Drawing up the public national Rational Pharmacotherapy Action Plan as part of social and health services reform in Finland: a bottom-up approach involving stakeholders

BACKGROUND

Ensuring equal access to medicines and their appropriate and safe use at reasonable costs are core functions of health systems. Despite that, few descriptions of national medicines policies' development processes and implementation strategies have been published. This study aimed to describe the government program-based development of the Rational Pharmacotherapy Action Plan in Finland as a part of the undergoing major health and social service system reform, also covering the implementation of rational pharmacotherapy in the reformed system and processes.

METHODS

The data of this qualitative study consisted of public reports and Steering Group meeting memos related to the development of the national Rational Pharmacotherapy Action Plan that the Ministry of Social Affairs and Health coordinated. Qualitative content analysis applying systems theory and the conceptual framework of integrated services as theoretical frameworks was used as an analysis method.

RESULTS

The national Rational Pharmacotherapy Action Plan covering 2018-2022 was created in a bottom-up development process involving a wide range of stakeholders. Rational pharmacotherapy was redefined by adding equality as the fifth pillar to complement the previously defined pillars of being effective, safe, high-quality, and cost-effective. The Action Plan formed a normative framework for long-term development, with a vision and principles focusing on people-centeredness, better coordination and management of the medication use processes, the continuity of treatment paths and the flow of patient and medicines information through partnerships, and evidence-informed policies and practices.

CONCLUSION

Through intensive stakeholder participation, the bottom-up approach created a national vision and principles of rational pharmacotherapy along with strong commitment to implementing the goals and measures. The concern lies in ensuring the continuity of the Action Plan implementation and achieving a balanced long-term development aligned with the integrated and reformed national social and health services system. The development of the pharmaceutical system has several national and EU-level dependencies requiring political long-term commitment. While the Action Plan differs from the national medicines policy, it forms a good basis for long-term development covering important parts of medicine policy at the micro, meso, and macro levels of the service system.

A system of key indicators for needs assessment at local level: The Finnish network of information producers

Healthcare needs assessment of a local population combines national and local health registries with practice-based data, surveys and qualitative methods. A working group in Finland has developed a system of key indicators for local needs assessment based on a comparative approach. It uses 45 key indicators within four different fields: demography, health behaviour, health status and use of health services. Indicators had to: describe an aspect of health affecting large groups; be available and accessible in existing data files; and be valid, reliable and easy to interpret. A user interface is needed to extract the indicators via the Internet. An educational package of instructions and exercises will be prepared. The use of evidence in health service planning needs to be strengthened. The project offers a new toolkit for healthcare needs assessment, planning of local health services and public health development.

[Implementation in Finnish]

Implementation research examines and promotes the uptake of research findings in various operational environments. The concepts of implementation research in Finnish are not yet established. In support of the research field we describe the Finnish equivalents of the central terms related to knowledge translation in healthcare and the frame of reference of Implementation research, with the national Current Care Guidelines as the starting point. The frame of reference is based on literature, experiences of the authors, iterative modification of the frame of reference on the basis of discussions, and results of expert inquiry. The frame of reference describes seven objects of evaluation, examples of research set-ups and methods as well as tools.

Healthcare professionals' intentions to use clinical guidelines: a survey using the theory of planned behaviour

Background

Finnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour.

Methods

A cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions.

Results

The results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals.

Conclusions

The results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.

[Supporting a patient's self-management]

Regardless of favorable results of health care, citizens still face with health risks which are associated with the life style. Shift from professional-centered care to patient-centered care sets challenging tasks and roles to professionals as well as patients. Professional's authority is transformed into a role of a patient's partner and trainer, with whom the patient negotiates the best treatment for him or her. Professional taking the role of a partner and a trainer strengthens the patient's self-management skills by supporting patient's empowerment, autonomy, motivation and self-efficacy when the patient is solving his or her health problems and making decisions. From the patient's point of view, self-management demands knowledge of objectives and means of treatment as well as willingness to take responsibility for one's own treatment and ways of living, as well as confidence to one's own resources and capabilities.

Feelings related to first patient experiences in medical school. A qualitative study on students' personal portfolios

Feelings and thoughts of medical students related to first patient experiences during the first clinical year were examined. Twenty-two volunteer third and fourth year medical students (15 women and 7 men) of the University of Helsinki participated in a portfolio course for 1 year. Their reflective learning diaries and writings on specific themes were analyzed by qualitative content analysis. First patient encounters were strong emotional experiences for medical students. The first patient examination was often described as an anxiety-provoking and confusing incident. Other emotionally significant encounters included helplessness when faced with serious illness and death, and role confusion when examining patients of one's own age but opposite sex. Students felt guilty for using patients for their own learning purposes. Portfolios as learning tools may help in recognizing key experiences and support professional development of medical students.

Use of alternative drugs in Finland

OBJECTIVES

The purpose of this study was to assess the use of alternative drugs among the adult population in Finland, especially to find out how the health status, health behaviour and use of licensed drugs and health care services are related to the use of alternative drugs.

DESIGN

A telephone interview was conducted in March 1992 with a response rate of 85%.

SUBJECTS

A random, representative sample of 2134 Finns aged between 15 and 74 years.

RESULTS

A total of 39% of the respondents had used one or more types of alternative drugs during the last year. Most common was the use of health food products. Women used all types of alternative drugs more often than men. The use of alternative drugs was more common among educated and urban respondents. Perceived health or existence of a long-standing illness was not related to alternative drugs use whereas reporting of psychosomatic symptoms was. Non-smoking was positively related to the use of alternative drugs and also active exercise among men. The use of non-prescription drugs, official and unofficial health services were positively related to alternative drugs use.

CONCLUSIONS

The use of alternative drugs is popular and it may increase in the future. The use of alternative drugs can be considered a form of medicalization. More information on products used and people using alternative drugs is needed.

Medically unexplained symptoms: perceptions of physicians in primary health care

BACKGROUND

Patients presenting with multiple symptoms represent a substantial part of a GP's total work load. At the same time, these patients account for the majority of the people on long-term sick-leave in Sweden today.

OBJECTIVE

The aim of this study was to explore GPs' perceptions and ways of managing patients with medically unexplained symptoms (MUS).

METHODS

Five focus group discussions were conducted with a total of 27 GPs. In the collection and analysis of data, a phenomenographic approach was used.

RESULTS

The GPs described how they used four different approaches to manage patients with MUS: a biomedical, a psychological, an educational and a psychosocial approach. Different approaches were used, depending on the patient and the situation, and the GPs even switched approach when working with the same patient.

CONCLUSIONS

In their work with patients with MUS, GPs need support and further training to improve the way the biomedical frame of reference is integrated with the humanistic perspective.

Physicians' gender and clinical opinions of reproductive health matters

The purpose of this study was to investigate the effect of physicians' gender when sex-specific conditions are being treated in a country where almost half of the physicians are women. Five Finnish surveys originally conducted for other purposes were reanalyzed. Two surveys examined physicians' and medical students' views about hormone therapy during and after menopause, one survey examined medical students' attitudes about medicines, one survey examined physicians' obstetric practices, and one examined contraceptive counselling. All the surveys showed more similarities than differences in the clinical decision-making of women and men physicians. In opinions about menopause the physician's medical specialty was more important than gender. Physicians' obstetrical practices were also similar in five cases out of six, but in one situation where medical factors were not a deciding issue, women physicians acted differently. These results suggest that socialization into the medical profession makes physicians' practices more alike and diminishes gender differences.

Alternative drug use for the climacteric in Finland

OBJECTIVES

To investigate the use of alternative drugs for the climacteric in Finland, which products are used, and who are the women using them.

METHODS

The study was based on a population-based survey conducted in 1989 among 2000 Finnish women aged 45-64 (response rate 86%).

RESULTS

11% of the women reported the use of alternative drugs for the climacteric. Food supplements and bee products were the most common types of alternative drugs used. Some of them may have allergic or other side effects. Users differ little from other women judging by health habits and the utilization of health care services. The best predictors for alternative drug use were urban residence, more than 9 years of general education, and among 50 54-year olds, the use of prescription or OTC drugs for menopause. Over half of the users of alternative drugs had also used hormone therapy.

CONCLUSIONS

Women using alternative drugs during and after the climacteric represent a large group. More information is needed about the clinical effects of alternative drugs, and the characteristics of alternative drug users.

Careprovider and obstetrical interventions--a comparative study of four European countries

The purpose of this study was to compare the treatment recommendations of obstetricians and midwives in four European countries: the Czech Republic, Finland, Hungary, and Slovenia. Intervention orientation was examined with six hypothetical patient cases. We wanted to learn whether midwives differ from obstetricians in their choices, and whether there is any variation among countries regarding the willingness of staff to intervene. In Finland the two professions were quite similar in their recommendations for interventions, but in Hungary and Slovenia, midwives and obstetricians differed from each other. There were also differences between the countries in the treatment recommendations, and there was disparity between opinions and actual obstetrical practices. Slovenian obstetrical staff were the most interventionistic in many cases, compared with others, although the actual frequency of interventions was no greater than in other countries. In Finland the staff were the most passive in their opinions, yet the actual proportion of interventions was greatest.

A survey on the use of alternative drugs during pregnancy

OBJECTIVE

To describe the use of alternative drugs during pregnancy.

DESIGN

A trial including 3 surveys on drug use during pregnancy in maternity centers in one area of Finland in 1985-86 (study 1), and a retrospective survey in 2 maternity hospitals in Finland in 1988 (study 2).

PATIENTS AND METHODS

Study 1: 2912 pregnant women (about 94% of pregnant women in the area during the study period); 97-88% returned questionnaires. Study 2: 180 out of 181 consecutive women giving birth. In study 1, drug use (including drug-like products) in the last two weeks was asked by questionnaires around 12th, 28th, and 36th gestation weeks. In study 2, women were interviewed 2-3 days after birth asking about any drugs used during pregnancy. Due to the method of asking, our studies underestimate the level of using alternative drugs.

RESULTS

In study 1, a total of 97 (3.6%) pregnant women reported use of alternative drugs. Most drugs were dietary supplements, and by current knowledge harmless. But a few women had used (potentially) dangerous drugs. The users were from the higher social class and they had also used pharmaceutical specialties more often than non-users. In study 2, 14% had used alternative drugs at some time during pregnancy.

CONCLUSION

Because our surveys showed that alternative drugs are used, possibly with increasing frequency, during pregnancy, further studies on safety are needed.