Equipping pharmacists for delivering pharmaceutical care to seniors: a qualitative systematic review of Asian seniors' social support.

BACKGROUND: Pharmacists must cater to seniors' needs and communicate better in delivering pharmaceutical care. However, pharmaceutical care for seniors is unique since they commonly depend on support from their social environment. Our study aimed to collect perceptions and experiences of Asian seniors regarding social support. METHODS: A qualitative systematic review of peer-reviewed articles between January 2012 and January 2022 was conducted using PubMed, Scopus, Academic Search Complete via EBSCOhost, ProQuest, and Google Scholar. Selected studies were extracted, and thematic synthesis was performed. RESULTS: A total of 23 qualitative studies with diverse rigor were included in this review. Themes that emerged around perceptions and experiences of social support were (1) family orientation, (2) having faith in religion, (3) the importance of the elderly providing support, (4) taboos, (5) elderly self-reliance, (6) elderly fear of being a burden, and (7) differences on perceptions and experiences regarding social support. A discussion on how these results may contribute to pharmacy practice is provided. CONCLUSION: This study reviews the available social support for seniors and highlights its importance for pharmacists.

What Do Seniors Believe About Medication Adherence? A Qualitative Study Among Seniors with Chronic Conditions in Yogyakarta, Indonesia.

Purpose: This qualitative study elicited beliefs about medication adherence among hypertensive seniors with polypharmacy. Methods: Twenty-one participants aged 60 or older with hypertension and other chronic conditions, with or without their family caregivers, residing surrounding Yogyakarta province, using five medicines or more routinely, were semi-structuredly interviewed by one researcher or one research assistant in January to April 2022. Behavioral, normative, and control beliefs were elicited using an interview guideline which was developed based on the Theory of Planned Behavior approach. Thematic analysis was applied. Results: The participants believed that taking medicines routinely was advantageous because the medicines kept their body in good condition and prevented disease worsening. However, there were concerns about the medications' harmful effects on kidneys, gastric, and the whole body, and that the medicines would not be effective anymore. Prescribers, family, and friends would likely approve of medication adherence. However, non-prescriber doctors, family, and neighbors, mainly those with experience with complementary/alternative medicines, would likely disapprove of medication adherence. Good physical and cognitive function, help from family and technology, mealtime regularity, a simple regimen and easy-to-read medication labeling, and good communication with prescribers were among the facilitators of medication adherence. Physical and cognitive decline, mealtime irregularity, tablets that must be cut before taken, insurance that does not cover all medicines, change in dosage regimen, and hard-to-tear-off medication packaging were among the barriers to medication adherence. Conclusion: Understanding these beliefs yields insights into the health communication approaches to improving seniors' medication adherence.

Understanding reasons for lack of acceptance of HIV programs among indigenous Papuans: a qualitative study in Indonesia.

BACKGROUND: Melanesians are indigenous Papuans racially and culturally different from most Indonesians. The Melanesia region is characterised by high poverty and inequalities, even though it has the highest revenue. Furthermore, Papua has the highest HIV prevalence rate, 24-fold higher than that of other regions. Therefore, this study aimed to examine the resistance of indigenous people residing in eastern Indonesia towards HIV programs. METHODS: This is a qualitative study analysed using grounded theory. Data were collected from July to September 2018 through semi-structured face-to-face interviews involving 23 Papuans. The interviews were conducted in Bahasa Indonesia, audio-recorded, summarised and transcribed for analysis. RESULTS: The results showed that being a good Papuan emerges from four interconnected categories, including culture and religion, dealing with modernisation, integrated HIV program and stigma reduction. As a substantive theory underpinning the indigenous people's experiences with HIV programs, 'Keep being a good Papuan' was a way of overcoming problems and dealing with modernism to eliminate HIV. This largely focuses on the local culture, implying any adjustment should keep their tradition and welcome modernism. CONCLUSIONS: The future of the HIV programs should be agreed upon, funded, implemented, measured and achieved by stakeholders. This could be achieved by elaborating a supportive culture and community-based interventions. Furthermore, the implementation should be prioritised to integrate and improve the programs' quality to take into account community needs and the available resources.

Assessment of Knowledge, Attitude, and Practice of Antibiotic Use among the Population of Boyolali, Indonesia: A Cross-Sectional Study.

Misuse and overuse of antibiotics are potential causes of the increasing prevalence of antibiotic resistance (ABR). Having information about the knowledge, attitude, and practices concerning antibiotics use by the public might help control ABR growth. Therefore, this cross-sectional study aimed to investigate the levels and associated factors of knowledge, attitude, and practice (KAP) of antibiotics use among the public. A questionnaire was designed and validated, which consisted of a total of 51 questions with four sections: demographics (6), knowledge (20), attitude (12), and practice (13) to measure KAP. Univariate analysis (using Mann-Whitney U and Kruskal-Wallis analysis) was applied to assess the differences in the mean scores of KAP. Linear regression analysis was performed to identify factors associated with KAP. Finally, using Spearman analysis we have examined the correlation between responses to the KAP. The sample size of this study was 575, with a 99.96% response rate. Regarding knowledge, 73.12% of respondents stated that antibiotics could be used to treat viral infections, and 63.35% of respondents answered that antibiotics could reduce fever. Concerning attitude, 50% of respondents had considered stopping taking antibiotics as soon as symptoms had disappeared. In analyzing practice, we found 40% of respondents obtained antibiotics from a pharmacy without a prescription from a physician, a nurse, or a midwife. Statistical analysis revealed that KAP about antibiotic use was significantly associated with gender, area of residence, level of education, and monthly income (p < 0.05). Our findings concluded that men, respondents with low income, those with low-level education, and those living in rural areas are more prone to excessive use of antibiotics without knowing the adverse effects of improper use and how it can contribute to high ABR. So it is urgently necessary to strengthen policies on antibiotics use, including drug provision, distribution, and sales. In addition, people with low KAP should be a priority consideration in education outreach initiatives.

The Impact of Pharmaceutical Policies on Medicine Procurement Pricing in Indonesia Under the Implementation of Indonesia's Social Health Insurance System.

BACKGROUND: Indonesia's social health insurance (Jaminan Kesehatan Nasional, JKN) has been implemented since 2014. To support medicine provision, the government launched policies reform on medicine pricing, procurement and reimbursement; hence, the system might affect medicine prices in the country. OBJECTIVE: To evaluate the effects of the pharmaceutical policies reforms on medicine procurement prices. METHODS: This was a pre-post observational study. Medicine price data were collected retrospectively from the 2013 Ministry of Health procurement price list, the 2017 e-catalogue procurement system, and the procurement departments at 2 hospitals in Jakarta and Cilegon (both categorized as region I). The 2013 national procurement price was compared with the 2017 e-catalogue price. The hospitals' procurement prices were collected from the data 3 years before and 3 years under Indonesia's social health insurance JKN (2011-2016), and the data were used to assess the medicine procurement prices in real conditions. The outcome measure was the difference in procurement prices before and under the JKN. RESULTS: The results showed that the procurement prices of 429 (79.6%) of 539 medicines listed in the 2017 e-catalogue decreased, of which 210 items (39.0%) showed over a 50% decrease. Nevertheless, the procurement prices of 104 items (19.3%) increased, especially those that were still under patent or those with a few brands registered in Indonesia. The procurement prices in public and private hospitals showed a similar trend, that is, a significant decrease. Interestingly, non-e-catalogue medicine prices also decreased quite steeply, although the prices of the branded generic category in the private hospital remained unchanged. CONCLUSION: The pharmaceutical policies under the JKN implementation had a profound impact on decreasing medicine procurement prices in Indonesia.

Rationing for medicines by health care providers in Indonesia National Health Insurance System at hospital setting: a qualitative study.

BACKGROUND: Universal Health Coverage (UHC) in Indonesia is planned to be fully implemented in 2019 through the National Health Insurance (NHI) launched in January 2014. However, limited financial resources cause health care providers (HCPs) to perform rationing in providing medicine services. The purpose of this study was to analyze rationing strategies performed by HCPs for potentially beneficial essential medicines due to financial constraints and other reasons in the Indonesian NHI Plan and evaluate its fairness. METHODS: A qualitative study was conducted to find out the rationing performed by 24 HCPs in NHI medicine services at hospital setting. Research methods included semi-structured interviews with eight physicians, eight pharmacists and eight nurses, and observations of prescriptions undergoing dispensing process. Respondents were purposively selected, and interview results were analyzed thematically. The strategies for rationing were categorized using the matrix developed by Maybin and Klein (denial, selection, delay, deterrence, deflection, and dilution), while contradictions in fairness were evaluated using the four conditions of accountability for reasonableness (relevance, publicity, appeals, and enforcement). RESULTS: The results showed that the most frequent rationing performed by physicians was dilution (to replace medicines with others which were perceived by physicians as less effective or less safe), denial (not to provide medicines not listed in the National Formulary and/or expensive medicine), and deterrence (to encourage patients to pay for medicine). Among pharmacists, the most frequently rationing performed was dilution (to reduce the amount of medicines), denial, and deterrence as performed by physicians. Almost no rationing strategy was performed by nurses. No formal procedure was available to guide the rationing. The rationale for rationing strategies, especially for non-clinical reasons, was often not communicated to patients, and there were few opportunities for patients to appeal the rationing strategies applied to them. There was no difference between the government and private hospitals in the rationing strategies adopted. CONCLUSIONS: Although rationing strategies were facilitating the implementation of National Formulary, they potentially raise problems related to the principles of medical ethics and distort a national health system's ability to progress towards UHC. If performed in the more standardized decision-making process, rationing would be of great benefits to patients and the system. Guidance for more explicit, fair and transparent of rationing should be developed at the hospital level.

Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study.

BACKGROUND: Despite opioid analgesics being essential for pain relief, use has been inadequate in many countries. We aim to provide up-to-date worldwide, regional, and national data for changes in opioid analgesic use, and to analyse the relation of impediments to use of these medicines. METHODS: We calculated defined daily doses for statistical purposes (S-DDD) per million inhabitants per day of opioid analgesics worldwide and for regions and countries from 2001 to 2013, and we used generalised estimating equation analysis to assess longitudinal change in use. We compared use data against the prevalence of some health disorders needing opioid use. We surveyed 214 countries or territories about impediments to availability of these medicines, and used regression analyses to establish the strength of associations between impediments and use. FINDINGS: The S-DDD of opioid analgesic use more than doubled worldwide between 2001-03 and 2011-13, from 1417 S-DDD (95% CI -732 to 3565; totalling about 3.01 billion defined daily doses per annum) to 3027 S-DDD (-1162 to 7215; totalling about 7.35 billion defined daily doses per annum). Substantial increases occurred in North America (16,046 S-DDD [95% CI 4032-28,061] to 31,453 S-DDD [8121-54,785]), western and central Europe (3079 S-DDD [1274-4883] to 9320 S-DDD [3969-14,672]), and Oceania (2275 S-DDD [763-3787] to 9136 S-DDD [2508-15,765]). Countries in other regions have shown no substantial increase in use. Impediments to use included an absence of training and awareness in medical professionals, fear of dependence, restricted financial resources, issues in sourcing, cultural attitudes, fear of diversion, international trade controls, and onerous regulation. Higher number of impediments reported was significantly associated with lower use (unadjusted incidence rate ratio 0.39 [95% CI 0.29-0.52]; p<0.0001), but not when adjusted for gross domestic product and human development index (0.91 [0.73-1.14]; p=0.4271). INTERPRETATION: Use of opioid analgesics has increased, but remains low in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe. Identified impediments to use urgently need to be addressed by governments and international agencies. FUNDING: International Narcotics Control Board, UN.

Use of medicines and adherence to standard treatment guidelines in rural community health centers, Timor-Leste.

The use of medicines and nurses'/midwives' adherence to standard treatment guidelines (STGs) were examined in Timor-Leste during the early stage of the nation's new health system development. A cross-sectional study was conducted as the quantitative element of mixed methods research. Retrospective samples from patient registration books and prospective observations were obtained in 20 randomly selected rural community health centers. The medicines use indicators, in particular the level of injection use, in Timor-Leste did not suggest overprescription. Prescribers with clinical nurse training prescribed significantly fewer antibiotics than those without such training (P < .01). The adjusted odds ratio of prescribing adherence for clinical nurse training, after accounting for confounders and prescriber clustering, was 6.6 (P < .01). STGs for nonphysician health professionals at the primary health care level have potential value in basic health care delivery, including appropriate use of medicines, in resource-limited communities when strategically developed and introduced.

Beliefs about the use of nonprescribed antibiotics among people in Yogyakarta City, Indonesia: a qualitative study based on the theory of planned behavior.

Although antibiotics are prescription-only medicine in Indonesia, they can be purchased without prescription. This qualitative study elicited beliefs about nonprescribed antibiotics use informed by the theory of planned behavior to develop a questionnaire for an expanded theory of planned behavior survey. Twenty-five (N = 25) adults with experience of using nonprescribed antibiotics were interviewed. Content analysis was applied. Participants reported that the use of nonprescribed antibiotics was advantageous in term of saving time and money and of reducing the number of medicines that need to be purchased, in contrast to a perception of what occurs with medical prescriptions. Potential adverse effects, poor health outcomes, and antimicrobial resistance were the perceived disadvantages. Facilitators of such use were the availability of over-the-counter antibiotics and successful experience in using antibiotics. Medication for children was the perceived barrier to such use. Family members and friends, especially those with health education background, approved of such use.

Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey.

BACKGROUND: Misconceptions about antibiotic use among community members potentially lead to inappropriate use of antibiotics in the community. This population-based study was aimed at examining common knowledge and beliefs about antibiotic use of people in an urban area of Indonesia. METHODS: The population of the study was adults (over 18 years old) in Yogyakarta City. A cluster random sampling technique was applied (N = 640). Data were collected using a pre-tested questionnaire and analyzed using descriptive statistics and correlation. RESULTS: A total of 625 respondents was approached and 559 respondents completed the questionnaire (90% response rate). Out of 559 respondents, 283 (51%) are familiar with antibiotics. Out of 283 respondents who are familiar with antibiotics, more than half have appropriate knowledge regarding antibiotic resistance (85%), allergic reactions (70%), and their effectiveness for bacterial infections (76%). Half these respondents know that antibiotics ought not to be used immediately for fever (50%). More than half have incorrect knowledge regarding antibiotics for viral infections (71%). More than half believe that antibiotics can prevent illnesses from becoming worse (74%). Fewer than half believe that antibiotics have no side effects (24%), that antibiotics can cure any disease (40%), and that antibiotic powders poured onto the skin can quickly cure injuries (37%). Those who are uncertain with these beliefs ranged from 25% to 40%. Generally, these respondents have moderate knowledge; where the median is 3 with a range of 0 to 5 (out of a potential maximum of 5). Median of scores of beliefs is 13 (4 to 19; potential range: 4 to 20). The results of correlation analysis show that those with appropriate knowledge regarding antibiotics would also quite likely have more appropriate beliefs regarding antibiotics. The correlation is highest for those who are male, young participants, with higher education levels, and have a higher income level. CONCLUSIONS: Misconceptions regarding antibiotic use exist among people in this study. Therefore, improving appropriate knowledge regarding antibiotic use is required.

Improving of type 2 diabetic patients' knowledge, attitude and practice towards diabetes self-care by implementing Community-Based Interactive Approach-diabetes mellitus strategy.

BACKGROUND: Community Based Interactive Approach-diabetes mellitus (CBIA-DM) is an active self-learning method. This study is aimed at improving type 2 diabetic patients' knowledge, attitude and practice on diabetes self-care by implementing the CBIA-DM strategy. Time series, pre and post quasi-experimental design, Intervention group underwent CBIA-DM, DM-club and Normal-care group acted as control. Data were collected in pre-intervention, immediately, one, three and six months post intervention. Ranging scores for pre and post test questionnaires were: knowledge (0-18) and attitude (9-45); categorizing as rational scales of the scores in good, fair and poor. Practicing in diabetes self-care was assessed using 12 questionnaires, and categorized as adhere and not adhere to DM self-care. Effectiveness of CBIA-DM was evaluated based on the increasing number of participants in good knowledge and attitude levels, and adherence in practicing diabetes self-care. RESULTS: CBIA-DM group shows increasing number of participants in good level of knowledge from 40 % (n = 30) up to 80 % at M + 3 with scores significantly improved from 13.1 ± 2.4 up to 15.4 ± 2.0 (Wilcoxon test, p < 0.05), attitude from 20 % up to 50 % at M + 3, with scores significantly improved from 33.5 ± 4.1 up to 34.9 ± 6.2 (p = 0.031) and increasing number of participants' adherence to all variables of DM self-care at M + 6 post intervention. CONCLUSIONS: CBIA-DM strategy is effective to improve diabetic patients' knowledge, attitude and practice on diabetes self-care. Repeating and improving the strategy program is needed to sustain the impact.

Application of standard treatment guidelines in rural community health centres, Timor-Leste.

OBJECTIVE: To analyse nurses' and midwives' knowledge of and attitudes towards standard treatment guidelines (STGs), which were developed to help their practices at rural community health centres (CHCs) in Timor-Leste. METHODS: Fifty-five nurses and midwives were individually interviewed. Data were analysed qualitatively using the Framework approach. RESULTS: Overall, the standard treatments for acute respiratory tract infections, malaria and diarrhoea were well known by the respondents. Clinical nurses showed precise and detailed knowledge, especially for antibiotic use. The respondents were willing to use STGs and believed that they 'should' follow them. This feeling arose due to their self-awareness as frontline health workers and, at the same time, as peripheral civil servants. The changes brought about by the introduction of STGs were positively perceived. Three components of the change were observed: the concept, daily practice and perceived patient satisfaction. The respondents had previously felt a lack of confidence and hoped to improve their capacity as health care workers; they became confident in their practices by using STGs. Self-confidence was identified more clearly in the clinical nurse interviews. Few difficulties in using STGs were indicated, and the respondents suggested ways to deal with these difficulties. DISCUSSION: By using the STGs, the nurses/midwives gained knowledge and self-confidence. The positive perception of the changes promoted further use of the STGs. Clinical nurse training positively influenced the knowledge of and attitudes towards the STGs. Few difficulties in applying STGs in daily practice were identified, which is contrary to previous studies that targeted physicians in the Western world. Development of STGs within a health policy framework was considered a key factor. The STGs exist across related policies and various programmes, which are interconnected. The Timor-Leste experience indicates the value of STGs for non-physician health care providers at the primary health care level.

Self medication with antibiotics in Yogyakarta City Indonesia: a cross sectional population-based survey.

BACKGROUND: Self medication with antibiotics has become an important factor driving antibiotic resistance. This study investigated the period prevalence, patterns of use, and socio-demographic factors associated with self medication with antibiotics in Yogyakarta City Indonesia. This cross-sectional population-based survey used a pre-tested questionnaire which was self-administered to randomly selected respondents (over 18 years old) in Yogyakarta City Indonesia in 2010 (N = 625). Descriptive statistics, chi-square and logistic regression were applied. RESULTS: A total of 559 questionnaires were analyzed (response rate = 90%). The period prevalence of self medication with antibiotics during the month prior to the study was 7.3%. Amoxicillin was the most popular (77%) antibiotic for self medication besides ampicilline, fradiomisin-gramisidin, tetracycline, and ciprofloxacin to treat the following symptoms: the common-cold including cough and sore throat, headache, and other minor symptoms; with the length of use was mostly less than five days. Doctors or pharmacists were the most common source of information about antibiotics for self medication (52%). Antibiotics were usually purchased without prescription in pharmacies (64%) and the cost of the purchases was commonly less than US $1 (30%). Previous experience was reported to be the main reason for using non-prescribed antibiotics (54%). There were no socio-demographic variables significantly associated with the actual practice of using non-prescribed antibiotics. However, gender, health insurance, and marital status were significantly associated with the intent to self medicate with antibiotics (P < 0.05). Being male (Odds Ratio = 1.7 (1.2 - 2.6)) and having no health insurance (Odds Ratio = 1.5 (1.0 -2.3)) is associated with the intent to self medicate with antibiotics. CONCLUSIONS: This study is the first population-based study of self-medication with antibiotics among the Indonesian population. Usage of non-prescribed antibiotics as well as intent of doing so is common across socio-demographic categories. Given the findings, factors influencing people's intentions to self medicate with antibiotics are required to be investigated to better understand such behavior. Impact of health insurance coverage on self medication with antibiotics should also be further investigated.