not value the guidelines as adequate tools for practice, or that the methods for dissemination, implementation, and maintenance of guidelines were not appropriate.

The discursive formation of health. A study of printed health education material used in primary care.

This study analyses printed educational material on cholesterol, food and health-related lifestyle changes used in primary care in southern Sweden. Two theoretically grounded perspectives are used: orientation of knowledge and rhetoric. According to the first one, the material contained many examples of abstract and detailed knowledge, such as tables of energy contents, and a little less of action-oriented and detailed knowledge, such as food recipes. We also found a few examples of comprehensive, abstract knowledge, such as theoretic explanations. Action-oriented and comprehensive knowledge, relating health to-lifestyle, were rare. The rhetoric style of the material was generally dominated by plain facts, without any identified voice (i.e. sender) or any emotional orientation. Overall, information was not related to 'the voice of the life-world' but to 'the voice of medicine', and it was in character more general than specific.

Understanding the unperceivable: ideas about cholesterol expressed by middle-aged men with recently discovered hypercholesterolaemia.

OBJECTIVE: We aimed to describe the perception of hypercholesterolaemia among middle-aged, urban men who had recently received the diagnosis of moderate hypercholesterolaemia. METHOD: Within a project screening for risk factors for coronary heart disease among 453 men, 63 were identified as moderately hypercholesterolaemic. Among these, 62 agreed to tape-recording and transcription of the first counselling on lipid-lowering, supplied by a registered nurse. The counselling was tailored to fit the needs of the individual patient, taking a starting point in whatever questions the patient expressed. The transcripts of the counselling sessions were analysed for their content. RESULTS: Five major themes were addressed by the men. It was hard to understand and accept the concept of hypercholesterolaemia, as the men did not feel unwell, and thus they did not receive any cues to taking action. Obesity and smoking was regarded as causes of hypercholesterolaemia, although the link between life-style and cholesterol level was unclear. Some men were aware of heredity traits of hypercholesterolaemia. Treatment suggestions included weight reduction and drug treatment, although there were ambiguous feelings towards drugs. Numerous misconceptions about diet were found. Many men expressed resistance to life-style changes and questioned the benefits of risk reduction. Information about hypercholesterolaemia was regarded as unreliable, as different sources gave incongruent information, and the information from individual sources changed over time. CONCLUSION: Unless medical professionals counselling patients for asymptomatic risk factors make efforts to disclose patients' conceptions of the condition, patients may misunderstand and counselling may become ineffective.

Health beliefs and heart disease risk among middle-aged Swedish men. Results from screening in an urban primary care district.

OBJECTIVE: To study the relationship between individual health beliefs and risk factors for coronary heart disease. DESIGN: Health beliefs indices, formed by factorial analysis of ratings of statements on health related matters in a questionnaire, were related to risk factors for coronary heart disease, assessed with physical examinations and self reports of medical history and habits. SETTING: An urban primary care district in Malmö, Sweden. SUBJECTS: A random sample of middle-aged men, invited to a health check-up. RESULTS: The participation rate was 453/705 (64%). "Perceived threat to health caused by illness" was positively related to previous information on high blood pressure, high plasma cholesterol, and/or diabetes (p = 0.01). In a model of logistic regression, adjusted for age, cohabitation, and previous medical history, health belief index on "threat to health" was related to low exercise habits (RR = 1.06, CI 1.01, 1.12). "Perceived control over illness" was related to high alcohol consumption (RR = 0.86, CI 0.75, 0.97), smoking (RR = 0.89, CI 0.79, 0.99), and high diastolic blood pressure (RR = 0.84, CI 0.75, 0.95). CONCLUSION: This cross-sectional study demonstrates relations between health beliefs, previous health-related experiences, and risk behaviour. To explore the causality of the former, longitudinal studies of changes in health beliefs after medical information are required.

My family dies from heart attacks. How hypercholesterolaemic men refer to their family history.

Patients often worry considerably about biomedically mild and self-limiting conditions. A previous study on non-selected primary care patients showed that this could be partly explained by frequent associations with cases of serious illness in their family histories. This study further investigated these phenomena in middle aged men with a recent diagnosis of hypercholesterolaemia. Sixty-three out of 453, 35-45-year-old male participants were diagnosed with moderate hypercholesterolaemia (6.5-7.7 mmol/l) in a health survey and received 20-30 minutes of life-style counselling. These sessions were audio-taped, transcribed and analysed with respect to the subjects' references to their family histories. Of the 63 men, 28 (45%) mentioned their family history. The main content category in these talks was perceived threat or risk, comprising the seriousness of the event in the family history on one hand and its believed relevance on the other. Fatal, serious or premature disease was discussed. Prevailing lay knowledge and beliefs about hypercholesterolaemia, risk factors and disease causation seemed to determine what conditions in the family history were judged relevant by the men. Several of the men referred to heredity and several regarded emotional closeness important. In a few cases the event referred to mainly functioned as an illustration or example of lay knowledge and beliefs. This study provides support for the view that the family history can play an important role for how asymptomatic patients interpret their risk factors for disease. This is important for the development of consultation skills.

Reported treatment of hypertension by family physicians in Sweden and Minnesota: a physician survey of practice habits.

OBJECTIVES: To compare family physicians' reported practice habits on hypertension in Sweden and Minnesota, and to assess to what extent different national guidelines account for differences. DESIGN: Random samples of family physicians were selected for telephone interviews on their practice of hypertension. SETTING: Primary care in southern Sweden and in Minnesota. SUBJECTS: Family medicine specialists. Participation rates were 236/264 (89%) in Sweden and 183/209 (88%) in Minnesota. MAIN OUTCOME MEASURES: Cut-off levels, and non-pharmacological and pharmacological treatment of hypertension, related to three case scenarios: a 48-year-old man, a 65-year-old man and a 65-year-old woman. RESULTS: Swedish physicians reported significantly higher levels of diastolic blood pressure than Minnesota physicians for the institution of treatment of hypertension for all case scenarios. In both countries, physicians adhered to the cut-off levels of their national guidelines in the case of the 48-year-old man. Minnesota physicians did not use age as a modifying factor for treatment cut-off levels, as did Swedish physicians. Swedish physicians emphasized alcohol, fat and stress reduction, and Minnesota physicians weight and salt reduction as non-pharmacological treatment. While Swedish physicians generally preferred beta-blockers, Minnesota physicians chose ACE inhibitors or calcium channel blockers as the first choice drug. CONCLUSION: Swedish and US guidelines on hypertension were identical except for higher cut-off level for drug treatment in Sweden. Minnesota physicians reported cut-off levels close to national guidelines. For 65-year-old patients, Swedish physicians reported applying a higher cut-off level than indicated by guidelines. Swedish physicians also reported preferring less expensive drugs. As a consequence of the differing national guidelines and the identified physicians' practice habits in the two medical communities, it is likely that the segments of the populations treated and the drug costs differ substantially.

Reported treatment of hypercholesterolemia by family physicians in Sweden and Minnesota.

Swedish guidelines on treatment of hyperlipidemia recommend higher cut-off levels for initiating treatment than do American guidelines, but are virtually identical for instituting and performing therapy. The aim of this study was to compare family physicians' reported practices in Sweden and Minnesota. We selected random samples of family physicians in southern Sweden and Minnesota for telephone interviews. Participation rates were 236/264 (89%) and 183/209 (88%), respectively. Swedish and Minnesota physicians adhered to their guidelines on cut-off levels in a case describing a 48-year-old man but, contrary to guidelines, reported higher cut-off levels for a 65-year-old man and a 65-year-old woman. In all cases described, Swedish physicians reported significantly higher cut-off levels. Swedish physicians were less prone to institute medication in older patients and less familiar with drugs. Minnesota physicians were more inclined to advise nicotinic acid derivatives (P < .0001 for all patient categories). Swedish physicians more frequently preferred resins (P = .00029) or fibrates (P = .0028) for the 48-year-old man and resins for the 65-year-old man (P = .0026). Despite common medical knowledge, the two medical communities are directed by different guidelines. Although adherence to cut-off levels was equally high in both groups, the use of lipid-lowering drugs has not become a familiar part of the therapeutic armamentarium for Swedish family physicians.

Dissemination and implementation of guidelines for lipid lowering.

Lipid lowering practice as reported by family physicians is described and related to current guidelines. During autumn 1989, a random physician sample was invited to a telephone interview, and 187 (93%) participated; they were asked about their awareness of consensus statements about hyperlipidaemia and their present practice habits in the diagnosis and treatment of hyperlipidaemia. Most commonly named sources of information were continuing medical education, consensus reports, professional journals and commercial sources. Most commonly used reference literature was consensus reports. The mean upper limit for desirable cholesterol in a 48-year old man was given as 6.2 mmol/l (recommended 5.2 mmol/l); non-pharmacological treatment was considered at 6.4 mmol/l (recommended 6.5) and pharmacological treatment at 8.0 (recommended 7.9). Exact consensus values were known by a minority of the physicians. Three-quarters of the physicians could name a first choice lipid lowering drug and half had a second choice. With the exception that those aware of a consensus report gave a significantly lower cut off point for pharmacological treatment (p = 0.043), there was no relationship between practice habits and source of information. Those stating consensus guidelines as their prime reference also gave a significantly lower cut-off point for non-pharmacological treatment (p = 0.036). We conclude that to influence medical practice, guidelines need extensive support from educational activities and quality assurance.