General Practitioners and Community Pharmacists' Collaboration in Primary Care: Small Steps for a Major Change.

BACKGROUND: Healthcare authorities worldwide search for ways to develop integrated care and interprofessional collaboration. In Belgium, Medical-Pharmaceutical Concertation (MPC) was introduced as a format to promote constructive dialogues between GPs and community pharmacists (CPs) with a focus on pharmacotherapy. OBJECTIVE: To evaluate the implementation of MPC from the perspective of healthcare authorities and GPs/CPs. METHODS: Mixed-methods approach, including semi-structured interviews with stakeholders and service users, observations of MPC meetings and surveys in GPs/CPs. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed inductively. RESULTS: The implementation of MPC took a slow start. Parties involved had divergent views on the goals of the MPC: stakeholders focused on measurable results, while service users aimed on improving interprofessional communication. Additionally, service users felt that the lack of local structures hindered consensus building and implementation of agreements in daily practice. Support from professional associations was considered indispensable for the implementation of MPC. In order to organize this efficiently, the establishment of an independent institution, coordinating the MPC initiative, was highly recommended. CONCLUSION: The study confirms that a thorough context assessment prior to implementation of a complex project is needed and that a step-wise approach should be respected to achieve effective interprofessional relationships.

Information as a crucial factor for toilet training by parents.

BACKGROUND: Toilet training (TT) is a milestone in a child's development. Nowadays, children complete TT later than previous generations. This can have detrimental consequences for the child, the parents, and the environment. TT is experienced as difficult and time-consuming; parents could benefit from guidelines to assist in this process. METHODS: Focus group discussions (FGDs) were used to explore parents' experiences in an inductive approach applying purposive sampling. The FGDs aimed to explore the type of information parents wanted to receive on TT, from whom and how. RESULTS: After six FGDs, including 37 participants with personal experience in TT, data saturation was achieved. The findings of this qualitative study show that reputable agencies, family, friends, day-care workers, and nursery school teachers were considered very helpful and trustworthy sources. TT information should be easily understandable and not contain scientific terms or much text. A colourful and illustrated brochure sent by regular mail is preferred. CONCLUSION: Our study allows to develop a source of correct and wanted information about TT that parents can and want to use, which helps them completing this training more easily and timely.

Community perceptions of epilepsy and its treatment in an onchocerciasis endemic region in Ituri, Democratic Republic of Congo.

BACKGROUND: A recent study in the Logo and Rethy health zones in the Ituri Province in the Democratic Republic of Congo (DRC) reported that the majority of the persons with epilepsy (PWE) had not been treated with anti-epileptic medication (AEM) or had stopped treatment. Prior to the implementation of an epilepsy treatment programme in these health zones, this study investigated the perceptions and experiences regarding epilepsy and its treatment amongst community leaders, PWE and/or their families, traditional healers and health professionals. METHODS: A total of 14 focus group discussions (FGD) and 39 semi-structured interviews (SSI) were conducted with PWE and/or their family members, community leaders, traditional healers, and health professionals in the Logo and Rethy health zones during February 2-19, 2017. RESULTS: In the two health zones, the clinical signs of convulsive epilepsy were recognized by community members. However, a variety of misconceptions about epilepsy were identified including the beliefs that epilepsy is a family-related condition, a contagious disease, is transmitted by insects, saliva or by touching a person of the same sex during seizures, or is caused by evil spirits and witchcraft. The role of traditional healers in spreading these beliefs was revealed. The study also reported sexual abuse on PWE, stigmatisation of PWE and loss of productivity of PWE and their families. Some PWE had been using AEM and traditional treatment but were not convinced about the efficacy of these treatment options. The lack of training of health providers about epilepsy care, financial barriers in obtaining AEM, and the shortage of AEM at primary health facilities were revealed. As remedies, the community requested access to a decentralized center for epilepsy treatment. They also proposed using churches and community health workers as communication channels for information about epilepsy. CONCLUSIONS: Clinical signs of convulsive epilepsy were recognized by the community in the Logo and Rethy health zones but many misconceptions about epilepsy were identified. A comprehensive community-based epilepsy treatment programme with an affordable uninterrupted AEM supply needs to be established. Such a programme should address stigma, misconceptions, sexual abuse and foster the rehabilitation of PWE to alleviate poverty.

Self-management of medication during hospitalisation: Healthcare providers' and patients' perspectives.

AIMS AND OBJECTIVES: To explore healthcare providers' and patients' perspectives on self-management of medication during the patients' hospital stay. BACKGROUND: Self-administration of medications relates to the process in which hospitalised patients-instead of healthcare professionals-prepare and consume medications by themselves. Literature suggests possible advantages of medication self-management such as increased patient satisfaction, adherence to pharmacotherapy and self-care competence. DESIGN: A qualitative descriptive study design was adopted, using semistructured interviews and qualitative content analysis to examine data. METHODS: Six physicians, 11 nurses, six hospital pharmacists and seven patients were recruited from one regional hospital and two university hospitals, situated in Belgium. Interviews were conducted between October 2014-January 2015. RESULTS: Strengths of medication self-management were described by participants, relating to benefits of self-management for patients, time-saving benefits for nurses and benefits for better collaboration between patients and healthcare providers. Weaknesses were also apparent for patients as well as for nurses and physicians. Opportunities for self-management of medication were described, relating to the organisation, the patient and the process for implementing self-management. Threats for self-management of medication included obstacles related to implementation of self-managed medications and the actual process of providing medication self-management. A structured overview of conditions that should be fulfilled before allowing self-management of medication concerned patient-related conditions, the self-managed medication and the organisation of self-management of medication. CONCLUSIONS: This study provides new insights on the strengths, weaknesses, opportunities and threats from the perspectives of key stakeholders. Interpretation of these findings resulted in an overview of adaptations in the medication management process to facilitate implementation of self-management of medication. RELEVANCE TO CLINICAL PRACTICE: A medication management process for self-management of medication was proposed. Further interventional studies are needed to test and refine this process before implementing it in daily practice.

The perception of parents and teachers about intermittent preventive treatment for malaria in school children in a semi-rural area of Kinshasa, in the Democratic Republic of Congo.

BACKGROUND: Intermittent preventive treatment (IPT) is likely to be the most promising therapeutic strategy to prevent malaria and its related adverse outcomes in schoolchildren. However, its successful implementation will depend on acceptability to key stakeholders such as parents and teachers. METHODS: A qualitative research was conducted, following a clinical trial assessing the effectiveness of IPT in schoolchildren (IPTsc), to understand the perceptions and experiences of parents and teachers with IPTsc, in two schools of Mokali, in Kinshasa, Democratic Republic of the Congo. Eighty parents participated in 8 focus group discussions and 6 school staff were involved in 6 semi-structured interviews. RESULTS: Parents experiences with IPTsc divided them into two groups (owning positive experiences and owning negative experiences with IPTsc). Three major themes emerged as key factors associated with reluctance of parents to IPT use in schoolchildren. These included wrong malaria-related knowledge, bad experience with IPTsc administered during the trial and misunderstanding of IPTsc. The school staff were generally willing to be trained to give medicine to schoolchildren within the scope of IPT. However, most parents were more comfortable with the use of health workers than teachers for drug administration. More importantly, all parents accepting IPT suggested to diagnose malaria infection before any administration of IPT, which is not in line with IPT principal. CONCLUSION: These results suggest that more efforts are needed to improve overall malaria-related knowledge in the community, specifically chemo-prevention strategies and the safety of the drugs used, to ensure the success of health interventions.

Evaluating the implementation fidelity of New Medicines Service for asthma patients in community pharmacies in Belgium.

BACKGROUND: In October 2013, a New Medicines Service (NMS) was introduced in community pharmacies in Belgium to support asthma patients who are novice users of inhaler devices with corticosteroids. The protocol-based intervention used the Asthma Control Test (ACT) and the Medication Adherence Report Scale (MARS) to assess asthma control and medication adherence. The NMS is the first initiative that puts advanced pharmaceutical care into practice in Belgium. The present study evaluated the degree to which the NMS program is delivered as intended, drawing on the concept of implementation fidelity (IF). METHODS: The main dimensions of IF and potential moderating and facilitating factors for the implementation of NMS in community pharmacies were evaluated using telephone interviews with pharmacists (n = 497), semi-structured interviews with patients eligible for NMS (n = 30), focus groups among general practitioners (n = 72) and lung specialists (n = 5), and a work system analysis in community pharmacies (n = 19). RESULTS: The uptake of NMS in Belgian community pharmacies remains low. In addition to practical barriers, pharmacists found it difficult to identify new asthmatic patients when they were not informed about the diagnosis. A lack of commitment from physicians, patients and pharmacists was noted in the early start-up phase of the program. Many pharmacists did not see how NMS differed from existing pharmaceutical care. Physicians considered this service as part of their own tasks and discouraged ACT for asthma follow-up in the community pharmacy. CONCLUSIONS: The introduction of the NMS program was not sufficiently embedded in the Belgian health care organization, causing low uptake and resistance to its implementation by pharmacists, patients, and other health care professionals. To increase the uptake of this type of service and its possible extension to other patient groups, more collaboration among the different health care professionals during design and implementation is necessary, as well as systematic data collection to monitor the quality of the service, better training of pharmacists, and more information for patients and physicians.

How to overcome hurdles in opiate substitution treatment? A qualitative study with general practitioners in Belgium.

BACKGROUND: Opiate substitution treatment (OST) is the administration of opioids (methadone or buprenorphine) under medical supervision for opiate addiction. Several studies indicate a large unmet need for OST in general practice in Antwerp, Belgium. Some hurdles remain before GPs engage in OST prescribing. OBJECTIVES: Formulate recommendations to increase engagement of GPs in OST, applicable to Belgium and beyond. METHODS: In 2009, an exploratory qualitative research was performed using focus group discussions and interviews with GPs. During data collection and analysis, purposive sampling, open and axial coding was applied. The script was composed around the advantages, disadvantages and conditions of engaging in OST in general practice. RESULTS: We conducted six focus groups and two interviews, with GPs experienced in prescribing OST (n = 13), inexperienced GPs (n = 13), and physicians from addiction centres (n = 5). Overall, GPs did not seem very willing to prescribe OST for opiate users. A lack of knowledge about OST and misbehaving patients creates anxiety and makes the GPs reluctant to learn more about OST. The GPs refer to a lack of collaboration with the addiction centres and a need of support (from either addiction centres or experienced GP-colleagues for advice). Important conditions for OST are acceptance of only stable opiate users and more support in emergencies. CONCLUSION: Increasing GPs' knowledge about OST and improving collaboration with addiction centres are essential to increase the uptake of OST in general practice. Special attention could be paid to the role of more experienced colleagues who can act as advising physicians for inexperienced GPs.

Consumer choice between common generic and brand medicines in a country with a small generic market.

BACKGROUND: Generic medicines offer an opportunity for governments to contain pharmaceutical expenditures, since generics are generally 10%-80% lower in price than brand medicines. Belgium has a small generic market that takes up 15% of the total pharmaceutical market in packages sold. OBJECTIVE: To determine the knowledge of consumers about the different available packages of a common over-the-counter medicine (acetaminophen) with regard to price advantage, quality, and effectiveness in a country with a small generic market. METHODS: We conducted an online survey in the general Flemish population using a questionnaire with 25 statements. The questionnaire also contained 2 informative interventions. First, we showed the price per package and per tablet that the patient would pay in the pharmacy. Second, we provided the respondent with general information about generic medication (equivalence, effectiveness, price, and recognition). Before and after the interventions, we probed for preferences and knowledge about the different packages. Multivariate logistic models were used to examine the independent effects of consumer characteristics on responses to the survey statements. RESULTS: We obtained a sample of 1,636 respondents. The general attitude towards generic medication was positive-only 5% would rather not use a generic. Nevertheless, only 17% of the respondents were able to recognize a generic medicine. Older consumers (aged 60 years and above) were more often confused about the different packages (OR = 2.59, 95% CI = 1.76-3.80, P ≤ 0.001). Consumers without a higher education degree tended to be more doubtful about the difference in effectiveness and quality between the different brands (OR = 0.59, 95% CI = 0.44-0.79, P ≤ 0.001). Consumer recognition of the name of the active substance of acetaminophen was poor. When different brands were displayed, possible price advantage seemed to be an important motive to switch to a cheaper brand. Consumers generally found medicines to be too expensive; however, consumers with medical or paramedical training had a different opinion. CONCLUSIONS: Two main recommendations can be made to increase the knowledge and enhance the trust in cheaper equivalent medicines. First, highlighting the name of the active substance on the label of medicine packages can reduce confusion and avoid health risks, especially among older consumers. Second, new investments or reallocation of budgets should be considered in order to provide consumers with authoritative information on the bioequivalence and price differences between the different available brands. This would be a cost-effective and potentially cost-saving investment for health care payers.

Medicine price awareness in chronic patients in Belgium.

INTRODUCTION: Under increasing pressure to contain health expenditures governments across Europe have implemented policies to increase responsible medicine use, e.g. by increasing co-insurance paid for by patients. In times of austerity, how do chronic disease patients perceive the medicine price they have to pay? METHOD: We used a mixed methods research design. First, we distributed a close-ended questionnaire among 983 chronic disease patients in 30 Flemish pharmacies. Second, we performed semi-structured interviews with 15 of these patients. We surveyed for knowledge on the prescription medicine they bought, as well as for their needs for information and their therapeutic compliance. RESULTS: Although patients express a lack (and a need) of information on prices during the consultation with the general practitioner (GP), (s)he hardly addresses medicine prices. Patients often only know the medicine price when they are at the pharmacy and patients need to decide to buy the medicine or not. This often results in patients taking the medicine when considered affordable within their social and financial context. CONCLUSION: It seems essential that patients are better informed about medicine prices as well as the constraints on physicians to prescribe cost-effectively. Therefore, medicine prices should be discussed more often during physician consults.

Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures: findings and future implications.

INTRODUCTION: The appreciable growth in pharmaceutical expenditure has resulted in multiple initiatives across Europe to lower generic prices and enhance their utilization. However, considerable variation in their use and prices. OBJECTIVE: Assess the influence of multiple supply and demand-side initiatives across Europe for established medicines to enhance prescribing efficiency before a decision to prescribe a particular medicine. Subsequently utilize the findings to suggest potential future initiatives that countries could consider. METHOD: An analysis of different methodologies involving cross national and single country retrospective observational studies on reimbursed use and expenditure of PPIs, statins, and renin-angiotensin inhibitor drugs among European countries. RESULTS: Nature and intensity of the various initiatives appreciably influenced prescribing behavior and expenditure, e.g., multiple measures resulted in reimbursed expenditure for PPIs in Scotland in 2010 56% below 2001 levels despite a 3-fold increase in utilization and in the Netherlands, PPI expenditure fell by 58% in 2010 vs. 2000 despite a 3-fold increase in utilization. A similar picture was seen with prescribing restrictions, i.e., (i) more aggressive follow-up of prescribing restrictions for patented statins and ARBs resulted in a greater reduction in the utilization of patented statins in Austria vs. Norway and lower utilization of patented ARBs vs. generic ACEIs in Croatia than Austria. However, limited impact of restrictions on esomeprazole in Norway with the first prescription or recommendation in hospital where restrictions do not apply. Similar findings when generic losartan became available in Western Europe. CONCLUSIONS: Multiple demand-side measures are needed to influence prescribing patterns. When combined with supply-side measures, activities can realize appreciable savings. Health authorities cannot rely on a "spill over" effect between classes to affect changes in prescribing.

Evolutions in both co-payment and generic market share for common medication in the Belgian reference pricing system.

BACKGROUND: In Belgium, a co-insurance system is applied in which patients pay a portion of the cost for medicines, called co-payment. Co-payment is intended to make pharmaceutical consumers more responsible, increase solidarity, and avoid or reduce moral hazards. OBJECTIVE: Our objective was to study the possible influence of co-payment on sales volume and generic market share in two commonly used medicine groups: cholesterol-lowering medication [statins (HMG-CoA reductase inhibitors) and fibrates] and acid-blocking agents (proton pump inhibitors and histamine H2 receptor antagonists). METHODS AND DATA: The data were extracted from the Pharmanet database, which covers pharmaceutical consumption in all Belgian ambulatory pharmacies. First, the proportion of sales volume and costs of generic products were modelled over time for the two medicine groups. Second, we investigated the relation between co-payment and contribution by the national insurance agency using change-point linear mixed models. RESULTS: The change-point analysis suggested several influential events. First, the generic market share in total sales volume was negatively influenced by the abolishment of the distinction in the maximum co-payment level for name brands and generics in 2001. Second, relaxation of the reimbursement conditions for generic omeprazole stimulated generic sales volume in 2004. Finally, an increase in co-payment for generic omeprazole was associated with a significant decrease in omeprazole sales volume in 2005. The observational analysis demonstrated several changes over time. First, the co-payment amounts for name-brand and generic drugs converged in the observed time period for both medicine groups under study. Second, the proportion of co-payment for the total cost of simvastatin and omeprazole increased over time for small packages, and more so for generic than for name-brand products. For omeprazole, both the proportion and the amount of co-payment increased over time. Third, over time the prescription of small packages shifted to an emphasis on larger packages. CONCLUSIONS: As maximum co-payment levels decreased over time, they overruled the reference pricing system in Belgium. The changes in co-payment share over time also significantly affected sales volume, but whether physicians or patients are the decisive actors on the demand side of pharmaceutical consumption remains unclear.

The potential influence of various initiatives to improve rational prescribing for proton pump inhibitors and statins in Belgium.

BACKGROUND: Proton pump inhibitors (PPIs) and statins have been among the top three most prescribed medicines in Belgium for more than a decade. Multiple demand-side measures have been introduced to improve rational prescribing generally, as well as for these two classes. OBJECTIVES: First, assessing the influence of general and specific reforms introduced in Belgium since 1997 on utilization and expenditure of the PPIs and statins. Second, suggesting additional measures to further improve rational prescribing based on experiences in other European countries. METHODS: A retrospective observational study for assessing the influence of multiple initiatives in Belgium on utilization and expenditure of the PPIs and statins from 1997 to 2009 was carried out. Data were extracted from the administrative database Pharmanet. Utilization was measured in terms of defined daily doses (DDDs) and DDDs/thousand inhabitants per day. RESULTS: Multiple reforms, including co-payments and reference pricing, appreciably enhanced rational prescribing for both PPIs and statins following generic availability. There was an eightfold increase in PPI utilization between 1997 and 2009, but only a twofold increase in reimbursed expenditure, helped by decreasing expenditure/DDD for the PPIs from €1.91 in 1997 to €0.52 in 2009. Similarly, a 20-fold increase was observed in statin utilization between 1997 and 2009, but only a fivefold increase in reimbursed expenditure, helped again by reimbursed expenditure/DDD decreasing from €2.05 in 1997 to €0.57 in 2009. Reduced co-payments for larger packs enhanced their prescription. CONCLUSION: Multiple reforms influenced utilization patterns and expenditure for the PPIs and statins, as well as the pack sizes dispensed. Additional demand-side measures are needed to further enhance rational prescribing, which can build on the experiences in other countries. These can be potentially transferred to other classes.

Flemish adolescents' perceptions of cigarette plain packaging: a qualitative study with focus group discussions.

OBJECTIVES: To find out whether there is a potential impact of the appearance of a plain cigarette package on the smoking perceptions and behavioural intentions of Flemish adolescents. DESIGN: We performed a cross-sectional study using the qualitative method of focus group discussions. SETTING: Flemish adolescents. PARTICIPANTS: We performed eight focus group discussions, in which 55 adolescents took part, 32 female and 23 male. Inclusion criteria were: Flemish male and female 15-year-olds to 16-year-olds and 17-year-olds to 18-year-olds attending regular high-school education or vocational training who were current or had ever been smokers. OUTCOME MEASURE (PLANNED AS WELL AS MEASURED): The opinions and perceptions of young Flemish smokers regarding the impact of cigarette packaging on their smoking behaviour. RESULTS: Plain packages are perceived as less attractive, cheap and unreliable for young people. Because of the unattractiveness of the plain packaging, the health warnings catch the eye much more strongly. CONCLUSIONS: In this first scientific study in Flanders on this topic, it emerged that plain packaging could be a strong policy tool to reduce the number of adolescents starting smoking. Validation of these findings by conducting a quantitative survey in the same target group is recommended.

How is an electronic screening and brief intervention tool on alcohol use received in a student population? A qualitative and quantitative evaluation.

BACKGROUND: A previous study among Antwerp college and university students showed that more male (10.2%-11.1%) than female (1.8%-6.2%) students are at risk for problematic alcohol use. The current literature shows promising results in terms of feasibility and effectiveness for the use of brief electronic interventions to address this health problem in college and university students. We evaluated this type of intervention and cite existing literature on the topic. OBJECTIVE: To develop a website, www.eentjeteveel.be, to motivate college and university students with problematic alcohol use to reduce alcohol consumption and increase their willingness to seek help. METHOD: The website contained a questionnaire (Alcohol Use Disorders Identification Test [AUDIT]) for students to test their alcohol use. According to their answers, the students immediately received personalized feedback (personal AUDIT score and additional information on risks associated with alcohol use) and a suggestion for further action. Afterward, students could send an email to a student counselor for questions, guidance, or advice. To obtain in-depth qualitative information on the opinions and experiences of students, we held 5 focus group discussions. The topics were publicity, experiences, impressions, and effects of the website. We analyzed the quantitative results of the online test in SPSS 15.0. RESULTS: More than 3500 students visited www.eentjeteveel.be; over half were men (55.0%). A total of 34 students participated in the focus group discussions. The mixture of quantitative and qualitative methods to evaluate the intervention allowed a thorough analysis and provided complementary results. The intervention was well received by the student population. However, some minor aspects should be reconsidered, such as website publicity and providing students with options that were added after intermediate evaluation. The intervention increased the motivation of students to think about their alcohol use but could not stimulate them to change their behavior. The website attracted relatively more male than female students and more students in the high-risk group than in the low-risk group. The high-risk group was more inclined to seek advice or guidance (23/400, 6%; χ(2) (2 = 32.4), P < .001) than the low-risk group (34/1714, 2%; χ(2) (2 = 32.4), P < .001). CONCLUSIONS: We gained unique insight into students' experiences, opinions, and perceptions with regard to the intervention. The results show that the intervention was positively received in the population, and the willingness to seek help was increased. However, real behavior change needs further research. The results of this study can assist health providers and researchers in better understanding college and university students' perceptions of eHealth initiatives.